late-onset cerebral toxoplasmosis 20 years after kidney transplantation in a patient with alport syndrome: a case report

Background: toxoplasma gondii is an obligate intracellular protozoan parasite that poses a significant risk to immunocompromised patients, particularly solid organ transplant recipients. cerebral toxoplasmosis most commonly occurs within the first-year post-transplant during peak immunosuppression. late-onset disease occurring decades later is exceptionally rare and poorly described, potentially leading to reduced clinical suspicion and delayed diagnosis in long-term survivors.case presentation: we report the case of a 42-year-old woman with a history of living-donor kidney transplantation at age 22 for end-stage renal disease secondary to alport syndrome. she presented with progressive neurological decline, including persistent headache, delirium, and generalized seizures, rapidly progressing to a glasgow coma scale (gcs) score of 4.brain imaging revealed multiple intracranial lesions suggestive of malignancy. however, stereotactic biopsy demonstrated necrotizing abscesses, and polymerase chain reaction (pcr) confirmed t. gondii infection. she received standard therapy with sulfadiazine, pyrimethamine, and folinic acid. her course was complicated by cytomegalovirus (cmv) viremia and probable invasive aspergillosis, requiring combined antimicrobial therapy. despite intensive multidisciplinary care, she developed severe cytopenia and multiorgan failure, ultimately resulting in death.discussion: cerebral toxoplasmosis, although typically an early post-transplant complication, may rarely present decades after transplantation in patients with persistent immunosuppression and additional infectious stressors. diagnosis is challenging due to nonspecific neurological features and radiological overlap with other intracranial diseases. concurrent opportunistic infections further complicate management and may increase treatment-related toxicity and mortality. this case highlights the need for lifelong clinical vigilance, individualized risk assessment, and sustained preventive strategies in transplant recipients.