A 55-year old man presented with a two-day history of headache, fever and generalized weakness. He had received a cadaveric kidney transplant 5 years earlier. His medications included 5 mg of tacrolimus twice a day and 10 mg of prednisone daily. On neurologic examination, he was confused and incoherent. Cranial nerves were normal, but he had a hazy left retina. Magnetic resonance imaging of the brain with the administration of gadolinium showed multiple enhancing lesion in both cerebral hemispheres. The treatment of choice in this condition is –

**Core Concept**
The patient's presentation suggests a central nervous system (CNS) infection, likely due to an opportunistic pathogen, given his immunosuppressed state following a kidney transplant. The use of **tacrolimus** and **prednisone** indicates a compromised immune system, making him susceptible to infections such as toxoplasmosis, cryptococcosis, or nocardiosis.

**Why the Correct Answer is Right**
The clinical presentation of headache, fever, generalized weakness, confusion, and multiple enhancing lesions in both cerebral hemispheres on MRI is highly suggestive of a CNS infection. In an immunocompromised patient, particularly one with a history of organ transplantation, **toxoplasmosis** is a common cause of such symptoms. The presence of multiple enhancing lesions, especially in the context of immunosuppression, points towards toxoplasmosis, which is typically treated with **sulfadiazine** and **pyrimethamine**.

**Why Each Wrong Option is Incorrect**
**Option A:** Without knowing the specific options, we can infer that any choice not targeting toxoplasmosis or another opportunistic CNS infection would be incorrect.
**Option B:** Similarly, any option not addressing the patient's immunocompromised state and the likely cause of his CNS symptoms would be wrong.
**Option C:** And any choice that does not involve antimicrobial therapy effective against common opportunistic pathogens in immunocompromised patients would be incorrect.
**Option D:** Assuming it does not align with the standard treatment for toxoplasmosis or other likely CNS infections in this context, it would also be an incorrect choice.

**Clinical Pearl / High-Yield Fact**
In immunocompromised patients, especially those with a history of organ transplantation, toxoplasmosis is a critical consideration for CNS lesions. The treatment typically involves a combination of **sulfadiazine** and **pyrimethamine**, with **folinic acid** to prevent bone marrow suppression.

**Correct Answer:** D. Sulfadiazine and pyrimethamine.

✓ Correct Answer: A. Trimethoprim-sulfamethoxazole