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CASE REPORT |
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Year : 2014 | Volume
: 7
| Issue : 6 | Page : 822-824 |
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Cytomegalovirus retinitis: A case report
Rajendra P Gupta
Department of Ophthalmology, PDVVPF's Medical College and Hospital, Ahmednagar, Maharashtra, India
Date of Web Publication | 18-Nov-2014 |
Correspondence Address: Rajendra P Gupta Department of Ophthalmology, PDVVPF's Medical College and Hospital, Opposite Government Milk Dairy, Vadgaon Gupta, Post: MIDC, Ahmednagar - 414 111, Maharashtra India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/0975-2870.144901
A 35 years old male patient came with the complaints of sudden diminution of vision in the right eye with floaters and flashes of light. He was found to be HIV positive 8 years back. He was diagnosed as a case of CMV retinitis and intravitreal ganciclovir was administered along with systemic treatment after which choroiditis in the right eye resolved. Keywords: AIDS, ART(Antiretroviral therapy), CMV retinitis (CMVR), HIV, RAPD (Relative afferent pupillary defect)
Keymessages: CMVR is the most common ocular manifestation of AIDS in India. Typically the disease occurs in AIDS patients with CD4+ counts <50 cells/mm 3 . [1]
How to cite this article: Gupta RP. Cytomegalovirus retinitis: A case report. Med J DY Patil Univ 2014;7:822-4 |
Introduction | | |
CMVR has been the most common opportunistic ocular infection and the leading cause of visual loss in AIDS patients representing about 90% cases of all infectious retinitis in this patient population. [2] Despite its well characterized clinical course and multitude of high quality studies for the treatment of this common disease, new forms of CMV infection being described as immune recovery secondary to combination drug therapy are becoming more common. CMVR is still a diagnostic and therapeutic challenge in many patients.
Case Report | | |
A 35 years old male patient came with the chief complaints of sudden diminution of vision in the right eye 6 months back which progressed over 1 week associated with floaters and flashes of light with generalized weakness, anorexia and disorientation. Patient was found to be HIV positive 8 years back but he has not taken any treatment. Two months prior to reporting to this hospital his symptoms worsened and he visited antiretroviral centre Pimpri where he was started on oral antiretroviral therapy (Drugs prescribed were: Stavudine 30 mg, Lamivudine 150mg, Nevirapine 400mg once a day) one week back. On examination DVR was hand movements with inaccurate projection of rays, while DVL was 6/6. Right eye pupil showed RAPD and rest anterior segment was within normal limits. Right eye fundus revealed hazy media due to vitreous haze; optic disc was pale with pigment clumps; blood vessels showed sclerosis and sheathing of vessels (signs of periphlebitis). Macula showed mottled appearance (pigmented and depigmented patches) and foveal reflex was absent. General fundus revealed features of active retinitis in the form of yellow chorioretinal patches, retinal hemorrhages and soft exudates [Figure 1]. Anterior segment and fundus of left eye were found normal.
Fundus fluorescein angiography (FFA) of right eye revealed hyperfluorescence correlating with the active chorioretinitis patches. There were also alternating areas of stippled hyperfluorescence and hypofluorescence at places suggestive of retinal pigment epithelium atrophy. FFA of left eye was normal.
Routine blood investigations showed reduced hemoglobin (8 gm%), raised ESR (38 mm at the end of 1 hr) and raised neutrophils (85%). LFT and RFT were within normal limits. Serum globulin was raised compared to serum albumin (serum globulin 3.9gm% and serum albumin 3.3gm%.
A provisional diagnosis of CMV retinitis was made based on the clinical findings while HIV retinopathy, toxoplasmic retinochoroiditis, CMV optic neuritis, Pneumocystis carinii choroidopathy, herpes zoster retinopathy and progressive outer retinal necrosis were considered in the differential diagnosis.
Treatment given was: Oral Ganciclovir 500mg 6 times a day Intravenous Ganciclovir 5mg/kg BD was administered from day 2 to 13. We have given intravitreal ganciclovir on day 2 (2 mg/0.1cc), day 5 (1mg/0.1cc) and day 8 (1mg/0.1cc) in the right eye as shown in [Figure 2]
On follow up day 9, there were features of acute anterior uveitis in right eye and IOP(AT) was 10 mm in right eye and 12mm in left eye. Posterior segment was not visible due to marked vitreous haze in right eye. Patient was diagnosed to have immune recovery uveitis in the right eye and was treated with topical steroids and atropine ointment.
On follow up day 16, uveitis had reduced, pupil was fixed and dilated due to atropine and IOP was normal. On fundus examination, vitreous haze reduced, optic disc was pale, macula appeared mottled and foveal reflex was absent. Chorioretinitis patch has resolved considerably and reduced in size remarkably[Figure 3]. Patient was discharged with advice to continue oral ganciclovir 3g/day.
Discussion | | |
Cytomegalovirus retinitis has 3 clinical forms: Classical form, pizza pie retinopathy, confluent retinal necrosis and sharp edge of lesions with hemorrhages. Little is known about the localization of latent CMV. [3] It is an ubiquitous herpes virus that usually results in asymptomatic infection but can cause a variety of diseases ranging from congenital, perinatal, acquired disseminated CMV infection to severe chronic infection in immunocompromised persons. [4],[5],[6]
In our case the CD4 count was 26 cells/mm 3 at the time patient presented to us. Along with old healed lesions, he had advanced active chorioretinitis lesions, which got resolved considerably by intravitreal and systemic ganciclovir therapy. As optic atrophy had already set in the vision did not improve even though the chorioretinitis patches had resolved. During the course of treatment patient had immune recovery uveitis and it was treated successfully.
References | | |
1. | Pertel P, Hirschtick R, Phair J, Chmiel J, Poggensee L, Murphy R. Risk of developing cytomegalovirus retinitis in persons infected with the human immunodeficiency virus. J Acquir Immune Defic Syndr 1992;5:1069-74. |
2. | Jabs D A. Ocular manifestations of HIV infection. Trans Am Ophthalmol Soc 1995;93:62383. |
3. | Bruggeman CA. Cytomegalovirus. Virchows Arch B Cell Pathol Incl Mol Pathol 1993;64:325-33. [ PUBMED] |
4. | Griffiths PD, Stagno S, Pass RF, Smith RJ, Alford CA Jr. Congenital cytomegalovirus infection: Diagnostic and prognostic significance of the detection of specific immunoglobulin M antibodies in cord serum. Pediatrics 1982;69:5449. |
5. | Palestine AG,Stevens G Jr,Lane HC, Masur H, Fujikawa LS, Nussenblatt RB, et al. Treatment of cytomegalovirus retinitis with dihydroxy propoxymethyl guanine.Am J Ophthalmol 1986;101:95101. |
6. | Hanshaw JB. Cytomegalovirus infections. Pediatr Rev 1995;16:438;quiz 49. |
[Figure 1], [Figure 2], [Figure 3]
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