A 34-year-old Hispanic woman who was human immunodeficiency virus (HIV)-positive presented with gradual loss of vision over a period of two to three months. Her last CD4 count was 384/mm3. Funduscopic examination of the eyes showed yellowish-white patches and hemorrhages.
What’s Your Diagnosis?
Toxoplasmic chorioretinitis
Herpes simplex retinitis
Cytomegalovirus retinitis
Cotton wool spots of HIV
Answer:
Cytomegalovirus retinitis
A variety of ocular diseases, as well as some cerebral maladies that have an influence on ocular functions, can occur in patients with HIV infection and full-blown acquired immunodeficiency syndrome (AIDS). Cytomegalovirus retinitis has become the most common infection of the eye in AIDS patients. It is characterized by progressively enlarging yellowish-to-white patches of retinal opacification, which are accompanied by retinal hemorrhages. They are usually located near the major retinal vascular arcades. Patients are often asymptomatic until there is involvement of the fovea or optic nerve or retinal detachment occurs. Ganciclovir (Cytovene®) has been found useful in the management of cytomegalovirus retinitis. Unfortunately, progression of the disease is common, even when maintenance therapy is used. Bone marrow suppression is an untoward effect, especially when zidovudine (Retrovir®) therapy is being undertaken. Intravitreal ganciclovir has been used as an alternative. Systemic foscarnet sodium (Foscavir®) is as effective as systemic ganciclovir against cytomegalovirus retinitis, but exhibits considerable toxicity, including renal dysfunction, hypomagnesemia, hypokalemia, hypocalcemia. seizures, fever, and rash, each of which is seen in more than 5% of patients.
Cotton wool spots are also common in HIV-infected patients, arising from either direct retinal infection by HIV or the deposition of circulating immune complexes. Cotton wool spots are benign and remit spontaneously. They appear as small, indistinct white spots, without exudation or hemorrhage, and are more commonly found in patients with AIDS than those with asymptomatic HIV infections, but the importance of this finding is not known. Toxo-plasmic chorioretinitis is usually unilateral and can cause blurring, central defects, and scotomas. Progression may result in glaucoma and blindness, but this is rare. White or dark pigmented scars may occur with healing. The inflammatory process persists for weeks to months us focally necrotic retinal lesions with blurred margins. Herpetic chorioretinitis also occurs in HIV-infected patients, usually us a manifestation of disseminated infection. Acute necrotizing retinitis is a rare but serious complication of herpes simplex virus infection.
Contributor Information
Muhammad W. Saif, Primary Care Internal Medicine, University of Connecticut School of Medicine.
Ellen Nestler, Internal Medicine, University of Connecticutt School of Medicine.
Marion Stoj, University of Connecticut & Chief, Department of Ophthalmology, Manchester Hospital, Manchester, CT.
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