[Cytomegalovirus retinitis despite normal CD4 levels in an HIV patient. Report of a case]

We report the case of a 54-year-old HIV-seropositive man who was referred to us with unilateral uveitis. The patient had been taking triple antiretroviral therapy (three reverse transcriptase inhibitors) for one week when he presented with blurring of vision in the left eye. Two weeks later, active cytomegalovirus retinitis was suspected after fundus examination and ganciclovir was immediately administered. Even if the CD4 cell count was normal (423/microliter), the diagnosis was confirmed by the presence of CMV in the anterior chamber. This case shows that an elevated CD4 count is not incompatible with CMV retinitis, especially at the beginning of the antiretroviral therapy.

An evaluation of serum soluble CD30 levels and serum CD26 (DPPIV) enzyme activity as markers of type 2 and type 1 cytokines in HIV patients receiving highly active antiretroviral therapy

This study evaluates serum CD26 (dipeptidyl peptidase IV, DPPIV) enzyme activity and serum levels of soluble CD30 as markers of T1 and T2 cytokine environments in HIV patients who achieved immune reconstitution after highly active antiretroviral therapy (HAART). Patients who had experienced inflammatory disease associated with pre-existent opportunistic infections after HAART (immune restoration diseases, IRD) were considered separately. Serum sCD30 levels and CD26 (DPPIV) enzyme activity were compared with IFN-gamma production by PBMC cultured with cytomegalovirus (CMV) antigen in controls and patient groups. High sCD30 levels were associated with low IFN-gamma production after antigenic stimulation in control subjects and, to a lesser extent, in immune reconstituted HIV patients. There was no association between serum CD26 (DPPIV) enzyme activity and IFN-gamma production or sCD30 levels. Serum sCD30 levels and CD26 (DPPIV) enzyme activity were significantly increased in immune reconstituted patients with high HIV viral loads. Patients who had experienced CMV retinitis as an IRD had significantly higher sCD30 levels than all other patient groups. Hence, high sCD30 levels may be a marker of a T2 cytokine environment in HIV patients with immune reconstitution and are associated with higher HIV viral loads and a history of CMV associated IRD.

Up-regulation of Fas ligand expression by human cytomegalovirus immediate-early gene product 2: a novel mechanism in cytomegalovirus-induced apoptosis in human retina

Human CMV (HCMV) is an important pathogen that causes widespread diseases in immunocompromised individuals. Among the opportunistic HCMV infections, HCMV retinitis is most common in transplant recipients and AIDS patients. It often leads to blindness if left untreated. The question as to how HCMV infection causes retinal pathogenesis remains unresolved. Here, we report that viral immediate-early gene product 2 (IE2), but not IE1, up-regulates the Fas ligand (FasL) expression in HCMV-infected human retinal pigment epithelium cells. Increased secretion of FasL from virally infected cells into cultured medium was observed upon HCMV infection. The capability of such cell-free medium to induce apoptosis of Fas (CD95)-expressing Jurkat cells further implies that Fas-FasL interaction might mediate cell death in the lesion of HCMV retinitis. To support this idea, we observed augmented soluble FasL levels in vitreous from AIDS patients with HCMV retinitis as compared with that from AIDS patients without HCMV infection. In addition, by in situ hybridization and immunohistochemistry, we detected enhanced signals of FasL, the existence of viral IE Ags and apoptotic cells at the same sites in the lesion of HCMV-infected retina. These results strongly suggest that IE2 induction of FasL expression in human retina might be an important event that takes place in the early stage of infection and finally leads to visual loss in individuals affiliated with HCMV retinitis.

[Clinical course of cytomegalovirus retinitis with the different antiretroviral therapies in our hospital]

PURPOSE

A study of protease inhibitors on CMV retinitis in HIV infected hospital patients.

METHOD

A retrospective study was performed in 485 diagnosed of AIDS, between January, 1990 and December 1998. Among those, 81 patients who were diagnosed of CMV retinitis, the following was studied: anti-retroviral treatment, anti CMV treatment, survival time and CD4 lymphocyte count.

RESULTS

Treatment with protease inhibitors in HIV patients showed an increase in life expectancy, reduced the incidence of CMV retinitis and a reduction in CMV retinitis prevention treatment was observed.

CONCLUSIONS

Treatment with protease inhibitors has reduced the rate of CMV retinitis in HIV patients.

Immune recovery vitritis and uveitis in AIDS: clinical predictors, sequelae, and treatment outcomes

PURPOSE

To determine 1) clinical predictors of an inflammatory syndrome associated with cytomegalovirus (CMV) retinitis (immune recovery vitritis or uveitis [IRV or IRU]); 2) clinical sequelae of IRV; and 3) the effect of corticosteroid treatment on visual acuity.

METHODS

A cohort study from the AIDS Ocular Research Unit of the University of California, San Diego, and a case series from the Cleveland Clinic consisted of patients who had acquired immunodeficiency syndrome and inactive CMV retinitis who responded to highly active antiretroviral therapy (HAART) with CD4 T-lymphocyte levels >60 cells/mm3. The cohort was followed for a median of 13.5 months following increase in CD4 count. The authors studied the occurrence of IRV, defined as symptomatic (vision decrease and/or floaters) vitritis of 1+ or greater severity associated with inactive CMV retinitis. Macular edema or epiretinal membrane formation was determined by clinical examination and fluorescein angiography. Five eyes were treated with sub-Tenon corticosteroid injections.

RESULTS

In the cohort study, 19 (63%) of 30 HAART responders developed IRV (26 eyes). The clinical spectrum of inflammation included vitritis, papillitis, macular edema, and epiretinal membranes. Eyes with CMV surface area >30% of the retina were at the highest risk (relative risk = 4.5) of developing IRV (P = 0.03). During follow-up, inflammation persisted without treatment for a median of 20 weeks and 14 patients (16 eyes) developed macular changes. Treatment resulted in vision improvement without reactivation of retinitis. Histology and immunohistochemistry of associated epiretinal membranes showed evidence of chronic inflammation with a predominant T-lymphocyte cell population. In the case series, 3 (38%) of 8 HAART responders developed IRV (4 eyes). All four eyes were treated and resulted in visual acuity improvement of one line.

CONCLUSIONS

Symptomatic IRV or IRU develops in a significant number of patients with CMV retinitis following successful HAART. Eyes with CMV surface area >30% of the retina are at the greatest risk. Eyes with IRV respond favorably to antiinflammatory therapy without reactivation of retinitis. Immune recovery vitritis may be the result of an immunologic reaction to latent CMV antigens in the eye in which T-lymphocytes play a role.

Frosted branch angiitis in a child with HIV infection

PURPOSE

In adults with human immunodeficiency virus (HIV) infection, frosted branch angiitis is commonly associated with cytomegalovirus retinitis and responds to anti-cytomegalovirus therapy. We describe the first pediatric case of HIV-associated frosted branch angiitis.

METHODS

Case report.

RESULTS

A 7-year-old HIV-infected male with frosted branch angiitis was refractory to induction doses of intravenous ganciclovir and foscarnet over a 2-month period. Although cytomegalovirus antigenemia resolved, the angiitis only improved after subsequent treatment with systemic corticosteroids.

CONCLUSION

Frosted branch angiitis in this patient was not attributed to cytomegalovirus. The pathogenesis of HIV-associated frosted branch angiitis may differ between children and adults.

Efficacy of the ganciclovir implant in the setting of silicone oil vitreous substitute

OBJECTIVE

To evaluate the efficacy of the ganciclovir implant in the setting of silicone oil vitreous substitute.

MATERIALS AND METHODS

The authors retrospectively reviewed the charts of 19 patients with cytomegalovirus retinitis who had both a ganciclovir implant and silicone oil vitreous substitute. None of the patients was receiving highly active antiretroviral therapy during the study period. Kaplan-Meier analysis was used to evaluate time to progression in eyes with the ganciclovir implant and silicone oil.

RESULTS

In all eyes, the ganciclovir device implantation preceded or coincided with silicone injection. Kaplan-Meier analysis revealed that time to 25% failure from the date of the presence of both the implant and oil was 129 days. Time to 25% failure from the date of ganciclovir device implantation was 179 days.

CONCLUSIONS

These results compare favorably with conventional treatment. The ganciclovir implant can be a useful treatment modality in eyes with silicone oil.

Retinal detachment risk in cytomegalovirus retinitis related to the acquired immunodeficiency syndrome

OBJECTIVES

To compare the incidence of retinal detachment in patients treated with the ganciclovir implant compared with those treated using systemic therapy only, among 511 patients with the acquired immunodeficiency syndrome (AIDS) and cytomegalovirus (CMV) retinitis and to describe the influence of highly active antiretroviral therapy (HAART) on retinal detachment incidence.

PATIENTS AND METHODS

All patients with AIDS and CMV retinitis at 1 center were followed up prospectively from CMV retinitis diagnosis for incidence of retinal detachment. Patient- and eye-specific data regarding demographic and clinical characteristics were collected at the time of CMV retinitis diagnosis. Use of anti-CMV and antiretroviral treatments and the development of an immunologic response to HAART during follow-up were recorded.

RESULTS

No significant difference in the rate of retinal detachment was found between eyes treated with systemic therapy only and those treated with ganciclovir implants, whether used as primary therapy or subsequent to using systemic anti-CMV therapy. The use of HAART was associated with a 60% reduction in retinal detachment rate (P<.001), with the greatest benefit observed among patients who developed an immunologic response to HAART.

CONCLUSIONS

Our results suggest that there is no substantial excess risk of retinal detachment when patients with AIDS and CMV retinitis are treated with ganciclovir implants as opposed to systemic anti-CMV therapy only. However, the use of HAART in these patients appears to reduce the risk of retinal detachment substantially.

First operation anatomic success and other predictors of postoperative vision after complex retinal detachment repair with vitrectomy and silicone oil tamponade

PURPOSE

To evaluate the role of first operation anatomic success compared with success after reoperation and preoperative characteristics in achieving ambulatory vision (>/=4/200) and good vision (>/=20/100) after repair of complex retinal detachment with vitrectomy and silicone oil tamponade.

METHODS

A prospective, observational, multicenter study of patients who underwent vitrectomy with silicone oil for retinal detachments associated with cytomegalovirus necrotizing retinitis or a non-cytomegalovirus necrotizing retinitis etiology, including proliferative diabetic retinopathy, giant retinal tear, proliferative vitreoretinopathy, and ocular trauma.

RESULTS

A higher rate of ambulatory vision was achieved in the first operation anatomic success cases, compared with the reoperation cases, for eyes with cytomegalovirus necrotizing retinitis (72% vs 50%, P < 0.01) and eyes without cytomegalovirus necrotizing retinitis (51% vs 38%, P = 0.04). For eyes with cytomegalovirus necrotizing retinitis, preoperative ambulatory vision (RR = 2.3, P < 0.0001) and reoperation (RR = 0.4, P = 0.05) were independent predictors of postoperative ambulatory vision. For eyes without cytomegalovirus necrotizing retinitis, preoperative ambulatory vision (RR = 4.0, p < 0.0001) and retinal detachment etiology (P = 0.02) were prognostic factors. Compared to eyes with trauma, eyes with giant retinal tear, proliferative vitreoretinopathy and proliferative diabetic retinopathy were 2.8 (P < 0.003), 2.2 (P = 0.01) and 1.6 (P = 0.17) times as likely to achieve postoperative ambulatory vision, respectively. Within the giant retinal tear group, a higher rate of ambulatory vision was achieved in the first operation anatomic success cases compared with the reoperation cases (66% vs 31%, P = 0.03). Although not statistically significant, similar outcomes occurred in the proliferative diabetic retinopathy (48% vs 25%) and proliferative vitreoretinopathy groups (54% vs 45%). Similar prognostic relationships were found for good visual acuity outcomes.

CONCLUSIONS

First operation anatomic success, preoperative visual acuity, and giant retinal tear or proliferative vitreoretinopathy as the retinal detachment etiology are important factors that predict visual outcome.

A deletion mutation in region V of the cytomegalovirus DNA polymerase sequence confers multidrug resistance

A patient with AIDS and cytomegalovirus (CMV) retinitis received ganciclovir and foscarnet for 20 and 5 months, respectively, with evidence of periodic disease progression. After this therapy, a CMV isolate from the patient was resistant to ganciclovir, foscarnet, and cidofovir. Sequence analysis showed a known ganciclovir resistance mutation in the viral UL97 phosphotransferase (L595F) and a new mutation in conserved region V of the DNA polymerase gene (pol) sequence (codons 981-982 deleted). The pol mutation was transferred to a laboratory CMV strain (Towne) by homologous recombination and selection with either ganciclovir or foscarnet. Recombinant viruses containing this deletion showed a 6-8-fold increased ganciclovir resistance and a 3-5-fold increased resistance to both foscarnet and cidofovir, compared with the wild-type CMV. A single mutation in region V of CMV pol can, therefore, confer multiple drug resistance in a clinical isolate.

Ocular involvement in systemic toxoplasmosis: a case report

We report a case of adult acquired toxoplasmosis with ocular involvement in a 29 year old immunocompetent female. The patient had an illness for approximately 3 weeks characterized by lymphadenopathy, malaise and rash that was diagnosed serologically as toxoplasmosis. At the time of diagnosis, she developed signs and symptoms of retino choroiditis. She had serologic evidence of cytomegalovirus (CMV) infection as well as the recent toxoplasma infection. The patient was treated with pyrimethanime, sulfadiazone and folic acid for 6 weeks, plus prednisone for 4 weeks, during which the illness resolved. Toxoplasmosis is a protozoan infection that occurs worldwide, and is the most common cause of infectious retinochoroiditis in otherwise healthy individuals. Most cases of Toxoplasma infection in the immunocompetent adult are asymptomatic. The most common clinical presentation is localized lymphadenopathy. Ocular signs, which are common in congenitally acquired toxoplasmosis, may rarely be the only manifestation of acquired systemic toxoplasmosis. It has been suggested that concomitant infection with a DNA virus, such as CMV or herpes simplex virus, may facilitate the penetration of protozoa into cells, or that antigenic stimulation from toxoplasma antigens may activate endogenous latent CMV in the recipient. The occurrence of ocular involvement during toxoplasmosis and its association with a DNA virus is reviewed.

Postmortem histological survey of the ocular lesions in a British population of AIDS patients

AIMS

To study ocular pathology and systemic correlations in a series of 73 postmortem eyes from British patients who died from AIDS before the introduction of a HAART regimen.

METHODS

The eyes were studied with conventional histology, special histochemical stainings, and immunohistochemistry.

RESULTS

72.6% of the cases showed chronic uveal inflammation, caused by opportunistic agents in 37.7% of them (cytomegalovirus (CMV) in 30.1%, C neoformans in 5.6%, and Gram positive bacteria in 1.8%). Cytoid bodies were noted in 10/73 eyes, three linked to CMV retinitis. Six retinal haemorrhages, four of which were secondary to CMV, were found. 14 specimens (19. 1%) showed foci of calcification, and a further 11 (15%) calcium oxalate deposits. In no cases were the calcific deposits suspected clinically. Six eyes (8.2%) did not show any abnormality.

CONCLUSIONS

CMV retinitis is the most common (28.7%, 21/73) ocular infection in this series and may occur either during or in the absence of systemic dissemination. Conversely, ocular cryptococcosis appears to be an epiphenomenon of systemic and CNS disease. No other opportunistic ocular infections were present in this series. Interesting findings were the presence of intraocular precipitates of calcium oxalate and calcium phosphate or carbonate in a significant number of cases (15% and 19%, respectively), and the high prevalence of idiopathic uveal inflammation (43.8%).

Cystoid macular edema in a patient with acquired immunodeficiency syndrome and past ocular history of cytomegalovirus retinitis after initiation of protease inhibitors

PURPOSE

To describe a patient with acquired immunodeficiency syndrome (AIDS) who presented with cystoid macular edema (CME) which was not associated with active cytomegalovirus (CMV) retinitis or AIDS-related microvasculopathy.

METHOD

A 32-year-old man with AIDS and a past ocular history of inactive CMV retinitis was placed on protease inhibitors when his CD4+ T lymphocyte counts dropped to 8 cells/mm3. Three months later, after his CD4+ T lymphocyte counts had increased to 196 cells/mm3 he complained of micropsia and metamorphopsia in his right eye of 1 week duration. The patient had a complete ocular examination including fluorescein angiography (FA).

RESULTS

Visual acuity (VA) was 7/10 OD. Fundus examination revealed CME and inactive CMV retinitis, and FA demonstrated CME and a hot disc. Two transseptal injections of corticosteroids were administered 2 weeks apart in the right eye as treatment of the CME. The patient reported gradual visual improvement and 6 weeks later, his VA was 10/10(-2). CME had resolved clinically and angiographically.

CONCLUSIONS

CME in our case is associated with inactive CMV retinitis and gradually increasing number of CD4+ T lymphocytes after initiation of treatment with protease inhibitors. It may be amenable to regional administration of corticosteroids without reactivation of retinitis.

Immune reconstitution syndromes in human immuno-deficiency virus infection following effective antiretroviral therapy

Effective antiretroviral therapy leads to rapid decrease in plasma HIV-1 RNA, frequently followed by an increase in CD4 T-helper cell counts. The improvement of immune function during highly active antiretroviral therapy has important impact on natural history of AIDS-related opportunistic disorders. Here we describe cases of unusual clinical inflammatory syndromes in CMV retinitis, hepatitis C, and atypical mycobacteriosis in HIV-1 infected patients associated with the initiation of antiretroviral therapy. Pathogenetic implications and therapeutic management of these new immunopathologic syndromes are discussed.

CMV complications in common variable immunodeficiency

A patient suffering from common variable immunodeficiency is described, who developed a myelitis under treatment with glucocorticosteroids. Later on, autoimmune complications had to be treated with azathioprine. An exacerbation of the myelitis, retinitis, encephalitis and colitis was observed and a cytomegalovirus infection diagnosed. This infection does not represent a typical complication of common variable immunodeficiency. A functional NK cell defect was detected that may contribute to susceptibility for cytomegalovirus infection in addition to immunosuppressive therapy.

Screening for CMV retinitis using chromatic discrimination thresholds and achromatic contrast sensitivity

BACKGROUND

Many patients with cytomegalovirus retinitis (CMVR) are unaware of visual disturbance so screening is advocated for patients with HIV and low CD4 counts. Many tests of retinal function have been recommended but few are effective at detecting CMVR. We assess the potential of chromatic discrimination thresholds and achromatic contrast sensitivity as screening tests for patients with CMVR.

METHOD

11 HIV+ patients with CMVR, 16 age matched HIV+ patients, and 29 age matched controls were recruited. Visual acuity, chromatic discrimination thresholds, and achromatic contrast sensitivity were measured. Fundal examination was performed by slit lamp biomicroscopy for HIV+ patients. Those with CMVR were photographed and the CMVR graded from the photographs.

RESULTS

Loss of chromatic discrimination was found in patients with CMVR (tritan p<0.0005, red/green p<0.05). The same group had deterioration in achromatic contrast sensitivity at 2.2, 3.4, and 10 cpd (p<0.05). There was correlation between the zone of CMVR with chromatic gratings (tritan r=0.83, p<0.005). No statistically significant difference was found between the HIV+ patients and the controls for all tests (p>0.1).

CONCLUSIONS

HIV+ patients with CMVR have a loss of chromatic discrimination and achromatic contrast sensitivity and this may be used to screen HIV+ patients for CMVR.

Cystoid macular edema in patients with acquired immune deficiency syndrome and cytomegalovirus retinitis

PURPOSE

To describe cystoid macular edema in patients with acquired immune deficiency syndrome treated with highly active anti-retroviral therapy, who had or had not already had cytomegalovirus retinitis.

MATERIALS AND METHODS

Case report.

RESULTS

Five acquired immune deficiency syndrome (AIDS) patients, successfully treated with highly active anti-retroviral therapy, were studied. Two had inactive cytomegalovirus retinitis and cystoid macular edema in both eyes. Two had inactive cytomegalovirus retinitis in both eyes and cystoid macular edema in one eye. One patient had inactive cytomegalovirus retinitis in one eye and cystoid macular edema in both eyes.

CONCLUSIONS

Cystoid macular edema may occur in AIDS patients treated with highly active anti-retroviral therapy even in cases without previous retinitis.

Long-term posterior and anterior segment complications of immune recovery uveitis associated with cytomegalovirus retinitis

PURPOSE

To identify and describe long-term posterior and anterior segment complications of immune recovery uveitis in patients with inactive cytomegalovirus retinitis who are undergoing highly active antiretroviral therapy-mediated recovery of immune function.

METHODS

A prospective cohort study at a university medical center. Twenty-nine eyes of 21 patients with immune recovery uveitis and inactive cytomegalovirus retinitis were followed for 14.5 to 116 weeks (median, 43 weeks) after diagnosis of immune recovery uveitis.

RESULTS

Nine eyes of nine patients developed visually important complications involving the posterior segment, anterior segment, or a combination of both. Posterior segment complications included severe proliferative vitreoretinopathy in three eyes and spontaneous vitreous hemorrhage from avulsion of a blood vessel secondary to contraction of the inflamed vitreous in one eye. Proliferative vitreoretinopathy recurred in all cases after surgery, severely compromising the visual outcome. Anterior segment complications included posterior subcapsular cataracts with vision decrease in five eyes and persistent anterior chamber inflammation after cataract extraction, resulting in posterior synechiae and large visually important lens deposits in three eyes.

CONCLUSION

Persistent inflammation in immune recovery uveitis may lead to vision-threatening complications, such as proliferative vitreoretinopathy, posterior subcapsular cataracts, and severe postoperative inflammation. Immune recovery uveitis is a chronic inflammatory syndrome that may result in complications months to years after the onset of inflammation.