Cytomegalovirus retinitis in HIV-negative patients: a practical management approach

Predictors for Recurrence of Cytomegalovirus Retinitis in HIV-Negative Patients

PURPOSE

To investigate the incidence of and predictive factors for recurrent cytomegalovirus retinitis (CMVR) in human immunodeficiency virus (HIV)-negative patients.

METHODS

A retrospective review of HIV-negative patients who were newly diagnosed with CMVR between January 2005 and February 2019.

RESULTS

Of 28 patients (44 eyes), 35.9% of eyes had a recurrence of CMVR after discontinuation of anti-CMV therapy. The incidence of CMVR recurrence was 17 per 100 eye-years. The factors significantly associated with CMVR recurrence were eyes with retinitis area of more than 25% (P = .013), absence of vitreous haze (P = .003), neutropenia at presentation (P = .001), and absence of systemic immunosuppression therapy prior to presentation (P = .002).

CONCLUSION

Eyes with a large area of retinitis, absence of vitreous haze, and neutropenia at presentation are predictive of CMVR recurrence while receiving systemic immunosuppression prior to CMVR presentation has a lower risk of CMVR recurrence.

NEOVASCULAR COMPLICATIONS FROM CYTOMEGALOVIRUS NECROTIZING RETINOPATHY IN PATIENTS AFTER HAPLOIDENTICAL HEMATOPOIETIC STEM CELL TRANSPLANTATION

PURPOSE

To report the incidence and clinical features of neovascular complications from cytomegalovirus (CMV) necrotizing retinopathy in patients after haploidentical hematopoietic stem cell transplantation.

METHODS

Thirty-nine patients (58 eyes) of CMV necrotizing retinopathy after haploidentical hematopoietic stem cell transplantation in our institute between January 2018 and June 2020 were retrospectively reviewed, and cases that developed neovascular complications during follow-up were identified and described.

RESULTS

Two (2 eyes) cases that developed neovascular glaucoma from CMV necrotizing retinopathy were identified. Both of them manifested as granular peripheral retinitis, panretinal occlusive vasculitis, and some degree of intraocular inflammation, which were consistent with chronic retinal necrosis. Insidious progression of isolated immune-mediated occlusive vasculitis that could only be observed on fundus fluorescein angiography without active retinitis or intraocular inflammation was recognized to be the cause in one of two cases.

CONCLUSION

Neovascular glaucoma developed in 5.1%/cases and 3.4%/eyes complicated by CMV chronic retinal necrosis and vasculitis in patients after haploidentical hematopoietic stem cell transplantation, which warrants the needs for long-term follow-up. Immune-mediated CMV vasculitis could be an isolated manifestation in patients with a minimal immune deviation and may only be found on fundus fluorescein angiography, which emphasizes the importance of fundus fluorescein angiography on a regular basis during follow-up.

Patterns of cytomegalovirus retinitis at a tertiary referral center in Turkey

PURPOSE

To analyze predisposing conditions in Turkish patients with CMV retinitis and to compare HIV-positive and HIV-negative patients.

METHODS

We reviewed medical charts and ocular images of 41 patients with CMV retinitis diagnosed between 1996 and 2019.

RESULTS

Eleven patients (27%) had HIV infection and 30 were immunocompromised from diverse causes. Initial visual acuity, type, zone, and extent of CMV retinitis, and response to anti-CMV treatment were not significantly different between the two groups. Vitreous haze and panretinal occlusive vasculopathy were the presenting features only in non-HIV patients, seen in 34% and 16% of eyes, respectively. Although not statistically significant, recurrent CMV retinitis was more common in non-HIV patients (17.4% vs. 4.3%/eye-year) and immune recovery uveitis was more common in HIV patients (43% vs. 26%/eye-year). Visual outcomes were similar. Final visual acuity of 1 logMAR or worse was significantly associated with the recurrence of CMV retinitis (odds ratio 9.67; p = 0.01) and also with the occurrence of immune recovery uveitis (odds ratio 4.31; p = 0.058).

CONCLUSIONS

Diverse immunocompromising conditions are more commonly associated with CMV retinitis than HIV infection in Turkish patients. Intraocular inflammation was more commonly associated with active retinitis in non-HIV patients and immune recovery uveitis was more common in HIV patients.

Development of cytomegalovirus retinitis after negative conversion of cytomegalovirus antigenemia due to systemic antiviral therapy

PURPOSE

Cytomegalovirus (CMV) antigenemia assays have been widely used as adjunct tests to diagnose tissue invasive CMV diseases, including cytomegalovirus retinitis (CMVR). In this study, we examined CMVR cases to assess the presence of CMV in sera and aqueous humor and antiviral therapy received prior to the onset of CMVR.

METHODS

A total of 37 eyes from 26 different cases of CMVR in patients who visited Hokkaido University Hospital between 2007 and 2015 were enrolled. The diagnosis of CMVR was established based on characteristic ophthalmoscopic findings and the presence of local and/or systemic CMV infection. Among the 26 cases, 3 cases (12%) were HIV-positive, while the other 23 cases (88%) were HIV-negative. The records of clinical and laboratory results were reviewed from clinical charts retrospectively.

RESULTS

CMV antigenemia was positive at the onset of CMVR in 14 cases (53.8%) and negative in the other 12 cases. In 9 cases among the antigenemia-negative cases (75.0%), the antigenemia had been previously positive and had turned negative before the onset of CMVR. In 12 of the 14 antigenemia-positive cases (85.7%) and in 8 of the 9 antigenemia-negative cases (88.9%) that were previously positive, systemic antiviral therapies had never been used or had been used before but had been discontinued prior to the onset of CMVR.

CONCLUSION

Even if viremia turns negative, the risk of developing CMVR exists for more than several weeks after the completion of systemic therapy.

Initial intravitreal injection of high-dose ganciclovir for cytomegalovirus retinitis in HIV-negative patients

BACKGROUND

The purpose of this study is to examine the clinical outcomes achieved by using initial high-dose intravitreal ganciclovir injections to treat cytomegalovirus retinitis in patients without human immunodeficiency virus (HIV) infection.

METHODS

Twenty-four eyes (24 patients) with cytomegalovirus retinitis received multiple intravitreal injections of ganciclovir in weekly intervals. A higher dose (6 mg) of ganciclovir was applied at the first intravitreal injection, and a lower dose was used for maintenance. Anterior aqueous humour was obtained before each injection. The best-corrected visual acuity and cytomegalovirus loads in the anterior aqueous humour were measured.

RESULTS

The mean cytomegalovirus DNA load in aqueous humour decreased significantly from (2.59 ± 2.28) × 10⁵ copies/mL at baseline to (1 ± 1.76) × 10⁴ copies/mL one month later. The aqueous cytomegalovirus DNA load was negative in 17 eyes (70.8%) one month later. No obvious improvement of best-corrected visual acuity was found during the treatment. A positive correlation was proven between initial cytomegalovirus DNA titers in aqueous humour and the total number of intravitreal injections of ganciclovir, as well as between the baseline and final best-corrected visual acuities. No severe complications developed.

CONCLUSIONS

An initial high dose of ganciclovir (6 mg) and continuous intravitreal injections of ganciclovir could significantly decrease the cytomegalovirus load in HIV-negative patients with cytomegalovirus retinitis.

TRIAL REGISTRATION

http://clinicaltrials.gov, NCT03598452, retrospectively registered on 24 July 2018.

Cytomegalovirus retinitis in HIV-negative patients - associated conditions, clinical presentation, diagnostic methods and treatment strategy

In recent years, numerous reports have tied cytomegalovirus retinitis (CMVR) with multiple systemic conditions in the absence of human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS). These range from reports in apparently healthy individuals, through conditions rendering limited immune dysfunction such as advanced age and diabetes mellitus, and finally severe immune dysfunction such as in haematological and rheumatological conditions. Reports are also emerging, suggesting that induced local ocular immunosuppression is a risk factor for CMVR. We herein present a comprehensive collection of the accumulated findings regarding CMVR in non-HIV patients. We summarize the spectrum of underlying morbidity that has been associated with CMVR, its clinical presentation, diagnostic methods and treatment choice in the attempt to suggest the optimal treatment strategy in this complicated and diverse patient population which is still currently lacking a consensus.

Cytomegalovirus Retinitis in Primary Immune Deficiency Disease

INTRODUCTION

To report an unusual case of CMV retinitis in Primary Immune Deficiency Disease (PIDD).

CASE REPORT

13-year-old child with combined T and B cell deficiencies was diagnosed of bilateral zone 1 CMV retinitis. Intravitreal injections were unable to be given in a regular and timely manner under general anaesthesia due to her underlying systemic disease. The child was treated with intravenous ganciclovir for 8 weeks until eventual resolution of the retinitis. However, visual acuity deteriorated due to progressive optic nerve involvement.

CONCLUSION

Paediatric patients often do not notice subtle symptoms of CMV retinitis. Although ocular manifestations are uncommon in PIDD, recognition and high index of suspicion will allow for timely referral, diagnosis, and treatment to be instituted for better visual outcomes.

Bilateral cytomegalovirus retinitis in a healthy infant

Purpose

To report a case of bilateral cytomegalovirus (CMV) retinitis in an otherwise healthy infant.

Methods

A four-month-old, healthy, male infant was evaluated for visual inattention.

Results

This full-term infant with a normal birth weight and an uneventful gestational period was referred with symptoms of visual inattention, fever, and agitation one week prior to admission. Ocular involvements were detected in the form of bilateral pan uveitis with diffuse bilateral retinitis and vasculitis with hemorrhage in the peripheral retina and posterior pole. CMV DNA was detected in the patient's ocular sample and cerebrospinal fluid by polymerase chain reaction (PCR). He was treated with intravitreal and systemic ganciclovir. Unfortunately, the infant died because of CMV encephalitis. Therefore, bilateral CMV retinitis (CMVR), which was probably transmitted from the mother, was diagnosed in this immunocompetent infant.

Conclusions

The present case highlights the possibility of CMVR in immunocompetent infant associated with systemic CMV infection, even during the postnatal period. Therefore, a high index of clinical suspicion and prompt treatment may be life-saving in similar cases.

Good syndrome and other causes of cytomegalovirus retinitis in HIV-negative patients-case report and comprehensive review of the literature

We describe a 65-year-old Thai woman who developed cytomegalovirus retinitis (CMVR) in the setting of Good syndrome-a rare, acquired partial immune deficiency caused by thymoma. The patient subsequently developed vitritis with cystoid macular edema (CME) similar to immune recovery uveitis (IRU) despite control of the retinitis with antiviral agents. A comprehensive review of the literature through December, 2014, identified an additional 279 eyes of 208 patients with CMVR in the absence of human immunodeficiency virus (HIV) infection. Including our newly reported case, 9 of the 208 patients (4.3 %) had Good syndrome. Twenty-one of the 208 patients (10.1 %) had CMVR related to intraocular or periocular corticosteroid administration. The remaining 178 patients (85.6 %) acquired CMVR from other causes. Within the subset of patients who did not have Good syndrome or did not acquire CMVR followed by intraocular or periocular corticosteroid administration, there were many other factors contributing to a decline in immune function. The most common included age over 60 years (33.1 %), an underlying malignancy (28.7 %), a systemic autoimmune disorder requiring systemic immunosuppression (19.1 %), organ (15.2 %) or bone marrow (16.3 %) transplantation requiring systemic immunosuppression, and diabetes mellitus (6.1 %). Only 4.5 % of the patients had no identifiable contributor to a decline in immune function. While the clinical features of CMVR are generally similar in HIV-negative and HIV-positive patients, the rates of moderate to severe intraocular inflammation and of occlusive retinal vasculitis appear to be higher in HIV-negative patients.

An unusual case of congenital cytomegalovirus infection-related retinopathy

Background

Cytomegalovirus (CMV) is the most common congenital infection, and chorioretinitis is the most common ophthalmic manifestation of congenital CMV infection. We experienced a unique case of CMV retinopathy showing unusual retinal vessels.

Case presentation

An infant boy weighing 1860 g was born at 36 weeks. He was diagnosed with severe symptomatic congenital CMV infection, which was confirmed by positive CMV-DNA in urine and whole blood, and he was referred to our ophthalmology department on his first day of life. Ophthalmoscopic examination and fluorescein angiography revealed no chorioretinitis but major retinal vascular occlusions and arterio-venous anastomosis associated with CMV detection in the aqueous humor. These findings regressed within a week after treatment with systemic gancyclovir administration.

Conclusions

To our knowledge, there are no reports of these ocular issues associated with congenital CMV infection. These findings may be useful for the early and rapid diagnosis of congenital CMV infection.