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Swain J, Sharma PK, Mohanty L, Panigrahi PK. Ocular manifestations in HIV patients attending a tertiary care hospital in Eastern India and correlation of posterior segment lesions with CD4+ counts. Indian J Ophthalmol 2023; 71:3701-3706. [PMID: 37991307 PMCID: PMC10788747 DOI: 10.4103/ijo.ijo_942_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 07/29/2023] [Accepted: 08/02/2023] [Indexed: 11/23/2023] Open
Abstract
PURPOSE We aimed to study the ocular manifestations in human immunodeficiency virus (HIV)-infected patients and the correlation of posterior segment lesions with CD4+ counts. METHODS This hospital-based, cross-sectional study enrolled HIV-positive patients attending the ophthalmology department of a tertiary care hospital in Eastern India. Complete demographic information was obtained for each patient. Comprehensive ophthalmic evaluation was done in each case. RESULTS A total of 184 HIV-positive patients were enrolled in the study. Ocular manifestations were detected in 62 cases. The prevalence of ocular manifestations in the present study was 33.69%. Mean age of patients included in the study was 34.8 ± 10.77 years. Prevalence of ocular manifestations was highest in the age group of 30-39 years (41.93%). Highest prevalence of ocular manifestations was noted in patients with low level of education and poor socioeconomic status. Sexual transmission was the major route of HIV transmission (in 92% of cases). Posterior segment lesions were seen in 69.35% of cases. HIV retinopathy was the most common posterior segment manifestation noted in 25 eyes. Significant positive correlation was noted between severities of posterior segment findings and CD4+ counts, which we found to increase with decrease in CD4+ counts (P < 0.001). CONCLUSION Detailed ophthalmic evaluation including fundus examination is must in all cases of HIV/acquired immunodeficiency syndrome (AIDS) patients as it may help in early diagnosis, treatment, and prevention of sight-threatening complications due to opportunistic infections.
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Affiliation(s)
- Jyotirmayee Swain
- Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, Siksha O Anusandhan (Deemed to be) University, 8-Kalinga Nagar, Bhubaneswar, Odisha, India
| | - Pramod Kumar Sharma
- Department of Ophthalmology, Veer Surendra Sai Institute of Medical Sciences and Research (VIMSAR), Pg chowk, Burla, Odisha, India
| | - Loknath Mohanty
- Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, Siksha O Anusandhan (Deemed to be) University, 8-Kalinga Nagar, Bhubaneswar, Odisha, India
| | - Pradeep Kumar Panigrahi
- Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, Siksha O Anusandhan (Deemed to be) University, 8-Kalinga Nagar, Bhubaneswar, Odisha, India
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Arevalo JF, Beatson B. Surgery for Infectious Retinitis - When Medical Therapy Is Not Sufficient: The Moacyr E. Alvaro Pan-American Lecture 2023. Ocul Immunol Inflamm 2023:1-9. [PMID: 36758250 DOI: 10.1080/09273948.2023.2174883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 01/05/2023] [Accepted: 01/26/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Viral retinitis composes a group of infectious ocular diseases with poor prognoses. With the advent of antivirals and HAART, the treatment of these diseases has evolved and ocular outcomes have improved. However, even with prompt medical treatment, a significant number of patients will experience complications that require surgical intervention. While there has been an abundance of research examining the medical treatment of CMV retinitis and acute retinal necrosis, the research examining surgical outcomes of complications such as retinitis-associated retinal detachment is comparatively limited. METHODS Literature review. RESULTS In this review, we discuss the current literature examining treatment of CMV retinitis and acute retinal necrosis, with a focus on surgical management of complications such as retinal detachment. CONCLUSIONS Despite significant improvements in the medical treatment of CMV retinitis and ARN over the last three decades, vision-threatening complications such as retinal detachment are relatively common and require surgical management via PPV, laser photocoagulation, and intraocular gas or silicone oil tamponade.
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Affiliation(s)
- J Fernando Arevalo
- Johns Hopkins University School of Medicine, Wilmer Eye Institute, Baltimore, Maryland, USA
| | - Bradley Beatson
- Johns Hopkins University School of Medicine, Wilmer Eye Institute, Baltimore, Maryland, USA
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Devilliers MJ, Ben Hadj Salah W, Barreau E, Da Cunha E, M'Garrech M, Bénichou J, Labetoulle M, Rousseau A. [Ocular manifestations of viral diseases]. Rev Med Interne 2020; 42:401-410. [PMID: 33168354 PMCID: PMC7646372 DOI: 10.1016/j.revmed.2020.08.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/07/2020] [Accepted: 08/30/2020] [Indexed: 01/08/2023]
Abstract
Les infections virales peuvent toucher l’ensemble des tuniques oculaires et mettre en jeu la fonction visuelle à plus ou moins courte terme. Les kératites et kérato-uvéites liées au virus HSV-1 sont les atteintes les plus fréquentes. Les récurrences entraînent une opacification cornéenne irréversible qui en fait la première cause de cécité d’origine infectieuse dans les pays occidentaux, et justifient un traitement antiviral préventif au long cours. Le zona ophtalmique (10 à 20 % des zonas), peut s’accompagner d’atteintes oculaires sévères (kératites, kérato-uvéites), dont 30 % deviennent chroniques/récurrentes, et de douleurs post-zostériennes, redoutables dans le territoire trigéminé. Les rétinites nécrosantes liées aux herpesvirus (HSV, VZV, CMV), sont rares mais constituent des urgences fonctionnelles absolues nécessitant un traitement antiviral par voie intraveineuse et intravitréenne. Les conjonctivites à adénovirus constituent la première cause de conjonctivite infectieuse. Le plus souvent bénignes, elles sont extrêmement contagieuses et peuvent se compliquer de lésions cornéennes invalidantes persistant plusieurs mois, voire années. Certaines arboviroses s’accompagnent de manifestations oculaires inflammatoires. Dans le cas du Zika, les infections congénitales peuvent se compliquer d’atrophie maculaire et/ou optique. Les conjonctivites sont très fréquentes à la phase aiguë de la maladie à virus Ebola, dont 15 % des survivants présentent des atteintes inflammatoires chroniques sévères liées à la persistance du virus dans les tissus uvéaux. Enfin, dans le cadre de la COVID-19, les conjonctivites ne sont pas très fréquentes mais peuvent être inaugurales, voire au premier plan et sont associées à une excrétion virale lacrymale qui doit faire prendre toutes les précautions.
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Affiliation(s)
- M-J Devilliers
- Service d'ophtalmologie, CHU de Bicêtre, Assistance publique-Hôpitaux de Paris, université Paris-Saclay, CRMR OPHTARA (maladies rares en ophtalmologie), 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France
| | - W Ben Hadj Salah
- Service d'ophtalmologie, CHU de Bicêtre, Assistance publique-Hôpitaux de Paris, université Paris-Saclay, CRMR OPHTARA (maladies rares en ophtalmologie), 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France
| | - E Barreau
- Service d'ophtalmologie, CHU de Bicêtre, Assistance publique-Hôpitaux de Paris, université Paris-Saclay, CRMR OPHTARA (maladies rares en ophtalmologie), 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France
| | - E Da Cunha
- Service d'ophtalmologie, CHU de Bicêtre, Assistance publique-Hôpitaux de Paris, université Paris-Saclay, CRMR OPHTARA (maladies rares en ophtalmologie), 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France
| | - M M'Garrech
- Service d'ophtalmologie, CHU de Bicêtre, Assistance publique-Hôpitaux de Paris, université Paris-Saclay, CRMR OPHTARA (maladies rares en ophtalmologie), 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France
| | - J Bénichou
- Service d'ophtalmologie, CHU de Bicêtre, Assistance publique-Hôpitaux de Paris, université Paris-Saclay, CRMR OPHTARA (maladies rares en ophtalmologie), 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France
| | - M Labetoulle
- Service d'ophtalmologie, CHU de Bicêtre, Assistance publique-Hôpitaux de Paris, université Paris-Saclay, CRMR OPHTARA (maladies rares en ophtalmologie), 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France; Département d'immunologie des maladies virales, auto-immunes, hématologiques et bactériennes (IMVA-HB/IDMIT) CEA, Fontenay-aux-Roses, France
| | - A Rousseau
- Service d'ophtalmologie, CHU de Bicêtre, Assistance publique-Hôpitaux de Paris, université Paris-Saclay, CRMR OPHTARA (maladies rares en ophtalmologie), 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France; Département d'immunologie des maladies virales, auto-immunes, hématologiques et bactériennes (IMVA-HB/IDMIT) CEA, Fontenay-aux-Roses, France.
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Varicella Zoster Meningitis, Optic Neuritis Preceding the Development of Posterior Outer Retinal Necrosis, and Central Retinal Artery Occlusion in a HIV Patient. Case Rep Med 2019; 2019:4213162. [PMID: 31467556 PMCID: PMC6701357 DOI: 10.1155/2019/4213162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/10/2019] [Indexed: 11/29/2022] Open
Abstract
Varicella-zoster virus (VZV) has been known to cause various eye disorders in both immunocompetent and immunocompromised patients. We present a case of a forty-nine-year-old female patient with acquired immunodeficiency syndrome (AIDS) who presented with headache, fever, and blurred vision. Cerebrospinal fluid (CSF) analysis was consistent with VZV meningitis. Magnetic resonance imaging (MRI) of the brain showed enhancement of the right optic nerve indicative of optic neuritis. She responded well to acyclovir and steroids and discharged on the same. Four weeks after discharge, she presented with sudden onset blindness in the left eye. A cerebral angiogram revealed left retinal artery occlusion and was treated with tissue plasminogen activator (tPA). Funduscopic examination showed patchy areas of necrosis in the periphery which were rapidly progressive, diagnostic of posterior outer retinal necrosis (PORN). She was started on ganciclovir and cidofovir and experienced significant improvement in her visual acuity.
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5
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Wu XN, Lightman S, Tomkins‐Netzer O. Viral retinitis: diagnosis and management in the era of biologic immunosuppression: A review. Clin Exp Ophthalmol 2019; 47:381-395. [DOI: 10.1111/ceo.13500] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 02/08/2019] [Accepted: 02/18/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Xia Ni Wu
- Ophthalmology, Moorfields Eye Hospital London UK
- Faculty of Brain Sciences, Institute of Ophthalmology London UK
| | - Sue Lightman
- Ophthalmology, Moorfields Eye Hospital London UK
- Faculty of Brain Sciences, Institute of Ophthalmology London UK
| | - Oren Tomkins‐Netzer
- Ophthalmology, Moorfields Eye Hospital London UK
- Faculty of Brain Sciences, Institute of Ophthalmology London UK
- Department of OphthalmologyBnai Zion Medical Centre Haifa Israel
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8
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Zhang L, Liu JJ, Li MT. Herpes simplex virus type 1 encephalitis and unusual retinitis in a patient with systemic lupus erythematosus. Lupus 2013; 22:1403-8. [PMID: 23970491 DOI: 10.1177/0961203313502112] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this report we discuss a case of a patient with systemic lupus erythematosus who developed herpes simplex virus type 1(HSV-1) infection presenting with encephalitis as well as necrotic and non-necrotic retinitis. The patient presented with typical clinical symptoms and radiologic abnormalities consistent with HSV-1 encephalitis and HSV-1 retinitis in patients with HIV infection, but lacked cerebrospinal fluid pleocytosis and had bilateral retinitis with poor visual acuity. To the best of our knowledge, this is the first such case reported in the literature.
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Affiliation(s)
- L Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, China
| | - JJ Liu
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, China
| | - MT Li
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, China
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9
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Abstract
Herpes zoster is a common condition that significantly affects health-related quality of life. Most cases occur in immunocompetent individuals older than 60 years; however, immunosuppressed patients are at particularly high risk. Post-herpetic neuralgia is the most common serious complication of herpes zoster, and is much more common in the very elderly. Vaccination with the zoster vaccine is recommended for most people older than 60, and reduces the incidence of herpes zoster and the occurrence of post-herpetic neuralgia.
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Affiliation(s)
- Kim M O'Connor
- Division of General Internal Medicine, University of Washington School of Medicine, WA, USA.
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10
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Parekh P, Oldfield EC, Marik PE. Progressive outer retinal necrosis: a missed diagnosis and a blind, young woman. BMJ Case Rep 2013; 2013:bcr-2013-009333. [PMID: 23608868 DOI: 10.1136/bcr-2013-009333] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present a 33-year-old woman with a history significant for HIV/AIDS (CD4 count of 17) and diabetes mellitus who was diagnosed as having progressive outer retinal necrosis (PORN) after presenting with peripheral vision loss. This case provided a diagnostic challenge and demonstrates the devastating effects of a misdiagnosis as it pertains to PORN.
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Affiliation(s)
- Parth Parekh
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
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Tseng CC, Chen SN, Hwang JF, Lin CJ, Chen HS. Progressive outer retinal necrosis associated with occlusive vasculitis in acquired immunodeficiency syndrome. J Formos Med Assoc 2012; 114:469-72. [PMID: 26002429 DOI: 10.1016/j.jfma.2012.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Revised: 04/16/2012] [Accepted: 04/16/2012] [Indexed: 11/18/2022] Open
Abstract
A 45-year-old man, a case of acquired immunodeficiency syndrome, received a highly active antiretroviral therapy at the outpatient service for 4 years without regular follow-up. He experienced progressively blurred vision for 6 months and a cutaneous zoster on his back 3 months ago. He was diagnosed with progressive outer retinal necrosis by polymerase chain reaction-restriction fragment length polymorphism using an aqueous humor sample, which revealed an existence of varicella zoster virus. He was given a combination of systemic, intravitreal antiviral and a highly active antiretroviral therapy. Occlusive vasculitis, an unusual finding for progressive outer retinal necrosis, developed in both eyes 1 week after the secondary intravitreal injection. Unfortunately, his vision deteriorated to no light perception in both eyes within 2 weeks. Progressive outer retinal necrosis is characterized clinically as showing minimal or no inflammation in the aqueous and vitreous humors, absence of retinal vasculitis, and patches of yellowish spots located deep in the retina. Physicians should pay attention to this rare case of progressive outer retinal necrosis associated occlusive vasculitis with very poor prognosis in spite of aggressive treatment.
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Affiliation(s)
- Chien-Chi Tseng
- Department of Ophthalmology, Changhua Christian Hospital, Taiwan
| | - San-Ni Chen
- Department of Ophthalmology, Changhua Christian Hospital, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Jiunn-Feng Hwang
- Department of Ophthalmology, Changhua Christian Hospital, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Chun-Ju Lin
- Department of Ophthalmology, Changhua Christian Hospital, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Optometry, Chung Hwa University of Medical Technology, Tainan, Taiwan.
| | - Huan-Sheng Chen
- An Hsin QingShui Clinic of Fresenius Medical Care Asia Pacific Co Ltd, Taichung, Taiwan
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Abstract
Acute retinal necrosis syndrome (ARN) is a rare retinitis caused by the herpes virus family, including herpes simplex virus and varicella zoster virus. ARN most commonly occurs in otherwise healthy patients of either sex at any age. It is characterized by an initial onset of episcleritis or scleritis, periorbital pain, and a frequently granulomatous anterior uveitis. The key criterion is a necrotizing retinitis starting in the periphery and spreading towards the posterior pole, associated with vitreous opacification. Optic neuropathy may also occur. A total of 75% of untreated eyes develop retinal detachment within the first two months after onset of the disease. Two out of three ARN cases show involvement of the fellow eye. Early intravenous antiviral therapy is mandatory to stop ARN progression. Peripheral retinal breaks can be treated by laser photocoagulation, thereby reducing the risk of retinal detachment. Vitreoretinal surgery is often required, and silicon oil is the tamponade of choice in ARN, resulting in good reattachment rates (90%). Visual prognosis, however, is guarded.
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14
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Banker AS. Posterior segment manifestations of human immunodeficiency virus/acquired immune deficiency syndrome. Indian J Ophthalmol 2008; 56:377-83. [PMID: 18711265 PMCID: PMC2636133 DOI: 10.4103/0301-4738.42413] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Ocular manifestations can occur in up to 50% of human immunodeficiency virus (HIV)/acquired immune
deficiency syndrome (AIDS) patients and posterior segment involvement is the most common presentation.
The posterior segment manifestations of AIDS can be divided into four categories: retinal vasculopathy,
opportunistic infections, unusual malignancies and neuro-ophthalmologic abnormalities. Retinal
microvasculopathy and cytomegalovirus (CMV) retinitis are the most common manifestations, even in the
era of highly active anti-retroviral therapy (HAART). Highly active anti-retroviral therapy has been shown
to cause regression of CMV retinitis, reduce the incidence of CMV-related retinal detachments, and prolong
patient survival. Immune recovery uveitis is a new cause of vision loss in patients on HAART. Diagnosis and
treatment are guided by the particular conditions and immune status of the patient.
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Affiliation(s)
- Alay S Banker
- Banker's Retina Clinic and Laser Centre, 5 Subhash Society, Behind Ishvar Bhuvan, Ahmedabad 380 009, India.
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Park KH, Bang JH, Park WB, Kim HB, Kim NJ, Ahn JK, Chang KH, Oh MD, Choe KW. Retrobulbar optic neuritis and meningoencephalitis following progressive outer retinal necrosis due to CMV in a patient with AIDS. Infection 2008; 36:475-9. [PMID: 18574556 DOI: 10.1007/s15010-007-6290-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2006] [Accepted: 05/03/2007] [Indexed: 11/26/2022]
Abstract
We report on a 34-year-old male patient with AIDS who developed retrobulbar optic neuritis and meningoencephalitis following bilateral progressive outer retinal necrosis (PORN) caused by cytomegalovirus (CMV). This case documents the presumed association of PORN with retrobulbar optic neuritis, and CMV meningoencephalitis in an AIDS patient.
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Affiliation(s)
- K H Park
- Department of Internal medicine, Seoul National University Hospital, 28 Youngun-dong, Chongro-gu, Seoul, South Korea
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You YS, Lee SJ, Lee SH, Park CH, Kwon OW. Progressive outer retinal necrosis combined with vitreous hemorrhage in a patient with acquired immunodeficiency syndrome. KOREAN JOURNAL OF OPHTHALMOLOGY 2007; 21:51-4. [PMID: 17460434 PMCID: PMC2629688 DOI: 10.3341/kjo.2007.21.1.51] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Purpose To describe an unusual case of rapidly progressive outer retinal necrosis (PORN) with vitreous hemorrhage in a 41-year-old woman with acquired immunodeficiency syndrome (AIDS), who had retinitis developed from what was probably varicellar-zoster virus combined with cytomegalovirus (CMV) and herpes simplex type 1,2, as proven by the polymerase chain reaction restriction fragment length polymorphism method (PCR-RFLP). Methods This study is a case report detailing clinical follow-up and an aqueous humor test by PCR-RFLP. Results The deep, white retinal lesions coalesced and progressively expanded in a circumferential manner, with sparing of the perivascular retina. However, retinal and vitreous hemorrhages, unusual findings for PORN, could be noted around the optic nerve. Varicellar-zoster virus (VZV), cytomegalovirus (CMV), and herpes simplex types 1,2 (HSV-1,2) were detected in the aqueous humor by PCR. Conclusions PORN has been described as a variant of necrotizing herpetic retinopathy, occurring particularly in patients with AIDS. Although the etiologic agent has been reported to be VZV, concurrent or combined etiologic agents can include HSV-1, HSV-2, and CMV in AIDS patients. Therefore, combined antiviral therapy with acyclovir and ganciclovir could be more reasonable as an initial therapy.
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Affiliation(s)
| | - Sung Jin Lee
- Department of Ophthalmology, Soonchunhyang University Hospital, Seoul, Korea
| | | | - Chang Hyun Park
- Department of Ophthalmology, Soonchunhyang University Hospital, Seoul, Korea
| | - Oh Woong Kwon
- The Institute of Vision Research and Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea
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Yin PD, Kurup SK, Fischer SH, Rhee HH, Byrnes GA, Levy-Clarke GA, Buggage RR, Nussenblatt RB, Mican JM, Wright ME. Progressive outer retinal necrosis in the era of highly active antiretroviral therapy: successful management with intravitreal injections and monitoring with quantitative PCR. J Clin Virol 2007; 38:254-9. [PMID: 17280866 DOI: 10.1016/j.jcv.2006.12.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2006] [Revised: 11/16/2006] [Accepted: 12/13/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND Progressive outer retinal necrosis (PORN) is an ocular disease in individuals with AIDS and is associated with substantial morbidity. The optimal management of PORN and its clinical course in the HAART era is unclear. OBJECTIVE We report a case of successfully managed PORN that provides insight into the monitoring and treatment of this disease. STUDY DESIGN Intravitreal injections and intravenous therapy targeted towards varicella zoster virus (VZV) were used to treat PORN. HAART was initiated for HIV-1 therapy. Serial PCR for VZV was performed on aqueous humor to monitor the clinical course. RESULTS The presence of VZV DNA from aqueous humor correlated with clinical exacerbations of disease. Initiation of twice weekly intravitreal injections with dual antiviral drugs appeared to be an important therapeutic intervention that resulted in remission of PORN. Secondary prophylaxis against VZV was successfully withdrawn after HAART induced partial immune recovery. CONCLUSION In addition to aggressive therapy with intravitreal injections, HAART and quantitative measurements of VZV DNA from aqueous humor have important roles in the management of PORN. A multidisciplinary approach involving specialists in infectious diseases, ophthalmology, and clinical microbiology will improve the chances for successful long-term outcomes.
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Affiliation(s)
- Philip D Yin
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA.
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Dworkin RH, Johnson RW, Breuer J, Gnann JW, Levin MJ, Backonja M, Betts RF, Gershon AA, Haanpaa ML, McKendrick MW, Nurmikko TJ, Oaklander AL, Oxman MN, Pavan-Langston D, Petersen KL, Rowbotham MC, Schmader KE, Stacey BR, Tyring SK, van Wijck AJM, Wallace MS, Wassilew SW, Whitley RJ. Recommendations for the management of herpes zoster. Clin Infect Dis 2007; 44 Suppl 1:S1-26. [PMID: 17143845 DOI: 10.1086/510206] [Citation(s) in RCA: 434] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The objective of this article is to provide evidence-based recommendations for the management of patients with herpes zoster (HZ) that take into account clinical efficacy, adverse effects, impact on quality of life, and costs of treatment. Systematic literature reviews, published randomized clinical trials, existing guidelines, and the authors' clinical and research experience relevant to the management of patients with HZ were reviewed at a consensus meeting. The results of controlled trials and the clinical experience of the authors support the use of acyclovir, brivudin (where available), famciclovir, and valacyclovir as first-line antiviral therapy for the treatment of patients with HZ. Specific recommendations for the use of these medications are provided. In addition, suggestions are made for treatments that, when used in combination with antiviral therapy, may further reduce pain and other complications of HZ.
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Affiliation(s)
- Robert H Dworkin
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA.
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Kosobucki BR, Freeman WR. Retinal Disease in HIV-infected Patients. Retina 2006. [DOI: 10.1016/b978-0-323-02598-0.50098-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ross A, McLean TW, Farber R, Weaver RG, Chauvenet A, Givner LB, Shetty AK. Retinitis following varicella in a vaccinated child with acute lymphoblastic leukemia. Pediatr Blood Cancer 2005; 45:191-4. [PMID: 15880424 DOI: 10.1002/pbc.20118] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Serious ocular disease following varicella (chickenpox) is rare in children. In addition, retinitis in children with hematologic malignancies may present a difficult diagnostic challenge because infectious retinitis may mimic leukemic involvement of the eye. We report a 7-year-old patient with T-cell acute lymphoblastic leukemia in remission who presented with visual complaints 2 weeks after developing chickenpox. Ophthalmologic evaluation revealed acute retinitis in the right eye. Prolonged therapy with acyclovir resulted in near complete recovery. Early diagnosis of VZV retinopathy and aggressive antiviral treatment is critical to prevent acute and long-term ocular sequelae.
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Affiliation(s)
- Ashley Ross
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA
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Kalpoe JS, van Dehn CE, Bollemeijer JG, Vaessen N, Claas ECJ, Barge RM, Willemze R, Kroes ACM, Beersma MFC. Varicella zoster virus (VZV)-related progressive outer retinal necrosis (PORN) after allogeneic stem cell transplantation. Bone Marrow Transplant 2005; 36:467-9. [PMID: 15995710 DOI: 10.1038/sj.bmt.1705085] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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22
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Ng WT, Versace P. Ocular association of HIV infection in the era of highly active antiretroviral therapy and the global perspective. Clin Exp Ophthalmol 2005; 33:317-29. [PMID: 15932540 DOI: 10.1111/j.1442-9071.2005.01001.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Ocular involvement is a common complication of HIV infection. Since the late 1990s, widespread use of highly active antiretroviral therapy (HAART) has altered the spectrum, and reduced the incidence of ocular involvement in developed countries. The incidence of the most common ocular opportunistic infection, cytomegalovirus retinitis, has decreased tremendously. However, immune recovery uveitis secondary to HAART has emerged as a frequent visually threatening condition. Early diagnosis and treatment with periocular steroids is helpful in minimizing visual loss. Clinicians should also be aware that certain antimicrobial agents used to treat opportunistic infections in HIV-positive patients are associated with potentially serious ocular side effects. In developing countries, where most of the world's 40 million HIV-positive patients live, the spectrum and incidence of ocular involvement differ from those in developed countries. The lack of HAART availability is among the many causes of these differences, which may include nutritional factors, basic medical care availability and the levels of exposure to different infectious agents. These factors add to the already challenging task of treating ocular complications and preventing blindness in HIV-positive patients in developing countries.
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Affiliation(s)
- Weng T Ng
- Department of Ophthalmology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
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23
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Abstract
PURPOSE OF REVIEW The virology, pathophysiology, and treatment of the varicella zoster virus (VZV) have been investigated for many years now. Infection with VZV has different ramifications for people of different ages and immune status. The various aspects of VZV disease make it difficult to treat. Selected aspects of VZV disease that pertain to ocular disease are presented. RECENT FINDINGS The risk factors for VZV disease in the different age spectrums and with concomitant immunodeficiencies have been further clarified. Studies suggest that the VZV may persist for prolonged periods on the cornea after herpes zoster ophthalmicus (HZO). Herpes Simplex Virus (HSV) or VZV may cause many cases of idiopathic uveitis with sectoral iris atrophy. The different patterns of retinal disease caused by VZV may relate to the immune status. Systemic antiviral medications for herpes zoster should be instituted within 72 hours of the rash but could be used later. Systemic antivirals combined with systemic corticosteroids improve the early quality of life in HZ patients. Postherpetic neuralgia is not prevented by early systemic antivirals or corticosteroids. Present systemic antivirals are all effective, but Famvir offers the best dosing schedule. The VZV vaccine is effective but there are some issues that suggest the need for a different vaccination regimen. SUMMARY Further research must be performed on the clinical and therapeutic aspects of the VZV disease. Although both the vaccine and systemic antivirals have brought tremendous improvements, the disease persists. Therapy lessens but does not eliminate many of the complications. The disease may manifest in unpredictable patterns in this era of vaccination.
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Abstract
The ocular posterior segment manifestations of AIDS may be divided into four categories: retinal vasculopathy, unusual malignancies, neuro-ophthalmologic abnormalities, and opportunistic infections. Microvasculopathy is the most common manifestation. Opportunistic infections, particularly cytomegalovirus retinitis and progressive outer retinal necrosis, are the most likely to result in visual loss due to infection or subsequent retinal detachment. Diagnosis and treatment are guided by the particular conditions and immune status of the patient.
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Affiliation(s)
- Tamara R Vrabec
- Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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25
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Breuer J. Commentary on Herpes zoster guidelines of the German Dermatological Society. J Clin Virol 2003. [DOI: 10.1016/s1386-6532(03)00032-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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26
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Gnann JW. Varicella-zoster virus: atypical presentations and unusual complications. J Infect Dis 2002; 186 Suppl 1:S91-8. [PMID: 12353193 DOI: 10.1086/342963] [Citation(s) in RCA: 198] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Varicella-zoster virus (VZV) is the etiologic agent of varicella (primary infection) and herpes zoster (reactivation of latent infection). Although varicella is most often a relatively benign and self-limited childhood illness, the disease can be associated with a variety of serious and potentially lethal complications in both immunocompetent and immunocompromised persons. One complication of varicella that appears to be increasing in frequency is serious bacterial soft tissue infections caused by group A streptococci. Issues related to management of varicella become especially complex when varicella involves pregnant women or susceptible neonates. Herpes zoster can be associated with a variety of neurologic complications, including a syndrome of delayed contralateral hemiparesis. Neurologic complications of herpes zoster, including chronic encephalitis, occur with increased frequency in AIDS patients. VZV retinitis is a potentially sight-threatening complication that occurs in both immunocompetent and immunocompromised persons. Current knowledge regarding pathogenesis and antiviral therapy is reviewed.
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Affiliation(s)
- John W Gnann
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama 35294-2170, USA
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27
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Affiliation(s)
- John W Gnann
- Departments of Medicine, University of Alabama at Birmingham, Birmingham, Ala 35294-2170, USA
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Zambarakji HJ, Obi AA, Mitchell SM. Successful treatment of varicella zoster virus retinitis with aggressive intravitreal and systemic antiviral therapy. Ocul Immunol Inflamm 2002; 10:41-6. [PMID: 12461702 DOI: 10.1076/ocii.10.1.41.10327] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To describe the successful treatment of varicella zoster virus retinitis (VZVR) using intravenous cidofovir as part of an aggressive management strategy. CASE REPORTS Two patients with bilateral VZVR were treated with a combination of intravenous cidofovir and ganciclovir with adjuvant intravitreal foscarnet or ganciclovir. Both patients maintained good vision in the less severely affected eye. Retinal detachment did not occur in either patient. CONCLUSIONS VZVR should be treated aggressively with a combination of intravenous and intravitreal therapy to improve visual prognosis. Intravenous cidofovir, in the absence of contra-indications, should be considered as part of this aggressive therapeutic approach, especially in patients with AIDS in whom the prognosis is particularly poor.
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Affiliation(s)
- H J Zambarakji
- Department of Ophthalmology, Chelsea and Westminster Hospital, London, UK
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29
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Abstract
We recently cared for an 11-year-old child with acute retinal necrosis syndrome, an ophthalmologic condition characterized by the triad of anterior uveitis, occlusive retinal vasculitis and progressive peripheral retinal necrosis. Acute retinal necrosis syndrome occurs primarily in nonimmunocompromised adults as a result of reactivated herpes simplex or varicella-zoster virus infection. Antiviral and antiinflammatory therapy appears to reduce the incidence of vision-threatening retinal necrosis and involvement of the contralateral eye.
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Affiliation(s)
- Sharon Chen
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry Rochester, NY, USA
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30
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Abstract
Varicella-zoster virus (VZV), a member of the human herpesvirus family, causes childhood chickenpox (varicella), becomes latent in sensory ganglia, and reactivates years later in immunocompromised and elderly persons to produce shingles (herpes zoster). Early in the AIDS epidemic, zoster was noted in adults and children infected with HIV. Severe and debilitating zoster-associated dermatological, ophthalmic, and neurological complications may occur in patients infected with HIV. Antiviral therapy can modify the duration of zoster and alleviate its attendant complications. Varicella vaccine may boost the immunity and prevent virus reactivation. VZV immune globulin (VZIG) prevents or modifies clinical illness in persons who have been exposed to varicella or zoster.
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Affiliation(s)
- A Vafai
- Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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Kashiwase M, Sata T, Yamauchi Y, Minoda H, Usui N, Iwasaki T, Kurata T, Usui M. Progressive outer retinal necrosis caused by herpes simplex virus type 1 in a patient with acquired immunodeficiency syndrome. Ophthalmology 2000; 107:790-4. [PMID: 10768344 DOI: 10.1016/s0161-6420(99)00143-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE/BACKGROUND To identify the etiologic agent of rapidly progressive outer retinal necrosis (PORN) in a 32-year-old man with acquired immunodeficiency syndrome (AIDS), who had retinitis developed from cytomegalovirus (CMV). Multiple yellowish spots appeared in the deep retina without evidence of intraocular inflammation or retinal vasculitis, diagnosed clinically as PORN. Death occurred after failure of multiple organs. DESIGN Case report. METHODS Both globes were taken at autopsy, fixed in formalin, and examined histopathologically and immunohistochemically to identify causative agents in the retinal lesions. MAIN OUTCOME MEASURE Immunohistochemistry. RESULTS All layers of the retina were severely damaged and contained focal calcification. Cytomegalic inclusion bodies were found in cells in the damaged retina of the right eye. Immunohistochemical studies for herpesviruses revealed the presence of CMV antigens in the right retina at the posterior pole and herpes simplex virus type 1 (HSV-1)-specific antigen in the periphery of both retinas. No varicella-zoster virus (VZV) antigen was detected in either retina. CONCLUSIONS PORN has been described as a variant of necrotizing herpetic retinopathy, occurring particularly in patients with AIDS. Although the etiologic agent has been reported to be VZV, HSV-1 can be an etiologic agent.
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Affiliation(s)
- M Kashiwase
- Department of Ophthalmology, Tokyo Medical University, Japan
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López-Cortés LF, Ruiz-Valderas R, Lucero-Muñoz MJ, Cordero E, Pastor-Ramos MT, Marquez J. Intravitreal, retinal, and central nervous system foscarnet concentrations after rapid intravenous administration to rabbits. Antimicrob Agents Chemother 2000; 44:756-9. [PMID: 10681351 PMCID: PMC89759 DOI: 10.1128/aac.44.3.756-759.2000] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Retinal, vitreous humor, brain, and cerebrospinal fluid (CSF) foscarnet levels were measured by high-performance liquid chromatography after administration of an intravenous dose of 120 mg/kg of body weight to 32 pigmented rabbits. A pharmacokinetic analysis was done using a two-compartment model. The penetration ratios, defined as ratios of retinal, vitreous humor, brain, and CSF areas under the concentration-time curve from 0 to 2 h were 110% +/- 1%, 12.3% +/- 0.7%, 118% +/- 1%, and 20.2% +/- 2.2%, respectively. These results suggest a good penetration of foscarnet into the retinal and brain tissues, reaching higher concentrations than those estimated from vitreous humor and CSF levels.
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Affiliation(s)
- L F López-Cortés
- Infectious Diseases Service, University of Seville, Seville, Spain.
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34
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Affiliation(s)
- D J Skiest
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas 75235-9113, USA.
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