Ground Rounds
Cytomegalovirus Retinitis in the Setting of an Undiagnosed HIV infection in an Asymptomatic Patient
Tracy Doll, OD, FAAO
Outline for Grand Rounds Submission for American Academy of Optometry Meeting in Seattle 2013
I.
II.
Case History
a. Patient demographics: 25 yo Hispanic Male, recently emigrated to the United States
from Latin America
b. Chief complaint: Itchy eyes over past 6months, No secondary concerns
c. Ocular, medical history/ Medications
i. Fungal infection of finger/toe nails
1. Oral antifungal medication of unknown name/dosage
ii. First eye exam
Pertinent findings
a. Clinical
i. Unremarkable entrance testing including EOMS and pupils
ii. BCVA of 20/20 OD, 20/25- OS
iii. Anterior segment: mild bilaterally inflamed pingueculae
iv. Posterior segment
1. One small blot heme in posterior pole OD- isolated
2. OS findings to be presented with photos
a. 2+ Vitritis
b. Scattered dot-blot hemes throughout posterior pole
c. Extensive patches of exudates, hemorrhaging and vascular
shealthing adjacent to areas of white, necrotic retina, at the end
of the vascular arcades extending into the peripheral retina,
particularly superiorly
b. Physical
i. Patient denies any symptoms of blur OS or any past incidence
ii. Patient denies any physical ailments
1. Blood pressure measured at 116/72mmHg RAS@10:45am.
2. Non-fasting blood glucose was measured at 120mg/dL @11:15am.
iii. Call for retinal consult immediately placed with tentative diagnosis of Acute
Retinal Necrosis in the absence of any significant medical history
1. Patient sees retinal specialist next day
2. New findings: mild keratic precipitates on the corneal endothelium OS
with a diffuse dendritic appearance on the left eye
3. Tentative Diagnosis of Acute Retinal Necrosis with Suspect CMV-like
lesions
c. Laboratory studies and findings
i. Unremarkable: Blood Chemistry, RPR,ACE, Lyme
III.
IV.
V.
VI.
VII.
VIII.
ii. Remarkable: CBC with Differential, Toxoplasma, Viral PCR, HIV blood test
Differential diagnosis
a. Primary/leading
i. Acute Retinal Necrosis
b. Others:
i. Diabetic Retinopathy
ii. Hypertensive retinopathy
iii. Toxoplasmosis
iv. Syphilis
Diagnosis and discussion
a. Confirmed Diagnosis of CMV retinitis in setting of HIV infection
b. Epidemiology of HIV/AIDS in the United States
i. STATS on incidence, prevalence
ii. Impact of HAART
iii. Patient demographics
c. Other signs of HIV infection in the eye
1. Retinal or conjunctival microvasculopathy
2. Kaposi Sarcoma
3. Secondary Infections
a. HSV, HZO, Fungal infections, toxoplasmosis, Cryptococcus,
pneumocystis
b. Uveitis, retinitis, choroiditis retinal detachment
d. Restrospective/Asymptomatic patient, but there were suggestive signs that HIV might
be present
i. Fungal infection of nails
ii. Mildly Reduced visual acuity
iii. Dramatic retinal lesions
Treatment and response to treatment
a. Intravitreal Acycolovir
b. Intravitreal Ganciclovir
c. Oral Valcyte
d. HAART
e. Immune reconstitution Uveitis
Conclusion
a. Importance of dilated posterior segment exams on even asymptomatic patients
b. Reminder that although HIV and AIDS are under much better treatment in the United
States, thanks to HAART, this condition or signs of HIV/AIDS should still be on the list of
differentials for ocular conditions
Bibliography
Thanks