Dr. Jaya Vohra, J20100, Dr.Padmamalini Mahendradas, Dr. Shetty Bhujang K,
Dr. Anand Vinekar, Dr. Ankush Kawali
Abstract:
AIM: To discuss the clinical features, management and outcome in CMV Retinitis in immunocompetent individuals.
Materials and Methods: Retrospective interventional case series of four immunocompetent patients with CMV retinitis. All patients underwent complete ophthalmic evaluation and relevant laboratory investigations. All patients underwent anterior chamber paracentesis and the aqueous humour in three cases and one from the blood.We subjected it for nested PCR(polymerase chain reaction) in three samples and RT PCR in one sampleand CMV infection was confirmed in all the cases. All patients received intravitreal ganciclovir therapy along with oral valganciclovir therapy,
Results: In our case series, one was an infant (5month old) where as the rest were 63,52,34 years old amd all were males. Three cases showed bilateral involvement and one case showed unilateral disease. In all cases diagnosis was confirmed with AC tap for PCR. Patients were treated with Intravitreal, topical and systemic Ganciclovir which resulted in resolution of the infection.
Conclusion:CMV retinitis can affect immunocompetent individuals as well and responds well to standard treatment. A high index of suspicion should be maintained if clinical characteristics suggest CMV retinitis, despite immunocompetent status.
Introduction:
Cytomegalovirus (CMV) retinitis usually affects severely immunosuppressed individuals. We are reporting four cases of CMV retinitis in an immunocompetent patients
Case Example:
Case 1
A30 year old male presented to us with history of febrile illness for 21 days, following which patient developed blurring of vision in the left eye. Right eye examination was normal. Best Corrected Visual Acuity was 6/6 in the Right eye (RE) and 618 in the Left eye (LE). Intraocular Pressure (IOP) was normal in both eyes (BE). LE anterior segment revealed fine pigments on the back of the cornea. Left eye fundus revealed vitreous haze, retinal haemorrhage with incomplete macular star with areas of retinal opacification. Provisional Diagnosis of LE Multifocal Retinitis was made. Patient was advised routine blood investigations viz Complete blood counts (CBC), Total Leucocyte count (TLC), Urine Microscopy , HIV 1 and 2 , VDRL, RPR and Chest X Ray along with AC Tap for PCR for VZV, CMV, HSV 1 and 2. AC Tap for PCR came out to be positive for CMV. HIV 1 and 2 was negative. Diagnosis of LE CMV Retinitis was made. Intravitreal Ganciclovir was planned for LE and patient was started on the Tablet Valganciclovir 900mg twice a day, Homide eye drop (e/d) at night and Nevanac e/d three times a day. Subsequently 12 Intravitreal Ganciclovir injections were given over a period of 3 months. Induction dose of Valganciclovir was continued for 2 months followed by maintenance dose of Valganciclovir for another 2 months. On his last follow up on 23/6/2017, patient has been doing well with BCVA in RE 6/6 and LE 6/6 p. Fundoscopy revealed resolved retinitis in the left eye.
Case 2
A 63 year old presented to us with complaints of blurring of vision in both eyes (BE) since 1 month. Patient had a history of fever with rashes one and a half month back for which no diagnosis could be made even after being thoroughly investigated. Patient had a history of old scrotal herpes. BCVA was 6/24 p in the RE and 6/12pin the LE .IOP was within normal limits in BE . Anterior Segment revealed Cells 2 +, Flare 2+ in both eyes. Fundoscopy revealed multiple retinitis lesions in BE. RE additionally had macular edema. Provisional Diagnosis of BE Multifocal retinitis with macular edema was made. Among the advised investigations CBC, ESR, TPHA, Weil Felix, WIDAL, Malarial parasite were normal, Chickungunya and Dengue Serology, platelets were normal. Serology of Mumps, Measles, rubella came out to be negative. Serum ANA, HIV1 and 2, Toxo IgG and Ig M was negative. AC Tap was advised for PCR for HSV 1 and 2, VZV, CMV. AC Tap for CMV came out to be positive. Subsequently 8 injections of Intravitreal Ganciclovir were given over a period of 2 months followed by oral Valganciclovir. On his last follow up on 26/10/2016, patient has been doing well with BCVA of ?? in the RE and in CF @1 meter. Fundoscopy revealed resolved retinitis in BE. LE OCT revealed ERM with Cystoid macular edema with gross changes in the photoreceptor layer. Patient has been advised LE vitrectomy with ERM removal with gas injection. Patient has been lost to follow up.
Case 3:
A 5 months old child 1000 gms with birth history of preterm 26 weeks, Respiratory Distress Syndrome, Mild Broncholmonary Disease, Acute Kidney Injury, Neonatal Hyperbilirubenemia, Patent Ductus Arteriosus, Apnea Of Prematurity, Left Sided Inguinal Hernia Reducible during screening of Retinopathy Of Prematurity;Fundoscopy revealed both eyes stage 3,zone 1,with plus and popcorns with retinitis lesions seen at the periphery..Child underwent Laser treatment for BE for the ROP. During follow up child developed bilateral peripheral Acute Retinal Necrosis(ARN) like clinical picture. TORCH profile revealed CMV Ig M antibody 2.69 ( > 1 is positive),CMV Ig G antibody 151.65 (6 > is positive),CMV Ig M antibody 8.3 ( > 1 is positive) . CMV detection by Real time PCR from the blood was positive. Child was started on oral valgancyclovirfor three weeks on follow up visual acuity was normal for the age and the retinitis lesions were healed well.
Case 4
A 34 year old male presented to us with complaints of diminution of vision in both eyes following a month of febrile illness. BCVA in the RE was CF 1.5 metres BE. IOP was within normal limits BE. Anterior Segment revealed 2+cells and 2+ flare in both eyes. Fundoscopy BE revealed Vitreous haemorrhage with multiple areas of retinitis. On Investigations Serum was negative for – ANA, Toxogondi IgG, HIV 1 and 2, Weil felix, Chickungunya IgM, Dengue IgG was positive. REAC Tap for PCR was positive for CMV and VZV. Diagnosis of CMV retinitis was made and patient was given intravitreal Ganciclovir in the REand was started on induction dose of 900mg Valganciclovir twice a day. Patient was referred back to referring ophthalmologist for further management
Discussion:
CMV infection is common worldwide. It is estimated that
40-100% of people are seropositive until the 4th decade of
life.1Following primary infection virus spreads hematogenously
and can infect the retina.2CMV retinitis is the most common opportunistic viral infection in HIV patients.3 It occurs usually as CD4 count decreases below 50/mm3.3It is also seen in immunocompromised patients like lymphoma, acute leukemia, and organ transplantation patients.4It is quite unlikely to encounter CMV retinitis in immunocompetent patients. There are few reports of CMV retinitis in otherwise healthy patients. Gupta S et al5reported nine cases that were immunocompetent at the time of diagnosis.Carlstrom G et al4also reported 2 cases of CMV retinitis that were immunocompetent. In most reports, patients were limited to those who had undergone intravitreal injection of intraocular corticosteroids. The cause is attributed to the local immunosuppression caused by corticosteroids.6,7Radwaan et al6 that patients previously exposed to CMV with comorbid diabetes mellitus, hypertension, or hypercoaguable states may be at higher risk for the development of CMV retinitis. This is particularly relevant following local or systemic immunosuppressant therapy, particularly regional or long-acting corticosteroid preparations. There was although no predisposing factor found in our patient.
CONCLUSIONS:
CMV retinitis in an immunocompetent patients is a rare event. High index of suspicion and correct diagnosis with appropriate antiviral therapy helped us to control the inflammation with improvement in the visual acuity. CMV infection presenting as bilateral ARN and good response to oral Valganciclovir in an infant has not been reported earlier.
REFRENCES :
- Krech U. Complement-fixing antibodies against cytomegalovirus in different parts of the world. Bull World Health Organ. 1973;49:103–106
- Lopez-Contreras J, Ris J, Domingo P, et al. Disseminated cytomegalovirus infection in an immunocompetent adult successfully treated with ganciclovir. Scand J Infect Dis. 1995;27:523e525.
- Jabs DA. Ocular manifestations of HIV infection. Trans Am Ophthalmol Soc. 1995;93:62383.
- Carlstrom G. Virologic studies on cytomegalic inclusion disease. ActaPaediatr Scand. 1965;54:17e22.
- Gupta Seema, Vemulakonda GA. Cytomegalovirus retinitis in the absence of AIDS. Can J Ophthalmol. APRIL 2013;48.
- RadwanAlaa, Metzinger Jamie Lynne. Cytomegalovirus retinitis in immunocompetent patients: case reports and literature review. OculImmunolInflamm. 2013;21:324e328.
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