Question of the Week

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A 36-year-old man presents with a 6-month history of decreased vision in his right eye. He has a history of HIV/AIDS and was recently started on HAART therapy. His last CD4+ count was 9 cells/mm3. Visual acuity without correction in his right eye showed he has light perception but is unable to recognize hand motion. His left eye is 20/30. He has a relative afferent pupillary defect (RAPD) in his right eye. On dilated fundus exam of the right eye, he has a white, fluffy lesion with overlying retinal hemorrhages near the fovea and mild optic disc pallor. The rest of the exam is unremarkable. An image of the retina is shown below.

Which of the following therapies is most appropriate to initiate at this time?

A. Laser ablation

B. Prednisone 

C. Penicillin

D. Ganciclovir

E. Reassurance

The correct answer is D. This patient’s history and exams are consistent with Cytomegalovirus (CMV) retinitis. This can present with decreased visual acuity, floaters, and flashes. Physical exam shows patchy areas of retinal necrosis with irregular borders and retinal hemorrhages, as seen in the image of this patient’s retina. CMV occurs in patients with a CD4+ count of 50 cells/mm3 or less. Although this patient was started on HAART therapy, he had only recently started on the treatment, which would not be enough time to build an immune response. Treatment for CMV includes ganciclovir, foscarnet, or cidofovir. Reassurance (Choice E) would be inappropriate, as this patient currently has an active CMV infection, which should be addressed immediately. The other therapies (Choice A, B, and C) are not appropriate therapies for CMV retinitis. 

Source: Muthialu A, Folk JC. Cytomegalovirus (CMV) Retinitis: 36-year-old Indian male with HIV and decreasing visual acuity. EyeRounds.org. December 18, 2006 ; Available from: http://webeye.ophth.uiowa.edu/eyeforum/cases/61-CMV-Cytomegalovirus-Retinitis-HIV.htm, 2006