From questions on page 1599
1. WHAT IS THE DIAGNOSIS IN AN HIV-INFECTED PATIENT BASED UPON THE INITIAL RETINAL APPEARANCES?
Posterior segment infections in HIV-infected patients present as a necrotising retinitis or choroiditis, categorised by the CD4+ count. Acute retinal necrosis (ARN), syphilis, toxoplasma and cryptococcus occur with higher CD4+ counts, whereas CMV and progressive outer retinal necrosis develop at lower CD4+ counts.1 In this case, a diagnosis of presumed serological negative CMV retinitis was deemed unlikely in the background of high CD4+ counts. However, this diagnosis was not completely excluded. Immune restoration inflammatory syndrome was unlikely, as the patient had not previously undergone HAART by the time of the initial presentation.
2. HOW WOULD YOU MANAGE THIS HIV-POSITIVE PATIENT WITH A HIGH CD4+ COUNT?
In January 2006, consultation with a national ocular HIV centre was undertaken, and it was suggested that the chronic course of retinitis together with signs of vascular attenuation may both indicate CMV retinitis. Brain imaging and lumbar puncture were not performed at this stage, due to the absence of neurological symptoms and signs. A trial of anti-CMV therapy was subsequently commenced in consultation with the patient. A vitreous biopsy was done, and a 2-week course of intravitreal injections of ganciclovir 2 mg/0.1 ml was commenced. Oral valganciclovir was initiated to reduce the risk of retinitis in the fellow eye and prevent extraocular involvement. The clinical appearance did not change after anti-CMV treatment (fig 1A), and the vitreous biopsy was PCR-negative for CMV, VZV and HSV.
In May 2006, the CD4 count was 210 cells/μl, and the hospital HIV service started HAART. There was a good response to HAART with a viral load reduction from 200 000 to 670 copies. In July …