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Editor,—HIV retinopathy is a benign abnormality of uncertain aetiology which was first described in AIDS patients in 1982.1 The retinal findings comprise cotton wool spots similar in appearance to those found in diabetes mellitus and immune complex disorders.2 While it may be associated with asymptomatic HIV infection the retinopathy is generally regarded as a feature seen in patients with laboratory evidence of significant immune deficiency.3 We report a patient in whom HIV retinopathy was noted during an acute seroconversion illness—a finding which has not been previously described.
A 44 year old heterosexual white woman presented to the regional infection unit with a 5 day history of myalgia, arthralgia, fever anorexia, and watery diarrhoea. On examination a diffuse macular rash was noted, there was generalised lymphadenopathy and cotton wool spots were noted on ophthalmoscopy of the right retina (Fig 1). Her diarrhoea persisted despite the absence of enteropaths and she was found to have an inflammatory infiltrate on rectal biopsy. Despite normal appearances on barium enema and multiple normal colonic biopsies she was thought likely to have mild inflammatory bowel disease and was treated with corticosteroids and mesalazine. Following discharge on this regimen her diarrhoea settled but she continued to lose weight. When readmitted 2 months later the cotton wool spots were again noted on examination. No other disease process liable to cause these was identified; her blood pressure was never higher than 140 mm Hg systolic/80 mm Hg diastolic, erythrocyte sedimentation rate was only 30 mm in the first hour, and autoantibody screen was negative—and in light of her ongoing weight loss, the patient was tested for HIV and found to be antibody positive. Retrospective analysis of stored serum from her first admission showed the presence of HIV antigen with undetectable antibody, indicating that she was undergoing a seroconversion illness at that time. Her absolute CD4+ lymphocyte count on the second admission was 220 cells ×106/l.
Her later clinical course following the diagnosis of HIV infection showed a rapid progression of the disease with a marked decline in CD4+ cell count and development of AIDS within 6 months of diagnosis (AIDS wasting being the AIDS defining illness). Her response to antiviral therapy was poor, leading to death 21 months after presentation.
HIV retinopathy is a benign feature of HIV disease which is principally recognised in patients with symptomatic disease or significantly reduced CD4+ cell counts.4 The aetiology is poorly understood and has variously been suggested to be due to circulating immune complexes1 or to direct infection of the retina by the human immunodeficiency virus.5
In the patient described cotton wool spots were ultimately attributed to her HIV disease and had been present since her presentation during a seroconversion illness. This finding has not been previously reported. Although she had a significantly depleted CD4+ cell count when it was first measured (several months after seroconversion) no measurement of her lymphocyte subsets was made at the onset of her illness and the degree of immunodeficiency associated with the acute seroconversion is therefore unknown. It is recognised that patients can progress rapidly from seroconversion to profound immunodeficiency and AIDS6-8 and that seroconversion itself can be associated with a marked fall in CD4+ cell count. The latter may have been relevant in our patient whose retinopathy may have reflected the severity of her seroconversion and the concomitant CD4+ lymphocyte depletion. Whether this finding of retinopathy during seroconversion is of any clinical value in aiding diagnosis or as a predictor of the subsequent clinical course is not clear, although it is interesting to note that progression to AIDS was rapid in this case. In the experience of the authors the finding proved helpful in stimulating consideration of the diagnosis in a patient with no obvious risk factors for HIV infection.
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