A 13 years old HIV infected boy on antiretroviral therapy (ART) consisting
of zidovudine (AZT), lamivudine (3TC) and nevirapine (NVP) for the past 7
years, presented with sudden onset vision impairment in February 2010. He
had presented to us at the age of 6 years due to left sided
choreoathetosis due to Antiphospholipid syndrome (APS)(1), following which
he was on regular ART and had adequate immunological recovery. On
admission, his weight was 24 kg and height was 125 cm. Ophthalmological
examination revealed bilateral disc edema, perivasculitis, cotton wool
spots with retinitis and retinal hemorrhages suggestive of CMV-retinitis
(visual acuity of finger counting was from 2 meter in both eyes). MRI
brain showed previous changes of APS syndrome. CMV viral load was not done
before starting treatment but HIV viral load was undetectable and CD4
count was 920/cmm and CMV IgM was positive. He was treated with
intravenous ganciclovir (10mg/kg/day in 2 divided doses) for 7 days and
later shifted to oral valganciclovir (250 mg/m2/day
in 2 divided doses) for 21 days. One week after starting ganciclovir, he
showed improvement in his vision with resolving retinal hemorrhages and
decreasing retinitis, and CMV viral load was undetectable. Follow up
fundus examination after 4 weeks showed resolved retinitis, with macular
scarring (left >right) with normal vision.
The prevalence of cytomegalovirus (CMV) retinitis in
HIV infected children is estimated at 5%(2), and commonly affects those
with low CD4 count beyond infancy and in those in whom HIV virus is
actively replicating. Before the introduction of HAART, patients with
cytomegalovirus retinitis commonly had CD4 counts less than 50 cells/µl
with minimal ocular inflammation(3). Our patient developed CMV retinitis
inspite of a higher CD4 count and undetectable HIV load. Age-adjusted CD4
counts are usually a reliable predictor of ocular complications of HIV
infection in older infants(4). However, that was not the case in this
child. CMV retinitis as part of immune reconstitution inflammatory
syndrome (IRIS) has also been reported(5). However our patient was on ART
for the past 7 years and had undetectable HIV viral load, ruling out IRIS.
We plan to monitor CMV viral load every 6 month. We conclude that all
patients with HIV disease should undergo routine ophthalmologic
examina-tions as CD4 counts and HIV viral load may not be predictive of
CMV retinitis.
References
1. Shah I, Chudgar P. Antiphospholipid syndrome in a
human immunodeficiency virus 1-infected child. Pediatr Infect Dis J 2006;
25: 185-186.
2. Dennehy PJ, Warman R, Flynn JT, Scott GB,
Mastrucci MT. Ocular manifestations and paediatric patients with acquired
immuno-deficiency syndrome. Arch Ophthalmol 1989; 107: 978–982
3. Robinson MR, Reed G, Csaky KG, Polis MA, Whitcup SM.
Immune recovery uveitis in patients with cytomegalovirus retinitis taking
highly active antiretroviral therapy. Am J Ophthalmol 2000; 130: 49-56.
4. Cunningham ET Jr, Margolis TP. Ocular manifestations
of HIV infection. N Engl J Med 1998; 339: 236-244.
5. Banker AS. HIV and eye diseases-our experience and review of
literature. Available at URL: http://eophtha.com/ejo15.html. Accessed on
April 9, 2010.