PURPOSE: We report a case of cytomegalovirus (CMV) retinitis following placement of an intravitreal dexamethasone implant in an immunocompetent patient diagnosed with non-infectious uveitis. CASE SUMMARY: A 60-year-old woman was referred to our hospital for recurrent anterior uveitis. Fundus examination and fluorescein angiography showed dense vitritis, but no definite retinal infiltration. After laboratory examinations, the patient was diagnosed with non-infectious panuveitis. Uveitis was much improved after the patient started taking oral steroid medication. However, the patient complained of systemic side effects from the oral steroids. Medication was stopped, and an intravitreal dexamethasone implant was fitted to address worsening inflammation. Two months later, perivascular retinal infiltration developed and vitritis recurred. Viral retinitis was suspected, and the patient underwent diagnostic vitrectomy adjunctive with intravitreal ganciclovir injection. Polymerase chain reaction of vitreous fluid confirmed the diagnosis of CMV retinitis. The patient has remained inflammation-free for more than 20 months after vitrectomy, single ganciclovir injection, and 2 months of oral valganciclovir medication. CONCLUSIONS: This is a case report of CMV retinitis following placement of an intravitreal dexamethasone implant in an immunocompetent patient without any risk factors or previous history of immunosuppression. Potential risk factors for CMV retinitis should be evaluated and careful follow-up should be performed when intravitreal dexamethasone injections are unavoidable for the treatment of non-infectious uveitis.
Cytomegalovirus Retinitis ; Cytomegalovirus ; Dexamethasone ; Diagnosis ; Female ; Fluorescein Angiography ; Follow-Up Studies ; Ganciclovir ; Humans ; Immunosuppression ; Inflammation ; Middle Aged ; Panuveitis ; Polymerase Chain Reaction ; Retinaldehyde ; Retinitis ; Risk Factors ; Steroids ; Uveitis ; Uveitis, Anterior ; Vitrectomy

PURPOSE: To study the treatment outcomes in patients who were administered multiple intravitreal ganciclovir injections more than 10 times alone without systemic anti-cytomegalovirus therapy for cytomegalovirus retinitis. CASE SUMMARY: A 64-year-old man who underwent immunosuppressive therapy after thymectomy due to an invasive thymoma and pure red-cell aplasia, a 60-year-old woman who underwent chemotherapy after diagnosis of diffuse large B-cell lymphoma, a 49-year-old man with a history of bone marrow transplantation due to acute myeloid leukemia, a 29-year-old woman with dermatomyositis treated with oral steroids and cyclosporine, and a 47-year-old woman who received intravitreal dexamethasone implant injections, intravitreal and subtenon steroid injections due to Behcet's disease were diagnosed with cytomegalovirus retinitis. All patients showed systemic complications such as pancytopenia after systemic anti-cytomegalovirus therapy, and therefore, they were administered multiple intravitreal ganciclovir injections alone. Best-corrected visual acuities improved in all patients, except in one case, where viral lesions were observed in the fovea. Retinal hemorrhaging and infiltrative lesions decreased in all patients. No severe complication was observed during the injection and in the follow-up period. CONCLUSIONS: Multiple intravitreal ganciclovir injections alone can be used as a treatment modality for cytomegalovirus retinitis to avoid the systemic side effects of systemic anti-cytomegalovirus therapy.
Adult ; Bone Marrow Transplantation ; Cyclosporine ; Cytomegalovirus Retinitis* ; Cytomegalovirus* ; Dermatomyositis ; Dexamethasone ; Diagnosis ; Drug Therapy ; Female ; Follow-Up Studies ; Ganciclovir* ; Humans ; Intravitreal Injections ; Leukemia, Myeloid, Acute ; Lymphoma, B-Cell ; Middle Aged ; Pancytopenia ; Red-Cell Aplasia, Pure ; Retinaldehyde ; Steroids ; Thymectomy ; Thymoma ; Visual Acuity

Systemic infections that are caused by various types of pathogenic organisms can be spread to the eyes as well as to other solid organs. Bacteria, parasites, and viruses can invade the eyes via the bloodstream. Despite advances in the diagnosis and treatment of systemic infections, many patients still suffer from endogenous ocular infections; this is particularly due to an increase in the number of immunosuppressed patients such as those with human immunodeficiency virus infection, those who have had organ transplantations, and those being administered systemic chemotherapeutic and immunomodulating agents, which may increase the chance of ocular involvement. In this review, we clinically evaluated posterior segment manifestations in the eye caused by hematogenous penetration of systemic infections. We focused on the conditions that ophthalmologists encounter most often and that require cooperation with other medical specialists. Posterior segment manifestations and clinical characteristics of cytomegalovirus retinitis, endogenous endophthalmitis, toxoplasmosis, toxocariasis, and ocular syphilis are included in this brief review.
Bacteria ; Cytomegalovirus Retinitis ; Diagnosis ; Endophthalmitis ; Eye Infections ; HIV ; Humans ; Inflammation* ; Organ Transplantation ; Parasites ; Specialization ; Syphilis ; Toxocariasis ; Toxoplasmosis ; Toxoplasmosis, Ocular ; Transplants

BACKGROUND: Cytomegalovirus (CMV) retinitis is one of the most important tissue-invasive CMV diseases in immunocompromised patients. Since 1980, non-invasive diagnostic methods, notably the CMV antigenemia assay, have been widely used as adjunct tests to diagnose tissue-invasive CMV diseases. However, there are limited data on the diagnostic value of the CMV antigenemia assay for diagnosing CMV retinitis. MATERIALS AND METHODS: We performed a retrospective review of all cases of CMV retinitis at Asan Medical Center, Seoul, South Korea over a 9-year period. The diagnosis of CMV retinitis was made by experienced ophthalmologists according to medical history and an ophthalmoscopic appearance of typical retinopathy, together with absence of an alternative diagnosis. RESULTS: We analyzed 44 patients with CMV retinitis (affecting 57 eyes) for whom the CMV antigenemia assay was performed. Of the 44 patients, 31 (70%) were HIV-uninfected and 13 (30%) were HIV-infected. The overall sensitivity of the CMV antigenemia assay was 66% (95% confidence interval [CI] 50–80%). The test’s sensitivity showed a non-significant trend towards being higher in HIV-infected patients than in HIV-uninfected patients (sensitivity 85% vs 58%, respectively, P = 0.16). In a subgroup analysis of the 35 patients without other concurrent tissue-invasive CMV disease, the sensitivity of the CMV antigenemia assay was 57% (95% CI 40–74%). CONCLUSIONS: The CMV antigenemia assay has limited value as a non-invasive diagnostic adjunct test for CMV retinitis. Therefore, the results of the assay need to be interpreted in the context of underlying disease, clinical presentation, and ophthalmoscopic findings.
Chungcheongnam-do ; Cytomegalovirus Retinitis* ; Cytomegalovirus* ; Diagnosis ; Humans ; Immunocompromised Host ; Korea ; Retinitis ; Retrospective Studies ; Seoul

Cytomegalovirus (CMV) is a relatively common viral pathogen, and CMV infection is generally assumed asymptomatic in general hosts. In immunologically compromised patients, CMV infection can cause further serious diseases such as pneumonitis, retinitis, encephalitis, and enterocolitis. A 40-year-old man is being presented with acute fever, myalgia, and sore throat. Laboratory findings have revealed elevated ESR, CRP, and ferritin levels. The patient was being treated for adult-onset Still's disease (AOSD). Three weeks later, although AOSD activity was under control, the patient began to complain about oral soreness, epigastric pain, and diarrhea. Endoscopy revealed multiple round ulcers with white patches in the esophagus and the stomach, sparing the colon. Anti-fungal agent is being administered but failed to bring improvements after 2 weeks of therapy. CMV infection is confirmed with pathology, antiviral agents were initiated after the ulcers subsided. Currently, clinical associations between CMV infection and AOSD are suggested. CMV infection may be considered as a differential diagnosis when multiple upper gastrointestinal ulcerative lesions develop within patients whom have been treated AOSD with immunosuppressive agents.
Antiviral Agents ; Colon ; Cytomegalovirus ; Cytomegalovirus Infections ; Diagnosis, Differential ; Diarrhea ; Encephalitis ; Endoscopy ; Enterocolitis ; Esophagus ; Ferritins ; Fever ; Humans ; Immunosuppressive Agents ; Pharyngitis ; Pneumonia ; Retinitis ; Still's Disease, Adult-Onset ; Stomach ; Stomach Ulcer ; Ulcer

We report a case of cytomegalovirus (CMV) retinitis after intravitreal bevacizumab injection. A 61-year-old woman with diabetic macular edema developed dense vitritis and necrotizing retinitis 3 weeks after intravitreal bevacizumab injection. A diagnostic vitrectomy was performed. The undiluted vitreous sample acquired by vitrectomy was analyzed by polymerase chain reaction and culture. Polymerase chain reaction of the vitreous was positive for CMV DNA. Other laboratory results did not show evidence of other infectious retinitis and systemic immune dysfunction. Human immunodeficiency virus antibodies were also negative. After systemic administration of ganciclovir, retinitis has resolved and there has been no recurrence of retinitis during the follow-up period of 12 months. Ophthalmologists should be aware of potential risk for CMV retinitis after intravitreal bevacizumab injection.
Angiogenesis Inhibitors/administration & dosage/adverse effects ; Antibodies, Monoclonal, Humanized/administration & dosage/*adverse effects ; Cytomegalovirus/genetics ; Cytomegalovirus Retinitis/diagnosis/*etiology/immunology ; DNA, Viral/analysis ; Diagnosis, Differential ; Female ; Humans ; Immunocompetence/*drug effects ; Intravitreal Injections ; Macular Edema/diagnosis/*drug therapy ; Middle Aged ; Polymerase Chain Reaction ; Vascular Endothelial Growth Factor A/antagonists & inhibitors

To report a case of cytomegalovirus (CMV) retinitis after intravitreal injection of triamcinolone acetonide (IVTA). A 77-year-old woman with macular edema due to central retinal vein occlusion (CRVO) developed peripheral retinitis 4 months after IVTA. A diagnostic anterior chamber paracentesis was performed to obtain DNA for a polymerase chain reaction (PCR) test for viral retinitis. The PCR test was positive for CMV DNA. Other tests for infective uveitis and immune competence were negative. Four months after presentation, gancyclovir was intravitreously injected a total of 5 times, and the retinitis resolved completely. CMV retinitis is a rare complication of local immunosuppression with IVTA. It can be managed with timely injection of intravitreal gancyclovir until recovery from local immunosuppression.
Aged ; Antiviral Agents/therapeutic use ; Cytomegalovirus/genetics ; Cytomegalovirus Retinitis/diagnosis/drug therapy/*etiology ; DNA, Viral/analysis ; Female ; Ganciclovir/therapeutic use ; Humans ; Immunosuppressive Agents/*adverse effects ; Injections ; Macular Edema/drug therapy/etiology ; Polymerase Chain Reaction ; Retinal Vein Occlusion/complications/*drug therapy ; Triamcinolone Acetonide/*adverse effects ; Vitreous Body

A 36-year old female with acute myelogenous leukemia presented with a sudden decrease in vision one month following bone marrow transplantation (BMT). She had been taking multiple immunosuppressants to treat her recently-developed graft-versus-host-disease (GVHD). Visual acuity was 20/60 in her right eye and 20/25 in her left. Ophthalmic examination revealed mild inflammatory reaction in both the anterior chamber and the vitreous of both eyes, as well as densely opaque yellow-white infiltrates with well-demarcated borders in the posterior retina of both eyes. She was originally diagnosed as CMV retinitis, but treatment with ganciclovir failed to improve her ocular condition. Subsequent work-up, including serology and brain MRI, led to a diagnosis of combined ocular and cerebral toxoplasmosis. After 6 weeks of antiparasitic therapy, her retinal lesions became inactive and her cerebral lesions improved. Immunosuppressed patients with necrotizing retinochoroiditis should be suspected of having toxoplasmosis. Accurate differentiation between this condition and CMV, and early intervention with the appropriate treatment may be critical to preserve the best vision.
Adult ; Anti-Bacterial Agents/therapeutic use ; *Bone Marrow Transplantation ; Chorioretinitis/*diagnosis/drug therapy/parasitology ; Clindamycin/therapeutic use ; Cytomegalovirus Retinitis/*diagnosis ; Drug Therapy, Combination ; Female ; Functional Laterality ; Humans ; Leukemia, Myeloid, Acute/*surgery ; Magnetic Resonance Imaging ; Tomography, Optical Coherence ; Toxoplasmosis, Cerebral/*diagnosis/drug therapy ; Toxoplasmosis, Ocular/*diagnosis/drug therapy ; Transplantation, Homologous ; Trimethoprim-Sulfamethoxazole Combination/therapeutic use

BACKGROUND: Cytomegalovirus (CMV) infection is an important cause of opportunistic diseases in HIV infected patients and also, "non-HIVs". This study was focused on the clinical features and efficacies of treatment of patients with CMV retinitis. MATERIALS AND METHODS: The medical records of patients diagnosed as CMV retinitis at the Severance hospital, Yonsei University Medical College from January 1992 to February 2006 were reviewed retrospectively. RESULTS: There were 16 HIV patients and 9 non-HIV patients; total 25 cases. The ratio of male and female was 6.3:1. 5 cases were infected with HIV by homosexual contacts, 6 cases were by heterosexual contacts, and 2 cases were by the infection which was pertinent to transfusion and blood products. Infection routes of 3 cases were unable to be determined. At the time of the diagnosis of HIV infection, the average age of patients was 38.2+/-6.6 years, and afterwards, the interval to the development of CMV retinitis was average 2.2+/-3.4 years. The number of CD4+ lymphocytes at the time of the diagnosis of HIV infection, and the diagnosis of CMV retinitis was 122.9/mm3 and 68.9/ mm3, respectively. One of non-HIV patients had undergone kidney-transplantation, and two had malignant lymphoma and four had aplastic anemia as their underlying diseases. The other one had systemic lupus. Their symptoms included visual disturbance, floater and visual field defects, but three of them felt no visual discomfort. In 5 AIDS patients, while administering the induction therapy of ganciclovir, it was terminated due to leukopenia caused by bone marrow suppression. One patient already lost the eyesight at the time of the diagnosis, and thus antiviral drugs were not administered. The other 19 cases were treated by intravenous ganciclovir or foscarnet, and their symptoms were improved. Among 16 HIV patients, 12 patients died an average of 8.0 months after the diagnosis of CMV retinitis. There was no mortality among non-HIV patients within 2 years. CONCLUSION: These results suggested that HIV patients with CD4 T lymphocytes lower than 100/mm3 were susceptible to CMV retinitis. There were clinical improvements in 68.8% prescribed with ganciclovir. In the fatalities' point of view, the awareness and recognition of CMV retinitis on AIDS patients has become increasingly important. In the immunocompromised hosts, it is important to perform aggressive treatment of CMV retinitis to prevent their complications.
Anemia, Aplastic ; Antiviral Agents ; Bone Marrow ; Cytomegalovirus Retinitis* ; Cytomegalovirus* ; Diagnosis ; Female ; Foscarnet ; Ganciclovir ; Heterosexuality ; HIV ; HIV Infections ; Homosexuality ; Humans ; Immunocompromised Host ; Korea* ; Leukopenia ; Lymphocytes ; Lymphoma ; Male ; Medical Records ; Mortality ; Retinitis ; Retrospective Studies ; T-Lymphocytes ; Visual Fields

BACKGROUND: Cytomegalovirus (CMV) infection is an important cause of opportunistic diseases in HIV infected patients and also, "non-HIVs". This study was focused on the clinical features and efficacies of treatment of patients with CMV retinitis. MATERIALS AND METHODS: The medical records of patients diagnosed as CMV retinitis at the Severance hospital, Yonsei University Medical College from January 1992 to February 2006 were reviewed retrospectively. RESULTS: There were 16 HIV patients and 9 non-HIV patients; total 25 cases. The ratio of male and female was 6.3:1. 5 cases were infected with HIV by homosexual contacts, 6 cases were by heterosexual contacts, and 2 cases were by the infection which was pertinent to transfusion and blood products. Infection routes of 3 cases were unable to be determined. At the time of the diagnosis of HIV infection, the average age of patients was 38.2+/-6.6 years, and afterwards, the interval to the development of CMV retinitis was average 2.2+/-3.4 years. The number of CD4+ lymphocytes at the time of the diagnosis of HIV infection, and the diagnosis of CMV retinitis was 122.9/mm3 and 68.9/ mm3, respectively. One of non-HIV patients had undergone kidney-transplantation, and two had malignant lymphoma and four had aplastic anemia as their underlying diseases. The other one had systemic lupus. Their symptoms included visual disturbance, floater and visual field defects, but three of them felt no visual discomfort. In 5 AIDS patients, while administering the induction therapy of ganciclovir, it was terminated due to leukopenia caused by bone marrow suppression. One patient already lost the eyesight at the time of the diagnosis, and thus antiviral drugs were not administered. The other 19 cases were treated by intravenous ganciclovir or foscarnet, and their symptoms were improved. Among 16 HIV patients, 12 patients died an average of 8.0 months after the diagnosis of CMV retinitis. There was no mortality among non-HIV patients within 2 years. CONCLUSION: These results suggested that HIV patients with CD4 T lymphocytes lower than 100/mm3 were susceptible to CMV retinitis. There were clinical improvements in 68.8% prescribed with ganciclovir. In the fatalities' point of view, the awareness and recognition of CMV retinitis on AIDS patients has become increasingly important. In the immunocompromised hosts, it is important to perform aggressive treatment of CMV retinitis to prevent their complications.
Anemia, Aplastic ; Antiviral Agents ; Bone Marrow ; Cytomegalovirus Retinitis* ; Cytomegalovirus* ; Diagnosis ; Female ; Foscarnet ; Ganciclovir ; Heterosexuality ; HIV ; HIV Infections ; Homosexuality ; Humans ; Immunocompromised Host ; Korea* ; Leukopenia ; Lymphocytes ; Lymphoma ; Male ; Medical Records ; Mortality ; Retinitis ; Retrospective Studies ; T-Lymphocytes ; Visual Fields