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JAMA Ophthalmology Clinical Challenge
June 2016

Atypical Retinitis in the Setting of Prior Cytomegalovirus Retinitis

Author Affiliations
  • 1Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 2Myrin Circle, Scheie Eye Institute, Philadelphia, Pennsylvania
JAMA Ophthalmol. 2016;134(6):709-710. doi:10.1001/jamaophthalmol.2015.4986

A man in his 60s had decreased visual acuity in the right eye. He had a history of human immunodeficiency virus (HIV) infection with a CD4 count of 25 and retinal detachment of the left eye secondary to cytomegalovirus (CMV) retinitis. He was taking trimethoprim-sulfamethoxazole for prophylaxis of Pneumocystis jiroveci pneumonia (formerly Pneumocystis carinii). On examination, visual acuity was 20/30 OD and no light perception OS, which was phthisical with no view of the fundus. In the right eye, the anterior segment was quiet, and there was 1+ nuclear sclerosis. Dilated fundus examination showed no vitritis, multiple discrete hyperpigmented scars (Figure, A, black arrowhead), and an area of inferotemporal retinal whitening (Figure, A, white arrowhead) with associated hemorrhage. The patient was presumptively diagnosed as having CMV retinitis based on the history of CMV retinitis in the contralateral eye, and the findings of hemorrhagic retinitis adjacent to chorioretinal scars suggestive of prior, healed CMV retinitis. He was treated with oral valgancyclovir, but 3 weeks later, the lesions had progressed, prompting admission for intravenous ganciclovir before being lost to follow-up for 1 month. On his return, his visual acuity had declined to 20/50 OD, there was mild vitritis, and there were new areas of retinitis along the inferior arcade (Figure, B, white arrowheads) and vascular sheathing (Figure, B, black arrowhead).

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