A clinical, histopathologic, and electron microscopic study of Pneumocystis carinii choroiditis

Infective pulmonary diseases and the eye: a narrative review

Several infectious pulmonary diseases affect the eye. An understanding of the association between infectious pulmonary and ocular diseases is pivotal to their successful management. We aimed to review the infections affecting both the lungs and the eye. The electronic database PubMed and the search engine Google Scholar were searched for relevant articles. Ocular tuberculosis (TB), usually not associated with clinical evidence of pulmonary TB, can affect almost all the ocular structures. Confirmation of the diagnosis of ocular TB requires demonstration of Mycobacterium tuberculosis in ocular fluids/tissues. Among the drugs used to treat TB, ethambutol, isoniazid, and linezolid may cause toxic optic neuropathy. Elderly, those with renal disease, diabetes mellitus, malnourished, alcoholics, and those who will receive ethambutol at doses greater than 15 mg/kg/day and for prolonged periods are at high risk of developing toxic optic neuropathy. These individuals should be referred to an ophthalmologist before initiating ATT for a baseline ophthalmic evaluation. Linezolid may also cause toxic retinal neuropathy. Rifampicin may cause yellowish-orange discoloration of tears and contact lenses. Adenovirus, coronavirus, influenza virus, respiratory syncytial virus, and rhinovirus exhibit both pulmonary and ocular tropism. Pneumocystis jirovecii choroiditis is rare and mainly seen when aerosolized pentamidine is used for pneumocystis pneumonia prophylaxis. Further research is needed to develop non-interventional strategies to diagnose ocular TB. Biomarkers for early detection of toxic optic neuropathy are a need of the hour. Genetic factors and mechanisms behind the development of ethambutol, isoniazid, and linezolid-induced toxic optic neuropathy need further study.

Oculosystemic pneumocystosis in 2 sibling Chihuahuas

Sibling female and male Chihuahuas were evaluated for a 9-month history of tachypnea that failed to respond to fenbendazole, doxycycline, amoxicillin-clavulanate, and prednisone. Physical examination identified tachypnea, hyperpnea, and harsh bronchovesicular lung sounds. Fundic examination disclosed diffuse chorioretinitis, manifested as multifocal chorioretinal granulomas in the female dog and occasional chorioretinal scars in the male dog. Thoracic radiographs indicated moderate to severe interstitial to broncho-interstitial infiltrates in both dogs. Serum and urine antigen and antibody testing in the female dog failed to identify infectious agents, but cytologic assessment of hepatic lymph node, liver, and splenic aspirates identified Pneumocystis trophozoites. Infection was confirmed in both dogs by 28S rRNA PCR sequencing from multiple tissue samples. The female dog responded well to trimethoprim-sulfamethoxazole, but the male dog was euthanized because of liver failure, presumably related to antimicrobial treatment.

Bilateral Placoid Choroiditis in an HIV-Positive Patient With Cryptococcus neoformans Meningitis and Disseminated Cryptococcal Disease

Purpose:

We report a presumptive case of bilateral placoid choroiditis secondary to disseminated Cryptococcus neoformans infection and review the literature on choroidal involvement of C neoformans.

Methods:

A case report is presented.

Results:

A 35-year-old HIV-positive man presented with disseminated cryptococcal infection. Cryptococcal meningitis was confirmed by lumbar puncture, and skin involvement was confirmed by microscopy of scrapings from a papular, umbilicated, ulcerated lesion. Ophthalmologic examination revealed intact visual acuity, clear vitreous, and multiple yellowish, placoid-appearing choroidal lesions in the posterior pole bilaterally.

Conclusions:

Multifocal choroiditis caused by C neoformans is an uncommon manifestation of disseminated infection, and placoid yellowish choroidal lesions are an unusual variant. These findings must be differentiated from choroidal tuberculosis and other infections. Multifocal choroiditis typically occurs in AIDS patients and may precede the presentation of meningitis. In such patients, choroidal lesions warrant investigation for systemic, life-threatening opportunistic infections.

AIDS and ophthalmology: the first quarter century

PURPOSE

To describe changes in the acquired immunodeficiency syndrome (AIDS) epidemic that are important to ophthalmologists, to provide an overview of issues relevant to current evaluation and treatment of human immunodeficiency virus (HIV)-related eye disease, and to identify problems related to the eye and vision that require continued study.

DESIGN

Literature review and commentary.

METHODS

Selected articles from the medical literature and the author's clinical and research experiences over 25 years were reviewed critically.

RESULTS

The AIDS epidemic has had a profound impact on ophthalmology since the ophthalmic manifestations of AIDS were first described in 1982. The introduction of highly active antiretroviral therapy (HAART) has markedly reduced the incidence of cytomegalovirus (CMV) retinitis, but has not eliminated new cases altogether. Treatment strategies for CMV retinitis have evolved over the past decade. Current issues of importance include choice of initial anti-CMV drugs; time at which anti-CMV drug treatment is discontinued in patients who achieve immune recovery; strategies for monitoring patients at risk for disease reactivation; and management of complications (retinal detachment, immune recovery uveitis). Attention also is being directed to the problem of visual disturbances (reduced contrast sensitivity, altered color vision, visual field abnormalities) that can occur in HIV-infected individuals without infectious retinopathies.

CONCLUSIONS

Ocular disorders associated with HIV disease remain important problems in the United States, despite HAART, and increasingly are important worldwide. The approach to management of CMV retinitis has evolved from short-term treatment of a preterminal infection to the long-term management of what has become a chronic disease. Many challenges remain to be addressed.

Anterior Segment and External Ocular Disorders Associated with Human Immunodeficiency Virus Disease

The eye is a common site for complications of human immunodeficiency virus (HIV) infection. Although cytomegalovirus retinitis remains the most prevalent of the blinding ocular disorders that can occur in individuals with the acquired immunodeficiency syndrome (AIDS), several important HIV-associated disorders may involve the anterior segment, ocular surface, and adnexae. Some of these entities, such as Kaposi sarcoma, were well described, but uncommon, before the HIV epidemic. Others, like microsporidial keratoconjunctivitis, have presentations that differ between affected individuals with HIV disease and those from the general population who are immunocompetent. The treatment of many of these diseases is challenging because of host immunodeficiency. Survival after the diagnosis of AIDS has increased among individuals with HIV disease because of more effective antiretroviral therapies and improved prophylaxis against, and treatment of, opportunistic infections. This longer survival may lead to an increased prevalence of anterior segment and external ocular disorders. In addition, the evaluation and management of disorders such as blepharitis and dry eye, which were previously overshadowed by more severe, blinding disorders, may demand increased attention, as the general health of this population improves. Not all individuals infected with HIV receive potent antiretroviral therapy, however, because of socioeconomic or other factors, and others will be intolerant of these drugs or experience drug failure. Ophthalmologists must, therefore, still be aware of the ocular findings that develop in the setting of severe immunosuppression. This article reviews the spectrum of HIV-associated anterior segment and external ocular disorders, with recommendations for their evaluation and management.

BILATERAL IDIOPATHIC MULTIFOCAL RETINAL PIGMENT EPITHELIUM DETACHMENTS IN OTHERWISE HEALTHY MIDDLE-AGED ADULTS

PURPOSE

To present the results of a clinicopathologic study of patients with bilateral idiopathic multifocal serous retinal pigment epithelial detachments (RPEDs).

METHOD

Retrospective review of the medical records of three middle-aged patients with innumerable RPEDs. The eye of one patient was available for histopathologic examination.

RESULTS

The presence of multiple serous RPEDs was verified with fluorescein angiography and optical coherence tomography in two patients and by histopathologic examination of one eye of a third patient, who developed a submacular hematoma and vitreous hemorrhage caused by a focal area of choroidal neovascularization.

CONCLUSIONS

No cause for the multifocal serous RPEDs was found.

Posterior segment manifestations of HIV/AIDS

The ocular posterior segment manifestations of AIDS may be divided into four categories: retinal vasculopathy, unusual malignancies, neuro-ophthalmologic abnormalities, and opportunistic infections. Microvasculopathy is the most common manifestation. Opportunistic infections, particularly cytomegalovirus retinitis and progressive outer retinal necrosis, are the most likely to result in visual loss due to infection or subsequent retinal detachment. Diagnosis and treatment are guided by the particular conditions and immune status of the patient.

Pneumocystis carinii granuloma of the optic nerve: a histopathologic case report

A 30-year-old man under treatment for acute leukemia died of Candida sepsis and Pneumocystis carinii pneumonia. A small granuloma containing Pneumocystis carinii was found in one optic nerve.

Differential diagnosis of CMV retinitis

Diagnosis of cytomegalovirus retinitis (CMVR) is usually made by retinal examination by an experienced ophthalmologist. The characteristic appearance of the infection is distinctive enough that recourse to ancillary tests or diagnostic procedures is rarely needed. However, atypical cases of CMVR or infections with other organisms in individuals at high risk for CMVR may require invasive diagnostic testing of ocular fluids or tissues using comparative antibody titers, amplification of organismal DNA or RNA, culture, or histology. A small number of other organisms are frequent enough as causes of intraocular infection that the typical appearances of these infections have become known. Familiarization of the clinician with the expected clinical presentation of various infections can facilitate diagnosis, selection of confirmatory diagnostic tests, and empiric therapy.

Detection of Pneumocystis carinii DNA in blood specimens from human immunodeficiency virus-infected patients by nested PCR

The detection of Pneumocystis carinii DNA in blood by PCR could be useful for studying the natural history of pneumocystosis and could also be a noninvasive diagnostic method. The results of previous studies are nevertheless conflicting. In our study, we compared three commercially available DNA extraction kits (GeneReleaser, QIAamp Tissue Kit, and ReadyAmp Genomic DNA Purification System) and proteinase K and proteinase K-phenol-chloroform treatments for the extraction of P. carinii DNA from dilutions of a P. carinii f. sp. hominis cyst suspension mixed with human whole blood. A rapid and simple nested PCR protocol which amplifies a portion of the mitochondrial large-subunit rRNA gene was applied to all the extraction products. The QIAmp Tissue Kit was the most effective kit for the isolation of amplification-ready P. carinii DNA and was used with nested PCR for the testing of whole-blood specimens from 35 immunocompetent control patients and 84 human immunodeficiency virus (HIV)-infected patients investigated for pulmonary disease and/or fever. In HIV-infected patients, P. carinii DNA was detected by nested PCR in blood samples from 3 of 14 patients with microscopically proven P. carinii pneumonia, 7 of 22 patients who were considered to be colonized with P. carinii, and 9 of 48 patients who were neither infected nor colonized with P. carinii. P. carinii DNA was not detected in blood specimens from the 35 immunocompetent patients. P. carinii DNA in blood might represent viable P. carinii organisms or DNA complexes released from pulmonary phagocytes. In conclusion, P. carinii DNA may be detected in whole blood from HIV-infected patients, but the nature and the meaning of the circulating form of P. carinii remain to be established.

Hyperthyroidism due to lymphoma involving the thyroid gland in a patient with acquired immunodeficiency syndrome: case report and review of the literature

A 31-year old woman with acquired immunodeficiency syndrome (AIDS) and a history of lymphoma presented with a 2-week history of severe hyperthyroid symptoms and new-onset neck swelling. On physical examination, she was found to be clinically hyperthyroid, with a markedly enlarged, diffuse, tender goiter. Thyroid function testing confirmed hyperthyroidism. The patient had a rapidly deteriorating clinical course and died within days of her presentation. At autopsy, near-complete replacement of the thyroid gland with anaplastic large cell lymphoma was found, without coexisting infectious or autoimmune processes in the gland. This is the first case report of a patient with AIDS developing symptomatic thyroid involvement by lymphoma, and one of only a few case reports of hyperthyroidism associated with lymphoma in general.

Ocular opportunistic infection incidences among patients who are HIV positive compared to patients who are HIV negative

OBJECTIVE

The purpose of the study was to examine the incidence of ocular opportunistic infections among patients who are human immunodeficiency virus (HIV) positive compared to patients who are HIV negative.

DESIGN

The study design was a retrospective cohort study.

PARTICIPANTS

All patients were recruited from 1984 until 1995 at the San Francisco General Hospital.

INTERVENTION

Incidences for numerous diagnoses were compared among the exposure group (HIV positive) and nonexposed control group (HIV negative).

MAIN OUTCOME MEASURES

The diagnoses studied were cytomegalovirus (CMV) retinitis, herpes zoster ophthalmicus, Pneumocystis carinii choroidopathy, herpes simplex keratitis, Toxoplasma retinitis, fungal retinitis, ocular syphilis, and ocular lymphoma.

RESULTS

Among the HIV-positive pool, there were 1800 patient visits with a total of 5200 person-years of follow-up. Among the HIV-negative control pool, there were 48,200 patient visits with a total of 30,100 person-years of follow-up. Incidence rates were calculated using the product-limit method, and risk ratios were calculated using the Cox proportional hazards model. Incidence rate differences were calculated using the incidence density method. Among the outcomes studied, only CMV retinitis, herpes zoster ophthalmicus, and, to a lesser extent, Toxoplasma retinitis showed both an elevated risk ratio and rate difference among patients who were HIV positive compared to patients who were HIV negative. Of the other outcomes studied, either the risk ratio, rate difference, or both were similar among patients who were HIV positive compared to patients who were HIV negative.

CONCLUSIONS

Not all ocular infections seen in patients who are HIV positive should be considered opportunistic, because many occur with similar incidence among patients who are HIV negative. The biologic reasons for this will require further study.

Chronic multifocal retinal infiltrates in patients infected with human immunodeficiency virus

PURPOSE

To describe the clinical features of a disorder characterized by chronic multifocal retinal infiltrates and uveitis in individuals with human immunodeficiency virus (HIV) disease.

METHODS

We reviewed the medical records of HIV-infected patients with multifocal retinal infiltrates of unknown cause seen by investigators at four institutions. The following data were collected: demographic characteristics, presenting signs and symptoms, laboratory test results, and course of disease.

RESULTS

We identified 26 HIV-infected patients (50 involved eyes) with this syndrome. Median CD4+ T-lymphocyte count at presentation was 272 per microl (range, 7 to 2,118 per microl). The most common presenting symptom was floaters. Median visual acuity of involved eyes at presentation was 20/20 (range, 20/15 to 20/100) and remained stable (median, 20/20; range, 20/15 to 20/70) after a median follow-up period of 9 months (range, 0 to 110 months). Typical retinal lesions were gray-white or yellow, irregular in shape, and less than 200 microm in greatest dimension. All were located in the midperiphery or anterior retina and enlarged slowly or remained static in size. Mild to moderate anterior chamber or vitreous humor inflammatory cells were present in 47 of 50 eyes (26 of 26 patients). Retinal lesions possibly responded to zidovudine but not to acyclovir or ganciclovir. Anterior chamber and vitreous humor inflammatory reactions responded to topical or periocular injections of corticosteroid.

CONCLUSIONS

Uveitis with chronic multifocal retinal infiltrates is a distinct clinical entity of unknown cause that occurs in HIV-infected patients. Retinal lesions may respond to antiretroviral therapy. Visual prognosis is good.

Presumed multifocal cryptococcol choroidopathy prior to specific systemic manifestation

PURPOSE

Disseminated cryptococcosis is a major cause of morbidity and mortality in immunocompromised individuals, especially those with the acquired immunodeficiency syndrome (AIDS). Early diagnosis and treatment greatly improves the outcome, so clinical clues that lead to prompt diagnosis are important.

METHODS

Three patients with AIDS in whom multifocal choroiditis and choroidal lesions were the initial signs of disseminated cryptococcosis were treated with systemic amphotericin B and flucytosine. All of the patients had a systemic work-up that included evaluation of the cerebral spinal fluid (CSF).

RESULTS

All three patients who were seen with the choroidal lesions as the presenting sign were noted to have either positive titers for cryptococcus or cultures that grew cryptococcus in the CSF. The choroidal lesions are presumed to be due to cryptococcus as no histopathologic or microscopic studies were available for ocular tissues. The choroidal lesions started to resolve one to three months after systemic treatment with amphotericin B and flucytosine.

CONCLUSION

Primary choroidal lesions in patients with AIDS may herald severe systemic disseminated disease. Funduscopic examination, however, may detect disseminated cryptococcal disease before other overt clinical manifestations, thereby allowing prompt institution of effective therapy.

Pneumocystis carinii infection of the conjunctiva in a patient with acquired immune deficiency syndrome

BACKGROUND

Ocular disease, especially the development of choroidal lesions, is a known extrapulmonary manifestation of Pneumocystis carinii infection in the acquired immune deficiency syndrome (AIDS). To our knowledge, conjunctival involvement due to P. carinii has not been described previously.

METHODS

The authors describe a 33-year-old homosexual male with AIDS in whom a large placoid, white lesion developed involving the tarsal conjunctiva of the right upper lid. Conjunctival malignancy was suspected and biopsies and swabs were taken. At this time, the patient had been receiving monthly aerosolized pentamidine prophylaxis for 18 months, and there was neither a history of pneumonia nor any clinical signs of disseminated infection due to P. carinii.

RESULTS

Histopathologic examination results of the conjunctival biopsy specimen showed a necrotic, frothy tissue surrounded by activated fibroblasts. Within this material, Gomori methenamine silver stains showed numerous round and cup-like cysts of P. carinii, confirming the diagnosis that had already been obtained by an indirect fluorescent-antibody stain of a conjunctival smear specimen.

CONCLUSIONS

The presence of white placoid conjunctival lesions in a patient with AIDS may indicate an infection due to P. carinii. Conjunctival disease due to P. carinii widens the spectrum of AIDS-associated ophthalmic pneumocystosis.

Extrapulmonary pneumocystosis

Extrapulmonary pneumocystosis is an exceedingly rare complication of Pneumocystis carinii pneumonia (PCP). Prior to the advent of the human immunodeficiency virus type 1 (HIV-1) epidemic, only 16 cases of extrapulmonary pneumocystosis in individuals who were immunocompromised by a variety of underlying diseases had been reported. Since the beginning of the HIV-1 and related PCP epidemic, at least 90 cases of extrapulmonary pneumocystosis have been reported. This review briefly presents a history of the discovery of P. carinii and its recognition as a human pathogen, the controversy regarding its taxonomy, and the epidemiology of this organism. A more detailed analysis of the incidence of extrapulmonary pneumocystosis in HIV-1-infected individuals and its occurrence despite widespread prophylaxis for PCP with either aerosolized pentamidine or systemic dapsone-trimethoprim is presented. The clinical features of published cases of extrapulmonary pneumocystosis in non-HIV-1-infected individuals are summarized and contrasted with those in HIV-1 infected individuals. The diagnosis of extrapulmonary pneumocystosis is discussed, and because clinical microbiologists and pathologists are the key individuals in establishing the diagnosis, the characteristic microscopic morphology of P. carinii as its appears when stained with a variety of stains is presented and reviewed. The review concludes with a brief discussion of treatments for extrapulmonary pneumocystosis.

The pancreas in AIDS

Although autopsy studies reveal significant pancreatic lesions in about 10% of AIDS patients, pancreatic lesions infrequently produce symptoms and are rarely recognized premortem. Patients with AIDS can develop pancreatic disease from causes not related to AIDS or AIDS-specific lesions. AIDS-specific causes include opportunistic infection, AIDS-associated neoplasia, and medications used to treat complications of AIDS. Pancreatic involvement is usually part of a widely disseminated tumor and rarely produces clinical symptoms.

Electroretinographic and psychophysical findings during early and late stages of human immunodeficiency virus infection and cytomegalovirus retinitis

PURPOSE

The authors examined electrophysiologic and psychophysical measures of retinal function in patients infected with human immunodeficiency virus (HIV) at different stages of infection, including patients with cytomegalovirus retinitis (CMVR).

METHODS

All patients had complete ophthalmologic examinations. Rod-mediated psychophysical thresholds were measured using a modified two-color dark-adapted perimetry technique. Rod-dominated full field flash electroretinograms (ERGs) were obtained as a function of flash intensity, followed by cone-dominated ERGs. The 26 patients infected with HIV (26 eyes) were categorized into three groups. Six patients were infected with HIV but had not progressed to acquired immunodeficiency syndrome (AIDS), and 14 had AIDS. Six patients had CMVR with less than 10% of the retina involved. The data were compared with results from age-similar control subjects.

RESULTS

Psychophysical thresholds as a function of retinal eccentricity were elevated for each of the three stages of HIV infection. The group of patients with CMVR had the greatest amount of threshold elevation and threshold elevation increased with retinal eccentricity. In addition, all three patient groups had abnormal electroretinographic findings. Patients with CMVR were affected more severely on all measures than were the other HIV-infected groups.

CONCLUSIONS

Results reveal that a diffuse functional retinal pathology exists in eyes with the funduscopic appearance of localized peripheral CMVR. Additionally, patients infected with HIV, including those without cotton wool spots, may have abnormal retinal function.

Ophthalmic complications of HIV infection

HIV retinopathy, a noninfectious microangiopathy, is the most common ocular manifestation of HIV infection. Opportunistic infections, neoplasms, neuro-ophthalmic lesions, and drug-induced lesions may also cause ocular problems. Opportunistic ocular infections, particularly CMV retinitis, are a major cause of morbidity in patients with AIDS. Because of the underlying chronic and progressive immune dysfunction, the ocular symptoms, signs, clinical course, and treatment are often atypical and severe, requiring protracted medical therapy.

AIDS and the eye. A 10-year experience

BACKGROUND

The AIDS database at Fairfield Hospital, Melbourne, maintains information on eye pathology as identified by the three visiting ophthalmologists. Patients underwent an eye consultation: if they had ocular symptoms; if signs were seen on direct ophthalmoscopy by physicians; or when their CD4+ve cell count fell below 50/microL. The first AIDS-associated eye signs were identified in mid-1984. In the subsequent decade, 3257 patients in Victoria tested positive for HIV, and 845 of the 1123 who developed AIDS were treated at Fairfield Hospital.

METHODS

We undertook a retrospective review of the Fairfield Hospital database to identify the AIDS-associated ocular problems seen.

RESULTS

Some 723 patients had an eye consultation. In the earliest stage of HIV infection, minor non-specific ophthalmic involvement may occur. As the disease progresses, microvasculopathy (cottonwool spots and haemorrhages) appears. External disease also occurs such as molluscum contagiosum and Kaposi's sarcoma of the conjunctiva. With more suppression of the immune system, opportunistic infections become common, and have a considerable visual morbidity. Cerebral toxoplasmosis (117 patients) is only rarely associated with ocular involvement (three patients), but cytomegalovirus (CMV) commonly causes retinitis [204 patients (24%)]. It has been the AIDS-defining illness in 26 patients. A majority had the disease confined to one eye. Mean CD4 cell count at onset is 15 +/- 5 microL and it has been associated with a viraemia in all but two patients. Late complications of CMV retinitis include relapse in 41 (20%), spread to the other eye in 24 (12%), and retinal detachment in 30 (15%). Visual impairment follows from retinal destruction, optic nerve involvement, and retinal detachment.

CONCLUSION

The ophthalmic workload from late ocular complications of AIDS is increasing. Newer and more effective methods of treatment are being developed. Ophthalmologists are becoming more aware of the need for universal precautions to avoid risks from this and other blood-borne infections.

Noncytomegalovirus-related chorio-retinal manifestations of the acquired immunodeficiency syndrome

The diagnosis of the ocular manifestations of AIDS is based initially on the clinical appearance of the lesions. However, retinal and choroidal lesions in AIDS patients are frequently the manifestation of disseminated disease. In one autopsy series, 15 of 18 patients with infectious choroiditis died of systemic infection by the same organism causing the choroiditis. Despite the fact that more than 90% of posterior segment infections in AIDS patients are caused by CMV, careful examination with appropriate consideration of differential diagnosis is necessary in all cases in which a classic pattern of CMV retinitis is not seen. Extensive history taking, discussion with the primary care physician, and the appropriate systemic work-up can greatly facilitate the diagnosis of the most likely cause of the apparent opportunistic infection. It is important to remember that noninfectious causes of HIV-related retinal disease can have a similar clinical pattern as infectious causes. In particular, physicians must be careful not to confuse early CMV retinitis with HIV-related noninfectious retinal vasculopathy, the most common retinal finding in patients with HIV disease. In a patient with multifocal superficial lesions in the posterior pole, particularly if the CD4+ count is more than 100 cells/microL, reevaluation rather than immediately initiating therapy may prevent the inadvertent commitment to chronic therapy implicit in a diagnosis of CMV retinitis.

Retinochoroiditis in the acquired immune deficiency syndrome. Findings in consecutive post-mortem examinations

A number of opportunistic agents may cause retinitis or retinochoroiditis in patients with the acquired immunodeficiency syndrome. Minimal consecutive data is available on the histopathologically confirmed prevalence of these ocular infections. A total of 48 consecutive patients with acquired immunodeficiency syndrome-related death underwent autopsy and had their eyes submitted for histopathological examination. Conventional light microscopy combined with immunohistochemistry revealed cytomegalovirus retinitis in 15 patients, toxoplasma gonddi retinochoroiditis in 3 patients and mycobacterial choroiditis in one individual with some infections being coexistent. Clinical examination prior to death was highly accurate in detecting cytomegalovirus retinitis, but failed to determine all non-cytomegalovirus causes of retinochoroiditis. Ten of 15 patients with cytomegalovirus retinitis had associated non-cular cytomegalovirus infections, most often in the brain and adrenals. After clinical detection of cytomegalovirus retinitis the median survival time was 5.5 months, not adversely affected by additional non-ocular cytomegalovirus infection.

Infectious multifocal choroiditis in patients with acquired immune deficiency syndrome

PURPOSE

The purposes of this study are to determine the incidence of infectious opportunistic choroiditis in patients with the acquired immune deficiency syndrome (AIDS), to study the association of these choroidal infections with systemic dissemination, and to investigate the life expectancy and cause of death in patients with infectious opportunistic choroiditis.

METHODS

A total of 470 eyes of 235 consecutive autopsies of patients with AIDS were examined by histopathologic methods. The clinical charts and autopsy reports of these patients were subsequently reviewed for presence of systemic dissemination of various infectious agents.

RESULTS

Of the 235 patients, 18 were found to have infectious choroiditis. The etiologic agents found were: Cryptococcus neoformans, Pneumocystis carinii, Mycobacterium tuberculosis, Histoplasma capsulatum, Candida, Aspergillus fumigatus, Toxoplasma gondii, and Mycobacterium avium-intracellulare. In 15 of these 18 patients, the cause of death was considered to be due to systemic dissemination of the organism causing the choroiditis. Only 4 of the 18 cases of infectious choroiditis were diagnosed during life, and the survival time of these patients after diagnosis was only 25 days. Five of the 18 patients also were found to have cytomegalovirus (CMV) infection of the retina.

CONCLUSION

Multifocal choroiditis due to endogenous infectious emboli in patients with AIDS reflects systemic dissemination and localization of infectious agents predominantly in the choriocapillaris. Early diagnosis and treatment are imperative and may be life-saving.

Systemic viral infections and their retinal and choroidal manifestations

Viruses are one of the most common causes of infections involving the posterior segment of the eye. Such infections can occur either on a congenital or an acquired basis, and may affect primarily the retina or the choroid. Congenital cytomegalovirus (CMV) and rubella infections may result in retinitis. CMV retinitis is also the most common cause of acquired viral retinitis, primarily because of the acquired immunodeficiency syndrome (AIDS). Other types of viral retinitis, such as those caused by herpes simplex or herpes zoster, can occur in immunocompromised or immunocompetent individuals. Retinitis or choroiditis caused by viruses such as measles, influenza, Epstein-Barr virus, and Rift Valley fever virus, typically occurs subsequent to an acute viral systemic illness. The systemic and ocular manifestations, as well as the histopathology, laboratory tests, differential diagnoses, and treatment regimens for each of the individual viruses are discussed in detail.

Disseminated pneumocystosis presenting as a pleural effusion

Extrapulmonary pneumocystosis recently has been reported in a number of tissues. Most cases occurred in patients receiving aerosolized pentamidine prophylaxis. We report a case of disseminated pneumocystosis presenting as a large pleural effusion without apparent lung involvement where Pneumocystis carinii was the only pathogen identified. The absence of parenchymal lesions on chest x-ray film, the lack of hypoxemia and the minimal uptake of gallium all argue against significant lung involvement. The patient was successfully treated with chest tube drainage, intravenous and inhaled pentamidine and orally administered dapsone and trimethoprim. The addition of inhaled pentamidine to intravenously administered pentamidine may have increased pleural fluid levels substantially and its use coincided with the patient's improvement.

Preparation and stability of a radioiodinated pentamidine isethionate analog

Iodopentamidine isethionate was heated for 70 min with [I-123]- or [I-125]-sodium iodide and ammonium sulphate in the absence of solvent at 140 degrees C. The product, [I-123]- or [I-125]-iodopentamidine isethionate, was purified by ion exchange chromatography. It was stable at room temperature in aqueous solution over several days, in human blood in vitro for at least 24 h (showing no binding to either cells or proteins), in urine over at least 15 h, and during nebulization in both ultrasonic and jet nebulizers.

Differential diagnosis of retinitis and choroiditis in patients with acquired immunodeficiency syndrome

Patients with acquired immunodeficiency syndrome (AIDS) are at high risk for developing retinitis. The most common forms of retinitis in such patients are those caused by cytomegalovirus (CMV) and Toxoplasma; however, retinitis or choroiditis can also be caused by other viral, protozoal, bacterial, and fungal agents. Differential diagnosis of these infections is based on a number of factors, including ophthalmoscopic appearance, underlying disease, clinical history, and severity of underlying immunosuppression. Rapid and accurate diagnosis is essential in preserving functional vision, as some forms of retinitis are rapidly progressive and since appropriate treatment varies by diagnosis.

A preliminary evaluation of 566C80 for the treatment of Pneumocystis pneumonia in patients with the acquired immunodeficiency syndrome

BACKGROUND

The drug 566C80 is an investigational hydroxynaphthoquinone that is active against Pneumocystis carinii in vitro and in animal models. Initial studies in humans indicate that 566C80 is safe and has adequate bioavailability after oral administration.

METHODS

We conducted an open-label trial of 566C80 in 34 adults with the acquired immunodeficiency syndrome (AIDS) and untreated pneumocystis pneumonia. All the patients had a partial pressure of arterial oxygen of at least 60 mm Hg while breathing room air. They were enrolled sequentially in three cohorts taking 566C80 at different dosages, all administered orally: 750 mg three times daily for 5 days, then twice daily for 16 days; 750 mg three times daily for 21 days; and 750 mg four times daily for 21 days.

RESULTS

All 34 patients survived, and 27 (79 percent) were successfully treated with 566C80 alone. The mean partial pressure of oxygen in 33 patients was 78 mm Hg at entry and 93 mm Hg after the course of 566C80 (P less than 0.001). In five patients (15 percent) the drug was discontinued because of lack of response. In four patients (12 percent), the drug was discontinued because of toxicity (fever and rash in two patients each). In two of these, treatment was considered to have succeeded because 566C80 was not discontinued because of toxicity until after day 14. Five of the successfully treated patients had rashes that resolved despite continued therapy. In nine patients, serum alanine aminotransferase levels rose above 100 U per liter. During the first three months after the completion of therapy, pneumocystis pneumonia recurred in 4 of the 27 successfully treated patients, and another 3 patients had recurrences between month 3 and month 6 of follow-up. The mean (+/- SEM) steady-state plasma levels of 566C80 were similar in the three cohorts: 16.3 +/- 2.10, 20.4 +/- 2.48, and 18.9 +/- 3.08 micrograms per milliliter in the patients taking the drug twice daily, three times daily, and four times daily, respectively.

CONCLUSIONS

From these preliminary data, the investigational compound 566C80 appears to be a safe, effective, and well-tolerated therapy for P. carinii pneumonia of mild-to-moderate severity in patients with AIDS.

Case report: hypothyroidism due to pneumocystis carinii thyroiditis in a patient with acquired immunodeficiency syndrome

Pneumocystis carinii is the most common cause of opportunistic pulmonary infection in AIDS patients and disseminated disease is being recognized with increasing frequency. We describe a patient with cavitary pulmonary disease, lymphadenopathy, thyroiditis, and associated hypothyroidism, all a result of P. carinii. The organism was easily demonstrated in a fine-needle aspirate specimen of the thyroid. This is the second reported case of clinically apparent Pneumocystis thyroiditis and the first reported case of hypothyroidism due to an opportunistic infection in a patient with AIDS. Clinicians should be aware of this entity and request a Grocott-Gomori methenamine-silver nitrate stain of appropriate cytology specimens to make the diagnosis.

A multicenter study of Pneumocystis choroidopathy

We studied 21 patients with the acquired immunodeficiency syndrome and presumed Pneumocystic carinii choroidopathy. The lesions were characteristically yellow to pale yellow in color, appeared at the level of the choroid, and were found in the posterior pole. They varied in size from 300 to 3,000 microns, initially increasing in number before treatment and eventually resolving after systemic antimicrobial therapy. Of the 21 patients, 18 (86%) had received inhaled pentamidine as prophylaxis against Pneumocystis pneumonia. Visual acuity and visual field testing showed little evidence of retinal destruction. Survival after the diagnosis of the choroidopathy ranged from two to 36 weeks. Pneumocystic choroidopathy offers an easily accessible clue to disseminated Pneumocystis infection. When comparing drugs for Pneumocystis prophylaxis, careful ocular examination can provide one indicator of the relative efficacy of protection against extrapulmonary disease.

Pneumocystis carinii, an opportunist in immunocompromised patients

Pneumocystis carinii has been recognized as a cause of pneumonia in immunocompromised patients for over 40 years. Until the 1980s, Pneumocystis pneumonia (pneumocystosis) was most often seen in patients undergoing chemotherapy for malignancy or transplantation. Infection could be prevented by trimethoprim-sulfamethoxazole prophylaxis; thus, it was an uncommon clinical problem. With the onset of the AIDS epidemic, Pneumocystis pneumonia has become a major problem in the United States because it develops in approximately 80% of patients with AIDS and because almost two-thirds of patients have adverse reactions to anti-Pneumocystis drugs. Thus, physicians and laboratories in any community may be called upon to diagnose and provide care for patients with Pneumocystis pneumonia. The classification of the organism is currently controversial, but it is either a protozoan or a fungus. P. carinii appears to be acquired during childhood by inhalation and does not cause clinical disease in healthy persons but remains latent. If the person becomes immunosuppressed, the latent infection may become activated and lead to clinical disease. Damage of type I pneumocytes by Pneumocystis organisms leads to the foamy alveolar exudate which is characteristic of the disease. Diagnosis is established by morphologic demonstration of Pneumocystis organisms in material from the lungs. Current efforts to find better anti-Pneumocystis drugs should provide more effective therapy and prophylaxis.