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Zhang J, Kamoi K, Zong Y, Yang M, Zou Y, Miyagaki M, Ohno-Matsui K. Cytomegalovirus Retinitis: Clinical Manifestations, Diagnosis and Treatment. Viruses 2024; 16:1427. [PMID: 39339903 PMCID: PMC11437412 DOI: 10.3390/v16091427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Revised: 08/27/2024] [Accepted: 09/06/2024] [Indexed: 09/30/2024] Open
Abstract
Cytomegalovirus (CMV) retinitis is the most common eye disease associated with CMV infection in immunocompromised individuals. The CMVR may initially be asymptomatic; however, relatively mild vitreous inflammation at the onset may be an important differential point from other diseases in HIV patients. Fundus photography, CD4 T-cell count, and telemedicine could be used to screen and monitor the high-risk population, particularly in resource-limited regions. Retinitis generally starts in the peripheral retina and advances toward the posterior pole, which could develop to the characteristic "pizza pie" appearance marked by central retinal necrosis and intraretinal hemorrhage. CMVR causes vision loss if left untreated, and early antiviral therapy significantly reduces the risk of vision loss. Alongside traditional antiviral treatments, immunotherapies including CMV-specific adoptive T-cell therapy and CMV immunoglobulin (CMVIG) are emerging as promising treatment options due to their favorable tolerability and reduced mortality. This review comprehensively examines CMV retinitis, encompassing the clinical features, differential diagnosis, laboratory tests, and updated treatment strategies to inform clinical management.
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Affiliation(s)
| | - Koju Kamoi
- Department of Ophthalmology and Visual Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8510, Japan; (J.Z.); (Y.Z.); (M.Y.); (Y.Z.); (M.M.); (K.O.-M.)
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2
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Jabs DA, Schneider MF, Pak JW, Beck-Engeser G, Chan F, Ambayec GC, Hunt PW. Association of Intermediate-Stage Age-Related Macular Degeneration with Plasma Inflammatory Biomarkers in Persons with AIDS. OPHTHALMOLOGY SCIENCE 2024; 4:100437. [PMID: 38304607 PMCID: PMC10831313 DOI: 10.1016/j.xops.2023.100437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/26/2023] [Accepted: 11/16/2023] [Indexed: 02/03/2024]
Abstract
Purpose To evaluate associations of plasma levels of inflammatory biomarkers with age-related macular degeneration (AMD) and cataract in persons with AIDS. Design Nested case-control study (analysis 1) and nested cohort study (analysis 2). Participants Analysis 1: persons with AIDS and incident intermediate-stage AMD (n = 26) and controls without AMD matched for age, race/ethnicity, and gender (n = 49) from The Longitudinal Study of Ocular Complications of AIDS. Analysis 2: 475 persons from LSOCA with baseline plasma biomarker levels followed prospectively for cataract. Methods In both analyses, cryopreserved plasma specimens obtained at baseline were assayed for monocyte chemoattractant protein (MCP)-1 (CC motif chemokine ligand [CCL] 2), macrophage inflammatory protein (MIP)-1β (CCL4), soluble tumor necrosis factor receptor (sTNFR) 2, interleukin (IL)-18, and fractalkine (CX3 motif chemokine ligand 1 [CX3CL1]). Main Outcome Measures Analysis 1: mean difference (cases - controls) in plasma biomarker levels. Analysis 2: incident cataract. Results After adjusting for plasma human immunodeficiency virus RNA level, CD4+ T-cell count, and smoking, elevated baseline plasma levels of sTNFR2 and IL-18 (mean differences [cases - controls] 0.11 log10[pg/mL]; 95% confidence interval [CI], 0.01-0.20; P = 0.024 and 0.13 log10[pg/mL]; 95% CI, 0.01-0.24; P = 0.037, respectively) each were associated with incident AMD. In a competing risk (with mortality) analysis, elevated baseline standardized log10 plasma levels of MCP-1, sTNFR2, IL-18, and fractalkine each were associated with a decreased cataract risk. Conclusions When combined with previous data suggesting that AMD is associated with elevated plasma levels of C-reactive protein, soluble CD14, and possibly IL-6, the association of elevated plasma levels of sTNFR2 and IL-18 with incident AMD, but not with incident cataract, suggests that innate immune system activation, and possibly NLRP3 inflammasome activation, may play a role in the pathogenesis of AMD in this population. Financial Disclosures The authors have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
- Douglas A. Jabs
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Wilmer Eye Institute, the Department of Ophthalmology, the Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael F. Schneider
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jeong Won Pak
- Department of Ophthalmology and Visual Sciences, the University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Gabriele Beck-Engeser
- Department of Medicine, the University of California, San Francisco, School of Medicine, San Francisco, California
| | - Fay Chan
- Department of Medicine, the University of California, San Francisco, School of Medicine, San Francisco, California
| | - Gabrielle C. Ambayec
- Department of Medicine, the University of California, San Francisco, School of Medicine, San Francisco, California
| | - Peter W. Hunt
- Department of Medicine, the University of California, San Francisco, School of Medicine, San Francisco, California
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Caplash S, Paez-Escamilla M, Westcott M, Dansingani KK, Indermill C, Kisma N, Frau E, Sahel JA, Bodaghi B, Jhanji V, Errera MH. Mimickers of anterior uveitis, scleritis and misdiagnoses- tips and tricks for the cornea specialist. J Ophthalmic Inflamm Infect 2024; 14:14. [PMID: 38594487 PMCID: PMC11004105 DOI: 10.1186/s12348-024-00396-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 03/29/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Anterior uveitis, inflammation of the anterior chamber and related structures, is a cohort of diseases that can present to almost any general or sub-specialty Ophthalmology practice. Its features classically involve anterior chamber cell and flare. Below the surface of these two signs exist a panoply of diagnoses. BODY: The purpose of this review is to provide a general framework for diagnoses of anterior uveitis that are often missed as well as non-uveitic pathologies that often mimic anterior uveitis. Diagnostic deviation in either direction can have vision-threatening and rarely life-threatening consequences for patients. Using a comprehensive literature review we have collected a broad spectrum of etiologies of anterior uveitis that are easily missed and non-uveitic pathologies that can masquerade as anterior uveitis. CONCLUSIONS We present a focused review on specific misdiagnosed anterior uveitis pathologies and some of the conditions that can masquerade as anterior uveitis and scleritis.
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Affiliation(s)
- Sonny Caplash
- Department of Ophthalmology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Manuel Paez-Escamilla
- Department of Ophthalmology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Mark Westcott
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, EC1V 2PD, UK
| | - Kunal K Dansingani
- Department of Ophthalmology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Chad Indermill
- Department of Ophthalmology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Nacima Kisma
- Universite Libre de Bruxelles, Hopital Universitaire de Bruxelles, 808 route de Lennik 1170, Bruxelles, Belgium
| | - Eric Frau
- Department of Ophthalmology, Centre hospitalier National des Quinze-Vingts, Paris, France
| | - Jose-Alain Sahel
- Department of Ophthalmology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Bahram Bodaghi
- Department of Ophthalmology, Pitié-Salpêtrière University Hospital, Sorbonne Universités, F-75013, Paris, France
| | - Vishal Jhanji
- Department of Ophthalmology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Marie-Helene Errera
- Department of Ophthalmology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA, 15213, USA.
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4
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Jabs DA, Van Natta ML, Schneider MF, Pak JW, Trang G, Jones NG, Milush J, Hunt PW. Association of elevated plasma inflammatory biomarker levels with age-related macular degeneration but not cataract in persons with AIDS. AIDS 2022; 36:177-184. [PMID: 34934018 PMCID: PMC9153135 DOI: 10.1097/qad.0000000000003104] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate the relationship between plasma biomarkers of systemic inflammation and incident age-related macular degeneration (AMD) in persons with the AIDS. DESIGN Case-control study. METHODS Participants with incident intermediate-stage AMD (N = 26) in the Longitudinal Study of the Ocular Complications of AIDS (LSOCA) and controls (N = 60) without AMD. Cryopreserved baseline plasma specimens were assayed for biomarkers of inflammation, including high-sensitivity C-reactive protein (CRP), interleukin (IL)-6, interferon-γ inducible protein (IP)-10, soluble CD14 (sCD14), soluble CD163 (sCD163), and intestinal fatty acid-binding protein (I-FABP). RESULTS After adjustment for age, sex, and race/ethnicity, baseline mean ± standard deviation (SD) log10(mg/ml) plasma levels of CRP (0.52 ± 0.60 vs. 0.20 ± 0.43; P = 0.01) and mean ± SD log10(pg/ml) plasma levels of sCD14 (6.31 ± 0.11 vs. 6.23 ± 0.14; P = 0.008) were significantly higher among cases (incident AMD) than among controls (no AMD). There was a suggestion that mean ± SD baseline log10(pg/ml) plasma IL-6 levels (0.24 ± 0.33 vs. 0.11 ± 0.29; P = 0.10) might be higher among cases than controls. In a separate analysis of 548 participants in LSOCA, elevated baseline levels of plasma inflammatory biomarkers were associated with a greater risk of mortality but not with an increased risk of incident cataract. CONCLUSION These data suggest that systemic inflammatory biomarkers are associated with incident AMD but not incident cataract in persons with AIDS, and that systemic inflammation may play a role in the pathogenesis of AMD.
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Affiliation(s)
- Douglas A Jabs
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health
- The Wilmer Eye Institute, Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark L Van Natta
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health
| | - Michael F Schneider
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health
| | - Jeong Won Pak
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Garrett Trang
- Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Norman G Jones
- Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Jeffrey Milush
- Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Peter W Hunt
- Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California, USA
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5
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Classification Criteria for Cytomegalovirus Retinitis. Am J Ophthalmol 2021; 228:245-254. [PMID: 33845015 PMCID: PMC8594755 DOI: 10.1016/j.ajo.2021.03.051] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 01/29/2021] [Accepted: 03/31/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE The purpose of this study was to determine classification criteria for cytomegalovirus (CMV) retinitis. DESIGN Machine learning of cases with CMV retinitis and 4 other infectious posterior/ panuveitides. METHODS Cases of infectious posterior/panuveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on diagnosis using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used in the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the infectious posterior/panuveitides. The resulting criteria were evaluated in the validation set. RESULTS A total of 803 cases of infectious posterior/panuveitides, including 211 cases of CMV retinitis, were evaluated by machine learning. Key criteria for CMV retinitis included: 1) necrotizing retinitis with indistinct borders due to numerous small satellites; 2) evidence of immune compromise; and either 3) a characteristic clinical appearance, or 4) positive polymerase chain reaction assay results for CMV from an intraocular specimen. Characteristic appearances for CMV retinitis included: 1) wedge-shaped area of retinitis; 2) hemorrhagic retinitis; or 3) granular retinitis. Overall accuracy for infectious posterior/panuveitides was 92.1% in the training set and 93.3% (95% confidence interval: 88.2-96.3) in the validation set. The misclassification rates for CMV retinitis were 6.9% in the training set and 6.3% in the validation set. CONCLUSIONS The criteria for CMV retinitis had a low misclassification rate and appeared to perform sufficiently well for use in clinical and translational research.
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Sudharshan S, Babu RB, Nair N, Biswas J. Combined infection of ocular tuberculoma and cytomegalovirus retinitis in the same eye of a patient with human immunodeficiency virus. Indian J Ophthalmol 2021; 68:1965-1967. [PMID: 32823438 PMCID: PMC7690518 DOI: 10.4103/ijo.ijo_1321_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | | | - Nivedita Nair
- Medical Research Foundation, Sankara Nethralaya, Bengaluru, Karnataka, India
| | - Jyotirmay Biswas
- Medical Research Foundation, Sankara Nethralaya, Bengaluru, Karnataka, India
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Lee WS, Parsons S, Cugley D, Rogers S, Lim LL, Hall A. Increased incidence of glaucoma medication usage in middle-aged Australian males taking antiretroviral medication - a population-based study. J Ophthalmic Inflamm Infect 2020; 10:30. [PMID: 33141357 PMCID: PMC7609505 DOI: 10.1186/s12348-020-00218-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 10/12/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND To investigate a possible association between glaucoma and the use of anti-retroviral therapy (ART) for HIV in the Australian population. METHODS A retrospective review of Australian Pharmaceutical Benefits Scheme data was undertaken from July 2012 to December 2016, inclusive. Three patient groups were compared: those on both topical intraocular pressure (IOP) -lowering medication and ART, those on ART only, and those on IOP-lowering medication only, using the 2016 Australian resident population to estimate prevalence. Odds ratios (95% confidence intervals, [CI]) with Fishers exact test for p values were calculated stratified by age and gender. RESULTS The number of prescriptions for topical glaucoma medications in the general Australian population increased progressively by age with a peak prevalence in those aged 80 years and above. Prevalence of ART was highest in males aged 40-49 and 50-59 years (0.41% [CI 0.40, 0.42] and 0.44% [CI 0.43, 0.45], respectively). Our analysis identified an increase in the prescription of IOP-lowering medication in males on ART aged 30-39 (OR 2.23 [CI 1.32, 3.75], p = 0.007) and 40-49 (OR 1.86 [CI 1.42, 2.43], p < 0.001), compared to those not on ART. There were no statistically significant increased odds for females or males aged 50 years or more. CONCLUSION Compared with the known increase in glaucoma prevalence with age in the general Australian population, a statistically significant increased prevalence in use of IOP-lowering medications was found in males on ART aged 30-49 years. The mechanism for this is yet to be determined, but possible causes include sequelae of HIV infection, a drug-induced side effect, or increased medical surveillance.
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Affiliation(s)
- Wen-Shen Lee
- Ophthalmology, The Alfred Hospital, Alfred Health, Melbourne, Australia
| | - Shaun Parsons
- Ophthalmology, The Alfred Hospital, Alfred Health, Melbourne, Australia.,Ophthalmology, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
| | - Dean Cugley
- Ophthalmology, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
| | - Sophie Rogers
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
| | - Lyndell L Lim
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia.,Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Anthony Hall
- Ophthalmology, The Alfred Hospital, Alfred Health, Melbourne, Australia.
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Abstract
PURPOSE OF REVIEW This review provides a historic perspective of the impact that major pandemics have had on human and their relationship with ophthalmology. The novel coronavirus epidemic is also analyzed, highlighting the relevance of the eye as a possible source of transmission, infection, and prognosis for the disease. RESULTS Smallpox is suspected to be present for more than 12 000 years. However, trachoma seems to be the first recorded ophthalmological infectious disease. The deadliest pandemics include the bubonic plague, smallpox, and Spanish flu. The CoVID-19 epidemic is still developing and measures need to be implemented to prevent further escalation of the crisis. SUMMARY Understanding the current facts in light of earlier historical evidence may help us prepare better to minimize the spread of infections in the future.
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Affiliation(s)
| | | | - Aaron Gold
- Murray Ocular Oncology and Retina, Miami, Florida, USA
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9
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Berkenstock M, Mopuru R, Thorne J, Scott AW. Analysis of new cases of uveitis at academic and community settings. Br J Ophthalmol 2020; 105:779-782. [PMID: 32727730 DOI: 10.1136/bjophthalmol-2020-316651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/01/2020] [Accepted: 06/20/2020] [Indexed: 11/04/2022]
Abstract
PURPOSE Describe the demographics of new patients with uveitis presenting to an urban, academic centre and affiliated, suburban satellite clinics to assess if changes in infrastructure were needed for clinical care. Secondarily, examine the frequency of infectious uveitides. METHODS A retrospective chart review of single academic centre of 436 consecutive, new patients with uveitis (686 eyes) and 3 affiliated, satellite clinics seen by 8 uveitis specialists from 1 July 2013 to 31 March 2017. Demographics recorded included patient age, race, associated systemic disease, uveitis chronicity, and anatomic location. The main outcome measure was comparing frequencies of patient demographics, immunosuppressive agent use, and infectious uveitis between locations. RESULTS 366 patients (587 eyes) were evaluated at the academic clinic and 70 (99 eyes) at the satellite locations. Anterior uveitis was the most common anatomic location; more acute, unilateral cases were seen at satellites (p=0.007; p=0.002, respectively). A larger percentage of posterior and panuveitis cases presented to the academic centre (p<0.0001). There was no difference in systemic disease association (p=0.925) or infectious uveitis cases (p=0.956). The use of non-corticosteroid immunosuppressive medications was higher at the academic clinic (p<0.001). CONCLUSIONS Anterior uveitis comprised the majority of cases in both clinics. Non-corticosteroid immunosuppressive agents were used more frequently at the academic clinic, reflecting more cases of chronic posterior and panuveitis. Compounded intravitreal injections, specialised ophthalmic imaging studies and high-risk medication monitoring can be centralised in the academic clinic. Infectious uveitis cases were seen at both locations, with an increase in syphilis diagnoses at the academic centre.
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Affiliation(s)
- Meghan Berkenstock
- Ocular Immunology Division, Johns Hopkins Wilmer Eye Institute, Baltimore, Maryland, USA
| | - Renuka Mopuru
- Ocular Immunology Division, Johns Hopkins Wilmer Eye Institute, Baltimore, Maryland, USA
| | - Jennifer Thorne
- Ocular Immunology Division, Johns Hopkins Wilmer Eye Institute, Baltimore, Maryland, USA
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10
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Testi I, Mahajan S, Agrawal R, Agarwal A, Marchese A, Curi A, Khairallah M, Leo YS, Nguyen QD, Gupta V. Management of Intraocular Infections in HIV. Ocul Immunol Inflamm 2020; 28:1099-1108. [PMID: 32162992 DOI: 10.1080/09273948.2020.1727533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose: Overview of treatment options for the most common intraocular opportunistic infections in patients with acquired immunodeficiency syndrome (AIDS), including ocular syphilis, ocular tuberculosis, toxoplasmic chorioretinitis, and viral retinitis. Method: Narrative Review. Results: Despite the huge advances in the development of combined antiretroviral therapy (cART) for the management of patients with human immunodeficiency virus (HIV) infection, opportunistic infections still represent a significant diagnostic dilemma and cause of ocular morbidity in patients with HIV. Conclusion: Although the treatment of intraocular infections in patients with AIDS may be challenging, prompt assessment of the clinical features and appropriate aggressive management of the underlying etiology are critical to avoid life and vision threatening.
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Affiliation(s)
- Ilaria Testi
- Moorfields Eye Hospital, NHS Foundation Trust , London, UK
| | - Sarakshi Mahajan
- Byers Eye Institute, Stanford University , Palo Alto, California, USA
| | - Rupesh Agrawal
- Moorfields Eye Hospital, NHS Foundation Trust , London, UK.,National Healthcare Group Eye Institute, Tan Tock Seng Hospital , Singapore, Singapore.,Singapore Eye Research Institute , Singapore, Singapore
| | - Aniruddha Agarwal
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh, India
| | - Alessandro Marchese
- Department of Ophthalmology, Scientific Institute San Raffaele, University Vita-Salute San Raffaele , Milan, Italy
| | - Andre Curi
- Research Laboratory of Infectious Diseases in Ophthalmology, National Institute of Infectious Diseases, Oswaldo Cruz Foundation , Rio de Janeiro, Brazil
| | - Moncef Khairallah
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir , Monastir, Tunisia
| | - Yee Sin Leo
- National Center for Infectious Disease, Tan Tock Seng Hospital , Singapore, Singapore
| | - Quan Dong Nguyen
- Byers Eye Institute, Stanford University , Palo Alto, California, USA
| | - Vishali Gupta
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh, India
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11
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Testi I, Ahmed S, Shah C, Agrawal R. Challenges in Treating Intraocular Inflammation in HIV Patients. Ocul Immunol Inflamm 2020; 28:1094-1098. [PMID: 32159416 DOI: 10.1080/09273948.2020.1726971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Purpose: To describe the challenges faced by uveitis specialists when managing human immunodeficiency virus (HIV) -infected patients diagnosed with ocular opportunistic infections. Methods: Narrative Review Results: Management of opportunistic ocular infections in HIV-infected subjects still represents a diagnostic and therapeutic challenge. Atypical and aggressive clinical features can often mislead the correct diagnosis, leading to a delay in therapy and thus, a poor clinical outcome. The reliability of standard serological tests may be affected by the immune system response, further contributing to the diagnostic challenge. Life-long monitoring and long-term antimicrobial maintenance are necessary to avoid recurrences and disease dissemination. Conclusions: A multidisciplinary approach is needed to achieve the best standard of care for HIV patients with ocular opportunistic infections.
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Affiliation(s)
- Ilaria Testi
- Moorfields Eye Hospital, NHS Foundation Trust , London, UK
| | - Safia Ahmed
- Cardiff China Medical Research Collaborative , Cardiff, UK.,Khmer Sight Foundation , Phnom Penh, Cambodia
| | - Camrun Shah
- Khmer Sight Foundation , Phnom Penh, Cambodia.,Exeter University , Exeter, UK
| | - Rupesh Agrawal
- Moorfields Eye Hospital, NHS Foundation Trust , London, UK.,Tan Tock Seng Hospital, National Health Care Group Eye Institute , Singapore, Singapore
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12
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Holland GN, Van Natta ML, Goldenberg DT, Ritts R, Danis RP, Jabs DA. Relationship Between Opacity of Cytomegalovirus Retinitis Lesion Borders and Severity of Immunodeficiency Among People With AIDS. Invest Ophthalmol Vis Sci 2019; 60:1853-1862. [PMID: 31042791 PMCID: PMC6890425 DOI: 10.1167/iovs.18-26517] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose To evaluate risk factors for severity of cytomegalovirus (CMV) retinitis lesion whitening (opacity), using a standardized scoring system. Methods We performed a cross-sectional, observational investigation of all individuals with newly diagnosed AIDS-related CMV retinitis in three randomized clinical trials and one prospective observational study. Opacity was scored by masked readers, using a prospectively defined ordinal 6-point scale. Demographic factors, laboratory data (CD4+, CD8+ T-lymphocyte counts, human immunodeficiency virus [HIV] blood levels), and lesion characteristics (location, size) were compared to the highest opacity score assigned to either eye. Among eyes with active lesions (scores ≥3), factors associated with severe opacity (scores 5, 6) were identified. Results There were 299 participants (401 eyes with CMV retinitis). In one or more comparisons, increased opacity was associated with lower CD4+ and lower CD8+ T-lymphocyte counts, higher HIV blood level, lack of antiretroviral therapy, male sex, race/ethnicity, and bilateral disease. In eyes with active disease, severe opacity was associated with lower CD4+ T-lymphocyte count, higher HIV blood level, older age, Karnofsky score, lesion size, and bilateral disease. No relationship was identified between opacity and lesion location. Conclusions Lesion border opacity (resulting from CMV activity) reflects level of immune function; as immunodeficiency becomes worse, CMV activity (and opacity) increases. The positive relationship between opacity and HIV blood level may reflect both immunodeficiency and increased CMV activity caused by transactivation of CMV by HIV. Scoring of opacity may be a useful, standard measure for continued study of CMV retinitis across different settings and populations. (Clinicaltrials.gov number for the HPMPC CMV Retinitis Trial: NCT00000142; Clinicaltrials.gov number for the Monoclonal Antibody CMV Retinitis Trial: NCT00000135; Clinicaltrials.gov number for the Ganciclovir-Cidofovir CMV Retinitis Trial: NCT0000014; Clinicaltrials.gov number for the Longitudinal Study of the Ocular Complications of AIDS: NCT00000168.).
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Affiliation(s)
- Gary N Holland
- Ocular Inflammatory Disease Center, UCLA Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Mark L Van Natta
- Center for Clinical Trials, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - David T Goldenberg
- Ocular Inflammatory Disease Center, UCLA Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Rory Ritts
- Ocular Inflammatory Disease Center, UCLA Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Ronald P Danis
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, Wisconsin, United States
| | - Douglas A Jabs
- Center for Clinical Trials, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States.,Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York, United States.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States
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13
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Hu F, Du Y, Peng XY. Successively bilateral cytomegalovirus retinitis in immunocompromised patient with Good's syndrome. Int J Ophthalmol 2018; 11:2021-2023. [PMID: 30588440 DOI: 10.18240/ijo.2018.12.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 11/21/2018] [Indexed: 11/23/2022] Open
Affiliation(s)
- Feng Hu
- Beijing Institute of Ophthalmology, Beijing 100005, China.,Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Yuan Du
- Beijing Institute of Ophthalmology, Beijing 100005, China.,Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Xiao-Yan Peng
- Beijing Institute of Ophthalmology, Beijing 100005, China.,Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
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Sezgin E, Van Natta ML, Thorne JE, Puhan MA, Jabs DA. Secular trends in opportunistic infections, cancers and mortality in patients with AIDS during the era of modern combination antiretroviral therapy. HIV Med 2018; 19:411-419. [PMID: 29573311 DOI: 10.1111/hiv.12609] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of the study was to estimate the incidence of, determine risk factors for, and investigate the consequences of opportunistic infections (OIs) and malignancies among patients with the acquired immune deficiency syndrome (AIDS) in the era of modern combination antiretroviral therapy (cART). METHODS Three enrolment periods (1998-2002, 2003-2005 and 2006-2012), corresponding to changes in predominant cART regimens, were compared among 1889 participants enrolled in a prospective cohort study, the Longitudinal Study of Ocular Complications of AIDS (LSOCA). Incidences of AIDS-related OIs and cancers were estimated. Multivariate logistic and Cox regression models were used to determine the effect of demographic and clinical characteristics on OIs and mortality. RESULTS Between participants enrolled in the 1998-2002 and 2006-2012 enrolment periods, the incidence of OIs decreased from 27 per 1000 person-years (PY) to 11 per 1000 PY (P < 0.001), and mortality decreased from 41 per 1000 PY to 18 per 1000 PY (P < 0.0001), corresponding to improvements in cART regimens. CONCLUSIONS Improvements in cART regimens led to a progressive decline in the incidence of OIs and mortality between 1999 and 2013 among patients with AIDS in the era of modern cART.
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Affiliation(s)
- E Sezgin
- Laboratory of Nutrigenomics and Epidemiology, Department of Food Engineering, Izmir Institute of Technology, Izmir, Turkey.,Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - M L Van Natta
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - J E Thorne
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Ophthalmology, The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - M A Puhan
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.,Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - D A Jabs
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Jabs DA, Van Natta ML, Pak JW, Danis RP, Hunt PW. Association of Retinal Vascular Caliber and Age-Related Macular Degeneration in Patients With the Acquired Immunodeficiency Syndrome. Invest Ophthalmol Vis Sci 2018; 59:904-908. [PMID: 29435590 PMCID: PMC5812413 DOI: 10.1167/iovs.17-23334] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 01/15/2018] [Indexed: 02/01/2023] Open
Abstract
Purpose To evaluate the relationship between retinal vascular caliber and AMD in patients with AIDS. Methods Participants enrolled in the Longitudinal Study of the Ocular Complications of AIDS had retinal photographs taken at enrollment. Retinal vascular caliber (central retinal artery equivalent [CRAE] and central retinal vein equivalent [CRVE]) and intermediate-stage AMD were determined from these retinal photographs. Photographs were evaluated by graders at a centralized reading center, using the Age-Related Eye Disease Study grading system for AMD and semiautomated techniques for evaluating retinal vascular caliber. Results Of the 1171 participants evaluated, 110 (9.4%) had AMD and 1061 (90.6%) did not. Compared with participants without AMD, participants with AMD had larger mean CRAEs (151 ± 16 μm versus 147 ± 16 μm; P = 0.009) and mean CRVEs (228 ± 24 μm versus 223 ± 25 μm; P = 0.02). The unadjusted differences were: CRAE, 4.3 μm (95% confidence interval [CI] 1.1-7.5; P = 0.009) and CRVE, 5.5 μm (95% CI 0.7-10.3; P = 0.02). After adjustment for age, race/ethnicity, sex, human immunodeficiency syndrome (HIV) transmission category, smoking, enrollment and nadir CD4+ T cells, and enrollment and maximum HIV load, the differences between patients with and without AMD were as follows: CRAE, 5.4 μm (95% CI 2.3-8.5; P = 0.001) and CRVE, 6.0 μm (95% CI 1.4-10.6; P = 0.01). Conclusions In patients with AIDS, AMD is associated with greater retinal arteriolar and venular calibers, suggesting a role for shared pathogenic mechanisms, such as persistent systemic inflammation.
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Affiliation(s)
- Douglas A. Jabs
- Department of Ophthalmology, The Icahn School of Medicine at Mount Sinai, New York, New York, United States
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, United States
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Mark L. Van Natta
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Jeong Won Pak
- Department of Ophthalmology, The University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Ronald P. Danis
- Department of Ophthalmology, The University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Peter W. Hunt
- The Department of Medicine, The University of California, San Francisco School of Medicine, San Francisco, California, United States
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16
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Jabs AW, Jabs DA, Van Natta ML, Palella FJ, Meinert CL. Insurance status and mortality among patients with AIDS. HIV Med 2017; 19:7-17. [PMID: 28696029 DOI: 10.1111/hiv.12531] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2017] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The aim of the study was to evaluate risk factors for mortality, including health care insurance status, among patients with AIDS in the era of modern combination antiretroviral therapy (cART). METHODS This study was part of the prospective, multicentre, observational Longitudinal Study of the Ocular Complications of AIDS (LSOCA). Patients were classified as having private health care insurance, Medicare, Medicaid, or no insurance. Hazard ratios (HRs) for death were calculated using proportional hazards regression models and staggered entries, anchored to the AIDS diagnosis date. RESULTS Among 2363 participants with AIDS, 97% were treated with cART. At enrolment, 31% of participants had private insurance, 29% had Medicare, 24% had Medicaid, and 16% were uninsured. Noninfectious, age-related diseases, such as hypertension, diabetes, and renal disease, were more frequent among persons with Medicare than among those with private insurance. Compared with those who were privately insured, mortality was greater among participants with Medicare [adjusted HR (HRadj ) 1.35; 95% confidence interval (CI) 1.08-1.67; P = 0.008]. Among participants with a suppressed HIV viral load, compared with those who were privately insured, HRadj values for mortality were 1.93 (95% CI 1.08-3.44; P = 0.02) for those with Medicare and 2.09 (95% CI 1.02-4.27; P = 0.04) for those with Medicaid. Mortality among initially uninsured participants was not significantly different from that for privately insured participants, but these participants typically obtained ART and insurance during follow-up. Compared with privately insured participants, time-updated HRadj values for mortality were 1.34 (95% CI 1.05-1.70; P = 0.02) for those with Medicare, 1.34 (95% CI 1.01-1.80; P = 0.05) for those with Medicaid, and 1.35 (95% CI 0.97-1.88; P = 0.05) for those who were uninsured. CONCLUSIONS In persons with AIDS, compared with those with private insurance, those with public insurance had increased mortality, possibly as a result of a greater burden of noninfectious, age-related diseases.
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Affiliation(s)
- A W Jabs
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - D A Jabs
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.,Departments of Ophthalmology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Departments of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - M L Van Natta
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - F J Palella
- Department of Medicine, The Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - C L Meinert
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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17
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Jabs DA, Van Natta ML, Pak JW, Danis RP, Hunt PW. Incidence of Intermediate-stage Age-related Macular Degeneration in Patients With Acquired Immunodeficiency Syndrome. Am J Ophthalmol 2017; 179:151-158. [PMID: 28499708 DOI: 10.1016/j.ajo.2017.05.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 04/28/2017] [Accepted: 05/01/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate the incidence of intermediate-stage age-related macular degeneration (AMD) in patients with acquired immunodeficiency syndrome (AIDS). DESIGN Cohort study. METHODS Patients enrolled in the Longitudinal Study of the Ocular Complications of AIDS (LSOCA) underwent 5- and 10-year follow-up retinal photographs. Intermediate-stage AMD (AREDS stage 3) was determined from these photographs by graders at a centralized Reading Center, using the Age-Related Eye Disease Study-2 grading system. The incidence of AMD in LSOCA was compared with that in the Multi-Ethnic Study of Atherosclerosis (MESA), a Human Immunodeficiency Virus (HIV)-uninfected cohort, which used a similar photographic methodology. RESULTS The incidence of AMD in LSOCA was 0.65/100 person-years (PY). In a multivariate analysis the only significant risk factor for AMD in LSOCA was smoking; the relative risk vs never-smokers was 3.4 for former smokers (95% confidence interval [CI] 1.3, 9.5; P = .02) and 3.3 for current smokers (95% CI 1.1, 9.7; P = .03). Compared with the MESA cohort, the race/ethnicity- and sex-adjusted risk of AMD in LSOCA was 1.75 (95% CI 1.16, 2.64; P = .008), despite the fact that the mean age of the MESA cohort was 17 years greater than the LSOCA cohort (61 ± 9 years vs 44 ± 8 years). CONCLUSIONS Patients with AIDS have a 1.75-fold increased race- and sex-adjusted incidence of intermediate-stage AMD compared with that found in an HIV-uninfected cohort. This increased incidence is consistent with the increased incidence of other age-related diseases in antiretroviral-treated, immune-restored, HIV-infected persons when compared with HIV-uninfected persons.
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Abshire M, Dinglas VD, Cajita MIA, Eakin MN, Needham DM, Himmelfarb CD. Participant retention practices in longitudinal clinical research studies with high retention rates. BMC Med Res Methodol 2017; 17:30. [PMID: 28219336 PMCID: PMC5319074 DOI: 10.1186/s12874-017-0310-z] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 02/11/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND There is a need for improving cohort retention in longitudinal studies. Our objective was to identify cohort retention strategies and implementation approaches used in studies with high retention rates. METHODS Longitudinal studies with ≥200 participants, ≥80% retention rates over ≥1 year of follow-up were queried from an Institutional Review Board database at a large research-intensive U.S. university; additional studies were identified through networking. Nineteen (86%) of 22 eligible studies agreed to participate. Through in-depth semi-structured interviews, participants provided retention strategies based on themes identified from previous literature reviews. Synthesis of data was completed by a multidisciplinary team. RESULTS The most commonly used retention strategies were: study reminders, study visit characteristics, emphasizing study benefits, and contact/scheduling strategies. The research teams were well-functioning, organized, and persistent. Additionally, teams tailored their strategies to their participants, often adapting and innovating their approaches. CONCLUSIONS These studies included specialized and persistent teams and utilized tailored strategies specific to their cohort and individual participants. Studies' written protocols and published manuscripts often did not reflect the varied strategies employed and adapted through the duration of study. Appropriate retention strategy use requires cultural sensitivity and more research is needed to identify how strategy use varies globally.
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Affiliation(s)
- Martha Abshire
- Johns Hopkins University School of Nursing, 525 North Wolfe Street, Suite 527, 21287, Baltimore, MD, USA.
| | - Victor D Dinglas
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Maan Isabella A Cajita
- Johns Hopkins University School of Nursing, 525 North Wolfe Street, Suite 527, 21287, Baltimore, MD, USA
| | - Michelle N Eakin
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Cheryl Dennison Himmelfarb
- Johns Hopkins University School of Nursing, 525 North Wolfe Street, Suite 527, 21287, Baltimore, MD, USA
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
- Johns Hopkins Institute for Clinical and Translational Sciences, Johns Hopkins University, Baltimore, MD, USA
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19
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Jabs DA, Van Natta ML, Holland GN, Danis R. Cytomegalovirus Retinitis in Patients With Acquired Immunodeficiency Syndrome After Initiating Antiretroviral Therapy. Am J Ophthalmol 2017; 174:23-32. [PMID: 27984023 DOI: 10.1016/j.ajo.2016.10.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 10/12/2016] [Accepted: 10/14/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE To evaluate the rates of new-onset cytomegalovirus (CMV) retinitis and worsening existing CMV retinitis in patients with AIDS after initiating combination antiretroviral therapy (cART) and the role of an immune recovery inflammatory syndrome (IRIS). DESIGN Cohort study. METHODS Immune recovery was defined as an increase in CD4+ T cells to ≥100 cells/μL; rates of new-onset CMV retinitis and of worsening of CMV retinitis (either increasing border activity or retinitis progression) were compared between those with and without immune recovery. RESULTS Among patients without CMV retinitis, 1 of 75 patients with immune recovery developed CMV retinitis in the first 6 months after initiating cART vs 1 of 31 without immune recovery (P = .14). Among patients with CMV retinitis, the rates of retinitis progression and increasing retinitis border activity among patients during the first 6 months after initiating cART in those with immune recovery were 0.11 per person-year (PY; 95% confidence interval [CI] 0-0.62) and 0.11 per PY (95% CI 0-0.62), respectively, vs 0.67 per PY (95% CI 0.22-1.56) and 0.40 per PY (95% CI 0.08-1.17), respectively, for those without immune recovery (P = .11 and .47). CONCLUSIONS Among persons with AIDS who experience immune recovery, there was neither an increased rate of new-onset CMV retinitis nor worsening of existing CMV retinitis in the first 6 months after initiating cART vs those without immune recovery. These data are consistent with the known 3- to 6-month lag in recovery of specific immunity to CMV after initiating cART and suggest that "immune recovery retinitis," a proposed immune recovery inflammatory syndrome phenomenon, is rare.
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Affiliation(s)
- Douglas A Jabs
- Departments of Ophthalmology and Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York; Center for Clinical Trials, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.
| | - Mark L Van Natta
- Center for Clinical Trials, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Gary N Holland
- UCLA Stein Eye Institute, Department of Ophthalmology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Ronald Danis
- Department of Ophthalmology, The University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Jeon S, Lee WK. Cytomegalovirus Retinitis in a Human Immunodeficiency Virus-negative Cohort: Long-term Management and Complications. Ocul Immunol Inflamm 2016; 23:392-9. [PMID: 25760914 DOI: 10.3109/09273948.2014.985385] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To examine the clinical outcomes achieved by using intravitreal ganciclovir injections combined with systemic anti-viral therapy in treating cytomegalovirus (CMV) retinitis in patients without human immunodeficiency virus (HIV) infection. METHODS Twenty-three eyes of 15 HIV-negative patients diagnosed with CMV retinitis were included in this retrospective study. RESULTS The median follow-up was 68 weeks (range, 12-156), and median number of injections was 10 (range, 2-22). The retinal lesions stopped progressing within 1-2 weeks following treatment. All of the eyes showed either unchanged or ≥2 line improvements of BCVA at last visit. There was no development of CMV retinitis in a fellow eye, or recurrence in a studied eye. Systemic complications such as neutropenia were not detected. CONCLUSIONS Intravitreal ganciclovir injections combined with systemic anti-viral treatment is a good therapeutic option for treating CMV retinitis without HIV infection. Such treatment provided favorable visual outcomes, with minimal ocular and systemic complications.
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Affiliation(s)
- Sohee Jeon
- a Department of Ophthalmology , Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine , Seoul , South Korea
| | - Won Ki Lee
- a Department of Ophthalmology , Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine , Seoul , South Korea
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21
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Iu LP, Fan MC, Lau JK, Chan TS, Kwong YL, Wong IY. Long-term Follow-up of Cytomegalovirus Retinitis in Non-HIV Immunocompromised Patients: Clinical Features and Visual Prognosis. Am J Ophthalmol 2016; 165:145-53. [PMID: 27005706 DOI: 10.1016/j.ajo.2016.03.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/04/2016] [Accepted: 03/10/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE To evaluate clinical features and long-term visual outcome of cytomegalovirus (CMV) retinitis in patients without human immunodeficiency virus (HIV) infection, and to determine factors that predict visual outcome. DESIGN Retrospective cohort study. METHODS Consecutive patients with CMV retinitis without HIV infection were reviewed. Main outcome measures included clinical features, proportion of eyes with 6-month and final visual acuity (VA) <20/70 and <20/400, and odds ratios of factors associated with poor visual outcome. RESULTS A total of 20 eyes from 13 patients were included with a median follow-up time of 17 months. All had at least 6 months of follow-up except 1 patient who died from sepsis at 1 month. At presentation, 50% of eyes had VA <20/70 and 25% had VA <20/400. Zone 1 involvement occurred in 55% and vitreous haze ≥grade 2+ occurred in 25%. Recurrence occurred in 33.3% at a mean time of 6.4 ± 3.3 weeks after discontinuation of anti-CMV therapy. The retinal detachment rate was 21.7% per eye-year and mortality rate was 11.7% per person-year. At final visit, 60% had VA <20/70 and 35% had VA <20/400. Macular involvement was significantly associated with poor final VA <20/400 (odds ratio = 25.00, P = .016). CONCLUSIONS CMV retinitis without HIV infection was often aggressive at presentation. Significant intraocular inflammation was not uncommon. The long-term visual outcome was poor, especially in those with macular involvement.
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Agarwal A, Singh R, Sharma A, Gupta V, Dogra MR. Ocular Manifestations in Patients with Human Immunodeficiency Virus Infection in the Pre-HAART Versus the HAART Era in the North Indian Population. Ocul Immunol Inflamm 2016; 25:396-404. [PMID: 26910292 DOI: 10.3109/09273948.2015.1133837] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To compare changes in the demographic profile and ocular manifestations in patients with HIV in the pre-HAART and HAART era in North India. METHODS In this single-center cross-sectional study, 100 HIV patients receiving HAART and 96 HIV patients in the pre-HAART era were enrolled. Prevalence of ocular manifestations of HIV was calculated for both cohorts. RESULTS The prevalence of ocular manifestations was not statistically different in the two eras (38%, SE: 4.85% in HAART era; 41.67%, SE: 5% in pre-HAART era) (p = 0.60). Mean CD4 counts were lower in the pre-HAART era compared with the HAART era (p < 0.001). In the HAART era, cytomegalovirus (CMV) retinitis and HIV retinopathy continued to remain the most common infectious and non-infectious cause of visual morbidity. CONCLUSIONS While the introduction of HAART has resulted in a major impact on the overall health of patients with HIV, the spectrum of ocular disease remains largely unchanged in developing countries such as India.
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Affiliation(s)
- Aniruddha Agarwal
- a Stanley M. Truhlsen Eye Institute , University of Nebraska Medical Center , Omaha , Nebraska , USA
| | - Ramandeep Singh
- b Department of Ophthalmology , Advanced Eye Centre, Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Aman Sharma
- c Division of Rheumatology, Department of Internal Medicine , Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Vishali Gupta
- b Department of Ophthalmology , Advanced Eye Centre, Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Mangat R Dogra
- b Department of Ophthalmology , Advanced Eye Centre, Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
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Ashraf DC, May KP, Holland GN, Van Natta ML, Wu AW, Thorne JE, Jabs DA. Relationship between Human Immunodeficiency Virus Neuroretinal Disorder and Vision-Specific Quality of Life among People with AIDS. Ophthalmology 2015; 122:2560-7. [PMID: 26350547 DOI: 10.1016/j.ophtha.2015.07.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 07/28/2015] [Accepted: 07/30/2015] [Indexed: 10/23/2022] Open
Abstract
PURPOSE Some human immunodeficiency virus (HIV)-infected individuals have evidence of optic nerve or retinal dysfunction that manifests as decreased contrast sensitivity, even with good best-corrected visual acuity (BCVA). This condition, termed HIV-related neuroretinal disorder (HIV-NRD), is a risk factor for vision impairment (BCVA <20/40), blindness (BCVA ≤20/200), and increased mortality. We investigated the effect of HIV-NRD on vision-specific quality of life (QOL). DESIGN Cross-sectional analysis of data from a prospective, observational study. PARTICIPANTS Individuals from the Longitudinal Study of the Ocular Complications of AIDS cohort who completed the National Eye Institute 25-item Visual Function Questionnaire (VFQ-25), had BCVA of 20/40 or better, and had no evidence of ocular opportunistic infection or cataract. METHODS We compared QOL by HIV-NRD status, adjusting for potential confounding variables, using multiple linear regression. Among those with HIV-NRD, we assessed the relationship between VFQ-25 and the logarithm of contrast sensitivity (logCS), using Spearman correlation. We defined a minimum clinically important difference (MCID) as 1 standard error of measurement from a well-characterized, historical population of individuals with a variety of ophthalmic disorders. MAIN OUTCOME MEASURES Subscales and composite VFQ-25 scores (0 = worst, 100 = best). RESULTS A total of 813 individuals met study criteria. Those with HIV-NRD (n = 39 [4.8%]) had a lower mean composite score than those without HIV-NRD (81 vs. 89; P = 0.0002) and lower mean scores in the following subscales: near activities (77 vs. 86; P = 0.004), distance activities (85 vs. 91; P = 0.01), social functioning (89 vs. 96; P = 0.0005), mental health (75 vs. 87; P = 0.0001), dependency (81 vs. 94; P < 0.0001), driving (75 vs. 85; P = 0.02), color vision (90 vs. 97; P < 0.0001), and peripheral vision (85 vs. 91; P = 0.0496). Score differences for each of these subscales met criteria for MCID. Among those with HIV-NRD, there was a positive correlation between logCS and composite score (r = 0.36; 95% confidence interval, 0.04-0.60). CONCLUSIONS HIV-NRD has a statistically significant and clinically meaningful association with decreased vision-specific QOL among people with AIDS and good BCVA.
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Affiliation(s)
- Davin C Ashraf
- Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - K Patrick May
- Department of Epidemiology, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland
| | - Gary N Holland
- Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California.
| | - Mark L Van Natta
- Department of Epidemiology, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland
| | - Albert W Wu
- Department of Epidemiology, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland; Department of Health Policy and Management, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland
| | - Jennifer E Thorne
- The Wilmer Eye Institute and Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Douglas A Jabs
- Department of Epidemiology, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland; Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Jabs DA, Van Natta ML, Sezgin E, Pak JW, Danis R. Prevalence of intermediate-stage age-related macular degeneration in patients with acquired immunodeficiency syndrome. Am J Ophthalmol 2015; 159:1115-1122.e1. [PMID: 25769246 PMCID: PMC6126535 DOI: 10.1016/j.ajo.2015.01.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 01/28/2015] [Accepted: 01/29/2015] [Indexed: 12/18/2022]
Abstract
PURPOSE To evaluate the prevalence of intermediate-stage age-related macular degeneration (AMD) in patients with acquired immunodeficiency syndrome (AIDS). DESIGN Cross-sectional study of patients with AIDS enrolled in the Longitudinal Study of the Ocular Complications of AIDS. METHODS Intermediate-stage AMD was determined from enrollment retinal photographs by graders at a centralized Reading Center, using the Age-Related Eye Disease Study grading system. Graders were masked as to clinical data. RESULTS Of 1825 participants with AIDS and no ocular opportunistic infections, 9.9% had intermediate-stage AMD. Risk factors included age, with an odds ratio (OR) of 1.9 (95% confidence interval [CI] 1.6, 2.3, P < .001) for every decade of age; the prevalence of AMD ranged from 4.0% for participants 30-39 years old to 24.3% for participants ≥60 years old. Other risk factors included the human immunodeficiency virus (HIV) risk groups of injection drug use (OR = 2.4, 95% CI 1.5, 3.9, P < .001) or heterosexual contact (OR = 1.9, 95% CI 1.3, 2.8, P = .001). Compared with the HIV-uninfected population in the Beaver Dam Offspring Study, there was an approximate 4-fold increased age-adjusted prevalence of intermediate-stage AMD. CONCLUSIONS Patients with AIDS have an increased age-adjusted prevalence of intermediate-stage AMD compared with that found in a non-HIV-infected cohort evaluated with similar methods. This increased prevalence is consistent with the increased prevalence of other age-related diseases in antiretroviral-treated, immune-restored, HIV-infected persons when compared to non-HIV-infected persons.
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Affiliation(s)
- Douglas A Jabs
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Center for Clinical Trials, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.
| | - Mark L Van Natta
- Center for Clinical Trials, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Efe Sezgin
- Center for Clinical Trials, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Jeong Won Pak
- Department of Ophthalmology, University of Wisconsin, Madison, Madison, Wisconsin
| | - Ronald Danis
- Department of Ophthalmology, University of Wisconsin, Madison, Madison, Wisconsin
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Jabs DA, Ahuja A, Van Natta ML, Lyon AT, Yeh S, Danis R. Long-term Outcomes of Cytomegalovirus Retinitis in the Era of Modern Antiretroviral Therapy: Results from a United States Cohort. Ophthalmology 2015; 122:1452-63. [PMID: 25892019 DOI: 10.1016/j.ophtha.2015.02.033] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 02/20/2015] [Accepted: 02/23/2015] [Indexed: 12/18/2022] Open
Abstract
PURPOSE To describe the long-term outcomes of patients with cytomegalovirus (CMV) retinitis and AIDS in the modern era of combination antiretroviral therapy. DESIGN Prospective, observational cohort study. PARTICIPANTS Patients with AIDS and CMV retinitis. METHODS Immune recovery, defined as a CD4+ T-cell count >100 cells/μl for ≥3 months. MAIN OUTCOME MEASURES Mortality, visual impairment (visual acuity <20/40), and blindness (visual acuity ≤20/200) on logarithmic visual acuity charts and loss of visual field on quantitative Goldmann perimetry. RESULTS Patients without immune recovery had a mortality of 44.4/100 person-years (PYs) and a median survival of 13.5 months after the diagnosis of CMV retinitis, whereas those with immune recovery had a mortality of 2.7/100 PYs (P < 0.001) and an estimated median survival of 27.0 years after the diagnosis of CMV retinitis. The rates of bilateral visual impairment and blindness were 0.9 and 0.4/100 PYs, respectively, and were similar between those with and without immune recovery. Among those with immune recovery, the rate of visual field loss was approximately 1% of the normal field per year, whereas among those without immune recovery it was approximately 7% of the normal field per year. CONCLUSIONS Among persons with CMV retinitis and AIDS, if there is immune recovery, long-term survival is likely, whereas if there is no immune recovery, the mortality rate is substantial. Although higher than the rates in the population not infected by human immunodeficiency virus, the rates of bilateral visual impairment and blindness are low, especially when compared with rates in the era before modern antiretroviral therapy.
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Affiliation(s)
- Douglas A Jabs
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Center for Clinical Trials, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.
| | - Alka Ahuja
- Center for Clinical Trials, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Mark L Van Natta
- Center for Clinical Trials, Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Alice T Lyon
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Steven Yeh
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Ronald Danis
- Department of Ophthalmology, University of Wisconsin, Madison, Wisconsin
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Jabs DA, Drye L, Van Natta ML, Thorne JE, Holland GN. Incidence and long-term outcomes of the human immunodefıciency virus neuroretinal disorder in patients with AIDS. Ophthalmology 2015; 122:760-8. [PMID: 25600199 DOI: 10.1016/j.ophtha.2014.11.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 10/29/2014] [Accepted: 11/11/2014] [Indexed: 10/24/2022] Open
Abstract
PURPOSE Patients with AIDS have an abnormality of retina/optic nerve function, manifested as decreased contrast sensitivity (in the absence of ocular opportunistic infections or media opacity), abnormalities on automated perimetry, and loss of retinal nerve fiber layer, even among those with good visual acuity, termed the "human immunodeficiency virus (HIV) neuroretinal disorder." The objectives of this study were to determine the prevalence, incidence, risk factors, and outcomes of HIV neuroretinal disorder. DESIGN Prospective cohort study. PARTICIPANTS A total of 1822 patients with AIDS without ocular infections or media opacities. METHODS Patients with HIV neuroretinal disorder were identified by a contrast sensitivity <1.50 log units in either eye in the absence of ocular opportunistic infections or media opacity. MAIN OUTCOME MEASURES Incidence of HIV neuroretinal disorder, mortality, visual impairment (visual acuity ≤20/50), and blindness (≤20/200) on logarithmic visual acuity charts. RESULTS Sixteen percent of participants had HIV neuroretinal disorder at enrollment. The estimated cumulative incidence by 20 years after AIDS diagnosis was 51% (95% confidence interval [CI], 46-55). Human immunodeficiency virus neuroretinal disorder was more common in women and African Americans. Risk factors for HIV neuroretinal disorder included hepatitis C infection, low CD4+ T cells, and detectable HIV RNA in the blood. Patients with HIV neuroretinal disorder had a 70% excess mortality versus those without it, even after adjusting for CD4+ T cells and HIV load (hazard ratio [HR], 1.7; 95% CI, 1.3-2.1; P < 0.0001). Patients with HIV neuroretinal disorder had increased risks of bilateral visual impairment (HR, 6.5; 95% CI, 2.6-10.6; P < 0.0001) and blindness (HR, 5.9; 95% CI, 2.8-13.7; P = 0.01) versus those without HIV neuroretinal disorder. CONCLUSIONS Human immunodeficiency virus neuroretinal disorder is a common finding among patients with AIDS, and it is associated with an increased mortality and an increased risk of visual impairment. Successful antiretroviral therapy decreases but does not eliminate the risk of HIV neuroretinal disorder.
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Affiliation(s)
- Douglas A Jabs
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Epidemiology, Center for Clinical Trials, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.
| | - Lea Drye
- Department of Epidemiology, Center for Clinical Trials, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Mark L Van Natta
- Department of Epidemiology, Center for Clinical Trials, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Jennifer E Thorne
- Department of Epidemiology, Center for Clinical Trials, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gary N Holland
- Department of Ophthalmology, Jules Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles, California
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Komatsu TE, Pikis A, Naeger LK, Harrington PR. Resistance of human cytomegalovirus to ganciclovir/valganciclovir: A comprehensive review of putative resistance pathways. Antiviral Res 2014; 101:12-25. [DOI: 10.1016/j.antiviral.2013.10.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 10/20/2013] [Accepted: 10/21/2013] [Indexed: 11/26/2022]
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Branch AD, Drye LT, Van Natta ML, Sezgin E, Fishman SL, Dieterich DT, Meinert CL, Jabs DA. Evaluation of hepatitis C virus as a risk factor for HIV-associated neuroretinal disorder. Clin Infect Dis 2013; 57:1618-25. [PMID: 24081683 DOI: 10.1093/cid/cit550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Both hepatitis C virus (HCV) and human immunodeficiency virus (HIV) penetrate the central nervous system. HIV-associated neuroretinal disorder (HIV-NRD), a visual impairment of reduced contrast sensitivity and reading ability, is associated with cytokine dysregulation and genetic polymorphisms in the anti-inflammatory interleukin 10 (IL-10) signaling pathway. We investigated associations between HCV and HIV-NRD and between HCV and single-nucleotide polymorphisms (SNPs) in the IL-10 receptor 1 (IL10R1) gene. METHODS Logistic and Cox regression analysis were used to analyze risk factors for HIV-NRD in 1576 HIV-positive patients who did not have an ocular opportunistic infection at enrollment. Median follow-up was 4.9 years (interquartile range, 2.4-8.8 years). Four IL10R1 SNPs were examined in a subset of 902 patients. RESULTS The group included 290 patients with chronic HCV infection, 74 with prior infection, and 1212 with no HCV markers. There were 244 prevalent cases of HIV-NRD and 263 incident cases (rate = 3.9/100 person-years). In models adjusted for demographics, HIV treatment and status, liver function, and immune status, both the prevalence and incidence of HIV-NRD were significantly higher in patients with chronic HCV infection (odds ratio = 1.54; 95% confidence interval [CI], 1.03-2.31 and hazard ratio = 1.62; 95% CI, 1.13-2.34, respectively), compared to patients with no HCV markers. Chronic HCV was associated with rs2228055 and 2 additional IL-10R1 SNPs expected to reduce IL-10 signaling. HIV-NRD was not significantly associated with these SNPs. CONCLUSIONS HCV is a possible risk factor for HIV-NRD. Genetic analysis suggests that alterations in the IL-10 signaling pathway may increase susceptibility to HIV-NRD and HCV infection. Inflammation may link HCV and HIV-NRD.
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Affiliation(s)
- Andrea D Branch
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Krauskopf K, Van Natta ML, Danis RP, Gangaputra S, Ackatz L, Addessi A, Federman AD, Branch AD, Meinert CL, Jabs DA. Correlates of hypertension in patients with AIDS in the era of highly active antiretroviral therapy. J Int Assoc Provid AIDS Care 2013; 12:325-33. [PMID: 23764503 PMCID: PMC4100586 DOI: 10.1177/2325957413491432] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND It is unclear whether HIV-related factors modify risk of hypertension (HTN). In a cohort of patients with AIDS, the authors determined HTN incidence and prevalence and assessed associated traditional, HIV-specific, and retinal vasculature factors. METHODS Prospective observational cohort included 2390 patients with AIDS (1998-2011). Univariate analysis was used to assess the impact of traditional- and AIDS-related risk factors for HTN prevalence and incidence. Multivariate regression analyses were used to evaluate the adjusted impact of these factors. RESULTS Hypertension prevalence was 22%(95% confidence interval [CI] 21%-24%) and was associated with traditional HTN risk factors (age, black race, and higher weight) as well as diabetes, hyperlipidemia, time since AIDS diagnosis, and higher CD4 counts. Hypertension incidence was 64.1 per 1000 person-years (95% CI 58.7/1000-69.9/1000). Age, race, weight, and diabetes were associated with incident HTN but HIV-specific factors were not. CONCLUSIONS Hypertension, a prevalent cardiovascular risk factor in patients with AIDS, is associated with traditional and metabolic risk factors.
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Affiliation(s)
- Katherine Krauskopf
- Division of General Internal Medicine, Mount Sinai School of Medicine, New York, NY
| | - Mark L. Van Natta
- Center for Clinical Trials, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Ronald P. Danis
- Fundus Photograph Reading Center, Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, WI
| | - Sapna Gangaputra
- Fundus Photograph Reading Center, Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, WI
| | - Lori Ackatz
- Department of Ophthalmology, Northwestern Medical Faculty Foundation, Chicago, IL
| | - Adrienne Addessi
- Department of Ophthalmology and Department of Pediatrics, Division of Infectious Diseases, New York University School of Medicine, New York, NY
| | - Alex D. Federman
- Division of General Internal Medicine, Mount Sinai School of Medicine, New York, NY
| | - Andrea D. Branch
- Division of Liver Diseases, Mount Sinai School of Medicine, New York, NY
| | - Curtis L. Meinert
- Center for Clinical Trials, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Douglas A. Jabs
- Center for Clinical Trials, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
- Division of Rheumatology, Department of Medicine, Mount Sinai School of Medicine, New York, NY
- Department of Ophthalmology, Mount Sinai School of Medicine, New York, NY
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Gupta S, Vemulakonda GA, Suhler EB, Yeh S, Albini TA, Mandelcorn E, Flaxel CJ. Cytomegalovirus retinitis in the absence of AIDS. Can J Ophthalmol 2013; 48:126-9. [PMID: 23561607 DOI: 10.1016/j.jcjo.2012.12.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 10/20/2012] [Accepted: 12/12/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate systemic and ophthalmic features associated with Cytomegalovirus (CMV) retinitis in immunocompetent patients. DESIGN Retrospective chart review. PARTICIPANTS Nine patients with CMV retinitis who were clinically immunocompetent at the time of diagnosis. METHODS Retrospective chart review of patients evaluated at the Casey Eye Institute, University of Washington, Bascom Palmer Eye Institute and University of Toronto. IRB approval was obtained. Retrospective chart review of patients evaluated at the Casey Eye Institute, University of Washington, Bascom Palmer Eye Institute and University of Toronto. IRB approval was obtained. RESULTS Seven of the nine patients in our series were 60 years of age or above. Three patients had intravitreal steroid and VEGF inhibitor injections in the preceding year in the affected eye. Five of the nine patients were initially misdiagnosed to have acute retinal necrosis (ARN) for which they were on Valacyclovir for a variable period of time. Seven patients had anterior chamber and eight had vitreous inflammation. Six of the nine patients exhibited vascular attenuation or obliteration. All patients showed improvement in retinitis within weeks following therapy with intravitreal foscarnet and/or ganciclovir and systemic valganciclovir.
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Affiliation(s)
- Seema Gupta
- Casey Eye Institute, Oregon Health and Science University, Portland, OR 97239, USA
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Vadlapudi AD, Vadlapatla RK, Mitra AK. Current and emerging antivirals for the treatment of cytomegalovirus (CMV) retinitis: an update on recent patents. ACTA ACUST UNITED AC 2013; 7:8-18. [PMID: 22044356 DOI: 10.2174/157489112799829765] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 09/30/2011] [Accepted: 10/04/2011] [Indexed: 12/17/2022]
Abstract
Cytomegalovirus (CMV) retinitis is the most common ocular opportunistic complication and a serious cause of vision loss in immunocompromised patients. Even though, a rise in human immunodeficiency virus (HIV) infected individuals seems to be a major factor responsible for the prevalence of CMV retinitis, the introduction of highly active antiretroviral therapy (HAART) significantly reduced the incidence and severity of CMV retinitis. Thorough evaluation of the patient's immune status and an exact classification of the retinal lesions may provide better understanding of the disease etiology, which would be necessary for optimizing the treatment conditions. Current drugs such as ganciclovir, valganciclovir, cidofovir and foscarnet have been highly active against CMV, but prolonged therapy with these approved drugs is associated with dose-limiting toxicities thus limiting their utility. Moreover development of drug-resistant mutants has been observed particularly in patients with acquired immunodeficiency syndrome (AIDS). Continuous efforts by researchers in the industry and academia have led to the development of newer candidates with enhanced antiviral efficacy and apparently minimal side effects. These novel compounds can suppress viral replication and prevent reactivation in the target population. Though some of the novel therapeutics possess potent viral inhibitory activity, these compounds are still in stages of clinical development and yet to be approved. This review provides an overview of disease etiology, existing anti-CMV drugs, advances in emerging therapeutics in clinical development and related recent patents for the treatment of CMV retinitis.
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Affiliation(s)
- Aswani D Vadlapudi
- Division of Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, 2464 Charlotte Street, Kansas City, MO 64108-2718, USA
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Jabs DA, Ahuja A, Van Natta M, Dunn JP, Yeh S. Comparison of treatment regimens for cytomegalovirus retinitis in patients with AIDS in the era of highly active antiretroviral therapy. Ophthalmology 2013; 120:1262-70. [PMID: 23419804 DOI: 10.1016/j.ophtha.2012.11.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 11/09/2012] [Accepted: 11/13/2012] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To describe the outcomes of different treatment approaches for cytomegalovirus (CMV) retinitis in the era of highly active antiretroviral therapy (HAART). DESIGN Prospective cohort study, the Longitudinal Study of the Ocular Complications of AIDS. PARTICIPANTS A total of 250 patients with CMV retinitis and a CD4+ T-cell count <100 cells/μl (n = 221) at enrollment or incident retinitis (n = 29) during cohort follow-up. METHODS The effects of systemic therapy (vs. intraocular therapy only) on systemic outcomes and the effect of intraocular therapies (ganciclovir implants, intravitreal injections) on ocular outcomes were evaluated. MAIN OUTCOME MEASURES Mortality, CMV dissemination, retinitis progression, and treatment side effects. RESULTS Regimens containing systemic anti-CMV therapy were associated with a 50% reduction in mortality (adjusted hazard ratio [HR], 0.5; 95% confidence interval [CI], 0.3-0.7; P = 0.006), a 90% reduction in new visceral CMV disease (adjusted HR, 0.1; 95% CI, 0.04-0.4; P = 0.004), and among those with unilateral CMV retinitis at presentation, an 80% reduction in second eye disease (adjusted HR, 0.2; 95% CI, 0.1-0.5; P = 0.0005) when compared with those using only intraocular therapy (implants or injections). Compared with systemic treatment only, regimens containing intravitreal injections had greater rates of retinitis progression (adjusted HR, 3.4; P = 0.004) and greater visual field loss (for loss of one half of the normal field, adjusted HR, 5.5; P < 0.01). Intravitreal implants were not significantly better than systemic therapy (adjusted HR for progression, 0.5; P = 0.26; adjusted HR for loss of one half of the visual field, 0.5; P = 0.45), but the sample size was small. Hematologic and renal side effect rates were similar between those groups with and without systemic anti-CMV therapy. The rate of endophthalmitis was 0.017 per eye-year (EY) (95% CI, 0.006-0.05) among those treated with intravitreal injections and 0.01 per EY (95% CI, 0.002-0.04) among those treated with an implant. CONCLUSIONS In the HAART era, systemic anti-CMV therapy, while there is immune compromise, seems to provide benefits in terms of longer survival and decreased CMV dissemination. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
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Affiliation(s)
- Douglas A Jabs
- Department of Ophthalmology, the Mount Sinai School of Medicine, New York, New York 10029, USA.
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Barrett L, Walmsley S. CMV retinopathy in the antiretroviral therapy era: prevention, diagnosis, and management. Curr Infect Dis Rep 2012; 14:435-44. [PMID: 22688820 DOI: 10.1007/s11908-012-0269-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Before the advent of antiretroviral therapy (ART), CMV retinitis was a common, debilitating opportunistic infection in the HIV-infected population. ART has had such a favorable impact on the prevention and management of CMV retinitis that it can be considered in some ways to be CMV therapy. Currently available CMV directed antiviral therapies are quite successful at limiting vision loss, but in resource limited settings there is still significant morbidity associated with the disease. This review summarizes the pathology, diagnosis, clinical course and treatment of retinitis in the pre-ART era to provide context for the contemporary clinical scenario, and highlights current management strategies. Important questions concerning host correlates of susceptibility and ideal therapy in the context of drug resistance are also briefly reviewed.
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Affiliation(s)
- Lisa Barrett
- Laboratory of Immunoregulation, National Institutes of Health, Bethesda, MD, USA
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Ganekal S, Jhanji V, Dorairaj S, Nagarajappa A. Evaluation of Ocular Manifestations and Blindness in HIV/AIDS Patients in a Tertiary Care Hospital in South India. Ocul Immunol Inflamm 2012; 20:336-41. [PMID: 22775065 DOI: 10.3109/09273948.2012.699133] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Sunil Ganekal
- Nayana Superspecialty Eye Hospital and Research Center, Davangere, Karnataka, India.
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Sugar EA, Jabs DA, Ahuja A, Thorne JE, Danis RP, Meinert CL. Incidence of cytomegalovirus retinitis in the era of highly active antiretroviral therapy. Am J Ophthalmol 2012; 153:1016-24.e5. [PMID: 22310076 DOI: 10.1016/j.ajo.2011.11.014] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 11/14/2011] [Accepted: 11/14/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE To estimate the incidence of cytomegalovirus (CMV) retinitis in the era of highly active antiretroviral therapy (HAART) and to characterize the factors associated with increased risk of CMV retinitis. DESIGN Prospective cohort study. METHODS A total of 1600 participants with acquired immunodeficiency syndrome (AIDS) but without CMV retinitis at enrollment who completed at least 1 follow-up visit in the Longitudinal Study of the Ocular Complications of AIDS (LSOCA) were seen every 6 months to obtain disease and treatment history, ophthalmic examination, and laboratory testing. Incidence of CMV retinitis and risk factors for incident CMV retinitis were assessed. RESULTS The incidence rate of CMV retinitis in individuals with AIDS was 0.36/100 person-years (PY) based upon 29 incident cases during 8134 PY of follow-up. The rate was higher for those with a CD4+ T cell count at the immediately prior visit below 50 cells/μL (3.89/100 PY, P < .01), whereas only 1 individual with a CD4+ T cell count of 50 to 99 cells/μL and 2 individuals with a CD4+ T cell count >100 cells/μL developed CMV retinitis. Having a CD4+ T cell count below 50 cells/μL at the clinical visit prior to CMV retinitis evaluation was the single most important risk factor (HR: 136, 95% CI: 30 to 605, P < .0001) for developing retinitis. CONCLUSIONS Patients with AIDS, especially those with severely compromised immune systems, remain at risk for developing CMV retinitis in the HAART era, although the incidence rate is reduced from that observed in the pre-HAART era.
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Chaudhary KM, Lieberman RM. Immune reconstitution uveitis complicated by vitreoretinal traction and formation of a retinal tear. Ophthalmic Surg Lasers Imaging Retina 2012; 43 Online:e44-6. [PMID: 22624795 DOI: 10.3928/15428877-20120517-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Accepted: 04/10/2012] [Indexed: 11/20/2022]
Abstract
The authors report a case of immune reconstitution uveitis induced by cytomegalovirus retinitis with subsequent development of vitreoretinal traction and a resultant retinal tear.
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Affiliation(s)
- Khurram M Chaudhary
- Department of Ophthalmology, Hofstra North Shore-Long Island Jewish Medical Center, Great Neck, NY 11021, USA.
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Gokulgandhi MR, Barot M, Bagui M, Pal D, Mitra AK. Transporter-targeted lipid prodrugs of cyclic cidofovir: a potential approach for the treatment of cytomegalovirus retinitis. J Pharm Sci 2012; 101:3249-63. [PMID: 22499243 DOI: 10.1002/jps.23140] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 02/25/2012] [Accepted: 03/16/2012] [Indexed: 01/24/2023]
Abstract
Cidofovir (CDF) and its cyclic analogue (cCDF) have shown potential in vitro and in vivo antiviral activity against cytomegalovirus (CMV) retinitis. However, hydrophilic nature of CDF may affect cell permeation across lipophilic epithelium and thus limit its effectiveness in the treatment of CMV retinitis. In the present study, we have tested a novel hypothesis, which involves chemical derivatization of cCDF into lipophilic transporter-targeted prodrug [via conjugation with different carbon chain length of lipid raft and targeting moiety (biotin) for sodium-dependent multivitamin transporter (SMVT)]. We have synthesized and characterized three derivatives of cCDF including biotin B-C2-cCDF, B-C6-cCDF, and B-C12-cCDF. Physicochemical properties such as solubility, partition coefficient (n-octanol/water and ocular tissue), bioreversion kinetics, and interaction with SMVT transporter have been determined. Among these novel conjugates, B-C12-cCDF has shown higher interaction to SMVT transporter with lowest half maximal inhibitory concentration value, higher cellular accumulation, and high tissue partitioning. Improvement in physicochemical properties, lipophilicity, and interaction with transporter was observed in the trend of increasing the lipid chain length, that is, B-C12-cCDF > B-C6-cCDF > B-C2-cCDF. These results indicate that transporter-targeted lipid analogue of cCDF exhibits improved cellular accumulation along with higher transporter affinity and hence could be a viable strategy for the treatment of CMV retinitis.
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Affiliation(s)
- Mitan R Gokulgandhi
- Division of Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, Kansas City, Missouri 64108, USA
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Retinal vessel caliber among people with acquired immunodeficiency syndrome: relationships with disease-associated factors and mortality. Am J Ophthalmol 2012; 153:434-444.e1. [PMID: 22019225 DOI: 10.1016/j.ajo.2011.08.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 08/18/2011] [Accepted: 08/19/2011] [Indexed: 11/21/2022]
Abstract
PURPOSE To evaluate relationships between retinal vessel caliber, AIDS-related factors, and mortality. DESIGN Longitudinal, observational cohort study. METHODS We evaluated data for participants without ocular opportunistic infections at initial examination (baseline) in the Longitudinal Studies of the Ocular Complications of AIDS (1998-2008). Semi-automated evaluation of fundus photographs (1 eye/participant) determined central retinal artery equivalent (CRAE), central retinal vein equivalent (CRVE), and arteriole-to-venule ratio (AVR) at baseline. Multiple linear regression models, using forward selection, identified independent relationships between indices and various host- and disease-related variables. RESULTS Included were 1250 participants. Mean follow-up for determination of mortality was 6.1 years. Smaller CRAE was related to increased age (P < .001) and hypertension (P < .001); larger CRAE was related to lower hematocrit (P = .002). Larger CRAE and CRVE were associated with black race (P < .001). Larger CRVE was related to smoking (P = .004); smaller CRVE was related to age (P < .001) and higher mean corpuscular volume (P = .001). We observed the following relationships with AIDS-associated factors: smaller CRAE and larger CRVE with history of highly active antiretroviral therapy (HAART; P < .001); and larger CRAE with lower CD4+ T lymphocyte count (P = .04). We did not identify independent relationships with human immunodeficiency virus RNA blood levels. There was a 12% (95% CI, 2%-21%) increase in mortality risk per quartile of decreasing AVR (P = .02). CONCLUSIONS Variations in retinal vascular caliber are associated with AIDS-specific factors and are markers for increased mortality risk. Relationships are consistent with the hypothesis that the vasculature is altered by known atherogenic effects of chronic HAART or the prolonged inflammatory state associated with AIDS.
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Kalyani PS, Fawzi AA, Gangaputra S, van Natta ML, Hubbard LD, Danis RP, Thorne JE, Holland GN. Retinal vessel caliber among people with acquired immunodeficiency syndrome: relationships with visual function. Am J Ophthalmol 2012; 153:428-433.e1. [PMID: 22019221 PMCID: PMC4859428 DOI: 10.1016/j.ajo.2011.08.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 08/15/2011] [Accepted: 08/19/2011] [Indexed: 12/11/2022]
Abstract
PURPOSE To evaluate relationships between retinal vessel caliber and tests of visual function among people with AIDS. DESIGN Longitudinal, observational cohort study. METHODS We evaluated data for participants without ocular opportunistic infections at initial examination (baseline) in the Longitudinal Studies of the Ocular Complications of AIDS (1998-2008). Visual function was evaluated with best-corrected visual acuity, Goldmann perimetry, automated perimetry (Humphrey Field Analyzer), and contrast sensitivity (CS) testing. Semi-automated grading of fundus photographs (1 eye/participant) determined central retinal artery equivalent (CRAE), central retinal vein equivalent (CRVE), and arteriole-to-venule ratio (AVR) at baseline. Multiple linear regression models, using forward selection, sought independent relationships between indices and visual function variables. RESULTS Included were 1250 participants. Smaller AVR was associated with reduced visual field by Goldmann perimetry (P = .003) and worse mean deviation (P = .02) on automated perimetry and possibly with worse pattern standard deviation (PSD) on automated perimetry (P = .06). There was a weak association between smaller AVR and worse CS (P = .07). Relationships were independent of antiretroviral therapy and level of immunodeficiency (CD4+ T lymphocyte count, human immunodeficiency virus [HIV] RNA blood level). On longitudinal analysis, retinal vascular indices at baseline did not predict changes in visual function. CONCLUSIONS Variation in retinal vascular indices is associated with abnormal visual function in people with AIDS, manifested by visual field loss and possibly by reduced CS. Relationships are consistent with the hypothesis that HIV-related retinal vasculopathy is a contributing factor to vision dysfunction among HIV-infected individuals. Longitudinal studies are needed to determine whether changes in indices predict change in visual function.
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Affiliation(s)
- Partho S Kalyani
- Ocular Inflammatory Disease Center, Jules Stein Eye Institute, Los Angeles, California, USA
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Limou S, Delaneau O, van Manen D, An P, Sezgin E, Le Clerc S, Coulonges C, Troyer JL, Veldink JH, van den Berg LH, Spadoni JL, Taing L, Labib T, Montes M, Delfraissy JF, Schachter F, O'Brien SJ, Buchbinder S, van Natta ML, Jabs DA, Froguel P, Schuitemaker H, Winkler CA, Zagury JF. Multicohort genomewide association study reveals a new signal of protection against HIV-1 acquisition. J Infect Dis 2012; 205:1155-62. [PMID: 22362864 DOI: 10.1093/infdis/jis028] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND To date, only mutations in CCR5 have been shown to confer resistance to human immunodeficiency virus type 1 (HIV-1) infection, and these explain only a small fraction of the observed variability in HIV susceptibility. METHODS We performed a meta-analysis between 2 independent European genomewide association studies, each comparing HIV-1 seropositive cases with normal population controls known to be HIV uninfected, to identify single-nucleotide polymorphisms (SNPs) associated with the HIV-1 acquisition phenotype. SNPs exhibiting P < 10(-5) in this first stage underwent second-stage analysis in 2 independent US cohorts of European descent. RESULTS After the first stage, a single highly significant association was revealed for the chromosome 8 rs6996198 with HIV-1 acquisition and was replicated in both second-stage cohorts. Across the 4 groups, the rs6996198-T allele was consistently associated with a significant reduced risk of HIV-1 infection, and the global meta-analysis reached genomewide significance: P(combined) = 7.76 × 10(-8). CONCLUSIONS We provide strong evidence of association for a common variant with HIV-1 acquisition in populations of European ancestry. This protective signal against HIV-1 infection is the first identified outside the CCR5 nexus. First clues point to a potential functional role for a nearby candidate gene, CYP7B1, but this locus warrants further investigation.
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Affiliation(s)
- Sophie Limou
- Laboratoire Génomique, Bioinformatique, et Applications, EA4627, Chaire de Bioinformatique, Conservatoire National des Arts et Métiers, Paris, France
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Teoh SC, Ou X, Lim TH. Intravitreal ganciclovir maintenance injection for cytomegalovirus retinitis: efficacy of a low-volume, intermediate-dose regimen. Ophthalmology 2011; 119:588-95. [PMID: 22137552 DOI: 10.1016/j.ophtha.2011.09.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Revised: 08/27/2011] [Accepted: 09/02/2011] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To report the clinical outcomes of highly active antiretroviral therapy (HAART)-naïve, human immunodeficiency virus (HIV)-positive patients with newly diagnosed cytomegalovirus (CMV) retinitis receiving intravitreal injections of a low-volume intermediate maintenance dose (1.0 mg/0.02 ml) of ganciclovir. DESIGN Nonrandomized, retrospective, interventional series. PARTICIPANTS A consecutive cohort of 34 eyes from 24 HAART-naïve patients with AIDS and diagnosed with CMV retinitis by retinal specialists at the Singapore Communicable Disease Centre. INTERVENTION Patients received a maintenance dose of 1.0 mg/0.02 ml of intravitreal ganciclovir once weekly after standard induction therapy with 2.0 mg/0.04 ml of twice weekly intravitreal ganciclovir. MAIN OUTCOME MEASURES Time to progression, visual acuity, and complications. Progression was observed using photographic documentation. RESULTS The median time to progression was 152 days (mean, 380.1 days, 95% confidence interval, 240.8-519.4). The median follow-up was 95 days (mean, 207.9 days). Three eyes developed rhegmatogenous detachments, but there was no endophthalmitis after 1858 injections. Contralateral involvement of CMV retinitis occurred in 17.6% of the patients. The cost estimate for intravitreal injections over a 6-month period was 11.7% that of sustained-release implants for unilateral treatment and 11.1% that of daily continuous intravenous infusions and oral valganciclovir compared with bilateral treatments. CONCLUSIONS Weekly low-volume, intermediate-dose (1.0 mg/0.02 ml) ganciclovir is an efficacious option in developing countries where newer options of sustained-release implants and oral valganciclovir are unavailable or prohibitively expensive. The regimen maintains a long time to progression, preserving vision while minimizing retinal toxicity complications.
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Affiliation(s)
- Stephen C Teoh
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Republic of Singapore
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Sezgin E, van Natta ML, Ahuja A, Lyon A, Srivastava S, Troyer JL, O'Brien SJ, Jabs DA. Association of host genetic risk factors with the course of cytomegalovirus retinitis in patients infected with human immunodeficiency virus. Am J Ophthalmol 2011; 151:999-1006.e4. [PMID: 21396623 PMCID: PMC3103625 DOI: 10.1016/j.ajo.2010.11.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 11/22/2010] [Accepted: 11/24/2010] [Indexed: 12/31/2022]
Abstract
PURPOSE To evaluate the effects of previously reported host genetics factors that influence cytomegalovirus (CMV) retinitis incidence, progression to acquired immune deficiency syndrome (AIDS), and efficacy of highly active antiretroviral therapy (HAART) for mortality, retinitis progression, and retinal detachment in patients with CMV retinitis and AIDS in the era of HAART. DESIGN Prospective, multicenter, observational study. METHODS Cox proportional hazards model based genetic association tests examined the influence of IL-10R1_S420L, CCR5-Δ32, CCR2-V64I, CCR5 promoter, and SDF-3'A polymorphisms among patients with mortality, retinitis progression, and retinal detachment. Participants were 203 European-American and 117 African-American patients with AIDS and CMV retinitis. RESULTS European-American patients with the CCR5 +.P1.+ promoter haplotype showed increased risk for mortality (hazard ratio [HR] = 1.83; 95% confidence interval [CI]: 1.00-3.40; P = .05). Although the same haplotype also trended for increased risk for mortality in African-American patients, the result was not significant (HR = 2.28; 95% CI: 0.93-5.60; P = .07). However, this haplotype was associated with faster retinitis progression in African Americans (HR = 5.22; 95% CI: 1.54-17.71; P = .007). Increased risk of retinitis progression was also evident for African-American patients with the SDF1-3'A variant (HR = 3.89; 95% CI: 1.42-10.60; P = .008). In addition, the SDF1-3'A variant increased the retinal detachment risk in this patient group (HR = 3.05; 95% CI: 1.01-9.16; P = .05). CONCLUSION Besides overall immune health, host genetic factors influence mortality, retinitis progression, and retinal detachment in patients with AIDS and CMV retinitis that are receiving HAART.
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Affiliation(s)
- Efe Sezgin
- Laboratory of Genomic Diversity, National Cancer Institute, Frederick, MD 21702, USA.
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Puhan MA, Ahuja A, Van Natta ML, Ackatz LE, Meinert C. Interviewer versus self-administered health-related quality of life questionnaires - does it matter? Health Qual Life Outcomes 2011; 9:30. [PMID: 21554737 PMCID: PMC3100232 DOI: 10.1186/1477-7525-9-30] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 05/10/2011] [Indexed: 12/05/2022] Open
Abstract
Background Patient-reported outcomes are measured in many epidemiologic studies using self- or interviewer-administered questionnaires. While in some studies differences between these administration formats were observed, other studies did not show statistically significant differences important to patients. Since the evidence about the effect of administration format is inconsistent and mainly available from cross-sectional studies our aim was to assess the effects of different administration formats on repeated measurements of patient-reported outcomes in participants with AIDS enrolled in the Longitudinal Study of Ocular Complications of AIDS. Methods We included participants enrolled in the Longitudinal Study of Ocular Complications in AIDS (LSOCA) who completed the Medical Outcome Study [MOS] -HIV questionnaire, the EuroQol, the Feeling Thermometer and the Visual Function Questionnaire (VFQ) 25 every six months thereafter using self- or interviewer-administration. A large print questionnaire was available for participants with visual impairment. Considering all measurements over time and adjusting for patient and study site characteristics we used linear models to compare HRQL scores (all scores from 0-100) between administration formats. We defined adjusted differences of ≥0.2 standard deviations [SD]) to be quantitatively meaningful. Results We included 2,261 participants (80.6% males) with a median of 43.1 years of age at enrolment who provided data on 23,420 study visits. The self-administered MOS-HIV, Feeling Thermometer and EuroQol were used in 70% of all visits and the VFQ-25 in 80%. For eight domains of the MOS-HIV differences between the interviewer- and self- administered format were < 0.1 SD. Differences in scores were highest for the social and role function domains but the adjusted differences were still < 0.2 SD. There was no quantitatively meaningful difference between administration formats for EuroQol, Feeling Thermometer and VFQ-25 domain scores. For ocular pain (VFQ-25), we found a statistically significant difference of 3.5 (95% CI 0.2, 6.8), which did, however, not exceed 0.2 SD. For all instruments scores were similar for the large and standard print formats with all adjusted differences < 0.2 SD. Conclusions Our large study provides evidence that administration formats do not have a meaningful effect on repeated measurements of patient-reported outcomes. As a consequence, longitudinal studies may not need to consider the effect of different administration formats in their analyses.
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Affiliation(s)
- Milo A Puhan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Jabs DA. Cytomegalovirus retinitis and the acquired immunodeficiency syndrome--bench to bedside: LXVII Edward Jackson Memorial Lecture. Am J Ophthalmol 2011; 151:198-216.e1. [PMID: 21168815 PMCID: PMC3057105 DOI: 10.1016/j.ajo.2010.10.018] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 10/08/2010] [Accepted: 10/11/2010] [Indexed: 11/29/2022]
Abstract
PURPOSE To update information on cytomegalovirus (CMV) retinitis in patients with acquired immunodeficiency syndrome (AIDS) and to integrate information on its pathogenesis and clinical outcomes. DESIGN Literature review. METHODS Selected articles from the medical literature, particularly large epidemiologic studies, including the Johns Hopkins Cytomegalovirus Retinitis Cohort Study, the Longitudinal Study of the Ocular Complications of AIDS, and the Cytomegalovirus Retinitis and Viral Resistance Study, were reviewed. Clinical information is discussed in light of knowledge on CMV, its pathogenesis, and its interactions with human immunodeficiency virus (HIV). RESULTS Cytomegalovirus uses several mechanisms to evade the immune system and establish latent infection in immunologically normal hosts. With immune deficiency, such as late-stage AIDS, CMV reactivates, is disseminated to the eye, and establishes a productive infection, resulting in retinal necrosis. HIV and CMV potentiate each other: CMV accelerates HIV disease, and CMV retinitis is associated with increased mortality. Randomized clinical trials have demonstrated the efficacy of treatments for CMV retinitis. Systemically administered treatment for CMV retinitis decreases AIDS mortality. Highly active antiretroviral therapy (HAART) effectively suppresses HIV replication, resulting in immune recovery, which, if sufficient, controls retinitis without anti-CMV therapy. Resistant CMV, detected in the blood, correlates with resistant virus in the eye and is associated with worse clinical outcomes, including mortality. Host factors, including host genetics and access to care, play a role in the development of CMV retinitis. CONCLUSIONS Clinical outcomes of CMV retinitis in patients with AIDS are dependent on characteristics of the virus and host and on HIV-CMV interactions.
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Affiliation(s)
- Douglas A Jabs
- Department of Ophthalmology, the Mount Sinai School of Medicine, New York, New York 10029, USA.
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Puhan MA, Van Natta ML, Palella FJ, Addessi A, Meinert C. Excess mortality in patients with AIDS in the era of highly active antiretroviral therapy: temporal changes and risk factors. Clin Infect Dis 2011; 51:947-56. [PMID: 20825306 DOI: 10.1086/656415] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Excess mortality has decreased among human immunodeficiency virus (HIV)-infected patients but without evidence of a decrease among patients with AIDS. We assessed temporal changes in excess mortality and elucidated risk factors for excess mortality in patients with AIDS diagnosed in the era of highly active antiretroviral therapy (HAART). METHODS We included 1188 patients of the Longitudinal Study of Ocular Complications in AIDS who were aged 25-64 years at enrollment and who received a diagnosis of AIDS after 1995. We calculated excess mortality as the age-, year-, and sex-adjusted difference in mortality rates between patients with AIDS and persons in the US general population during the period 1999-2007. We used a relative survival model to identify risk factors for excess mortality. RESULTS There were a mean of 50 excess deaths per 1000 person-years (95% confidence interval [CI], 44-57 excess deaths per 1000 person-years) during 1999-2007. Excess mortality almost halved, with an annual decrease of 8.0% per year (95% CI, 3.0%-12.7%; P = .002) but remained high at 36 excess deaths per 1000 person-years in 2007. Viral load >400 copies/mL (compared with <or= 400 copies/mL; risk ratio, 3.4; 95% CI, 2.3-5.0), CD4(+) count <200 cells/μL (compared with >or= 200 cells/μL; risk ratio, 2.7; 95% CI, 1.9-3.9), and cytomegalovirus retinitis (risk ratio, 1.6; 95% CI, 1.2-2.1) were the strongest risk factors for excess mortality. CONCLUSIONS Excess mortality among patients with AIDS was nearly halved in the HAART era and most strongly linked to stage of HIV disease. These results reflect the continuing improvements in AIDS management but also highlight that excess mortality remains ∼5 times higher in patients with AIDS than in HIV-infected patients without AIDS.
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Affiliation(s)
- Milo A Puhan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205, USA.
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Lai TYY, Wong RLM, Luk FOJ, Chow VWS, Chan CKM, Lam DSC. Ophthalmic manifestations and risk factors for mortality of HIV patients in the post-highly active anti-retroviral therapy era. Clin Exp Ophthalmol 2010; 39:99-104. [PMID: 20796263 DOI: 10.1111/j.1442-9071.2010.02400.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Timothy Y Y Lai
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong Eye Hospital, Hong Kong, China.
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Effect of host genetics on incidence of HIV neuroretinal disorder in patients with AIDS. J Acquir Immune Defic Syndr 2010; 54:343-51. [PMID: 20531015 DOI: 10.1097/qai.0b013e3181deaf4d] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Approximately 10%-15% of patients with AIDS but without ocular opportunistic infections will have a presumed neuroretinal disorder (HIV-NRD), manifested by reduced contrast sensitivity and abnormal visual fields. The loss of contrast sensitivity often is sufficient to impair reading speed. To evaluate the effect of host genetics on HIV-NRD, we explored validated AIDS restriction gene variants CCR5Delta32, CCR2-64I, CCR5 P1, SDF-3'A, IL-10-5'A, RANTES -403A, RANTES -28G, RANTES-In1.1C, CX3CR1-249I, CX3CR1-280M, IFNG-179T, MDR1-3435T, and MCP-1364G, each of which has been implicated previously to influence HIV-1 infection, AIDS progression, therapy response, and antiviral drug metabolism, and an IL-10 receptor gene, IL-10R1, in the Longitudinal Study of the Ocular Complications of AIDS cohort. In European Americans (cases = 55, controls = 290), IL-10-5'A variant and its promoter haplotype (hazard ratio = 2.09, confidence interval. 1.19 to 3.67, P = 0.01), in African Americans (cases = 54, controls = 180), RANTES-In1.1C and the associated haplotype (hazard ratio = 2.72, confidence interval.: 1.48 to 5.00, P = 0.001), showed increased HIV-NRD susceptibility. Although sample sizes are small and P values do not pass a strict Bonferroni correction, our results suggest that, in European Americans, an IL-10-related pathway, and, in African Americans, chemokine receptor ligand polymorphisms in RANTES are risk factors for HIV-NRD development. Clearly, further studies are warrented.
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Jabs DA, Ahuja A, Van Natta M, Lyon A, Srivastava S, Gangaputra S. Course of cytomegalovirus retinitis in the era of highly active antiretroviral therapy: five-year outcomes. Ophthalmology 2010; 117:2152-61.e1-2. [PMID: 20673591 DOI: 10.1016/j.ophtha.2010.03.031] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Revised: 03/09/2010] [Accepted: 03/10/2010] [Indexed: 10/19/2022] Open
Abstract
PURPOSE To describe the 5-year outcomes of patients with cytomegalovirus (CMV) retinitis and AIDS in the era of highly active antiretroviral therapy (HAART). DESIGN Prospective, multicenter, observational study. PARTICIPANTS A total of 503 patients with AIDS and CMV retinitis. METHODS Follow-up every 3 months with medical history, ophthalmologic examination, laboratory testing, and retinal photographs. Participants were classified as having previously diagnosed CMV retinitis and immune recovery (CD4+ T cells ≥ 100 cells/μl), previously diagnosed retinitis and immune compromise, and newly diagnosed CMV retinitis (diagnosis <45 days before enrollment). MAIN OUTCOME MEASURES Mortality, retinitis progression (movement of the border of a CMV lesion ≥ ½ disc diameter or occurrence of a new lesion), retinal detachment, immune recovery uveitis (IRU), and visual loss (< 20/40 and ≥ 20/200). RESULTS Overall mortality was 9.8 deaths/100 person-years (PY). Rates varied by group at enrollment from 3.0/100 PY for those with previously diagnosed retinitis and immune recovery to 26.1/100 PY for those with newly diagnosed retinitis. The rate of retinitis progression was 7.0/100 PY and varied from 1.4/100 PY for those with previously diagnosed retinitis and immune recovery to 28.0/100 PY for those with newly diagnosed retinitis. The rate of retinal detachment was 2.3/100 eye-years (EY) and varied from 1.2/100 EY for those with previously diagnosed retinitis and immune recovery to 4.9/100 EY for those with newly diagnosed retinitis. The rate of IRU was 1.7/100 PY and varied from 1.3/100 PY for those with previously diagnosed retinitis and immune recovery at enrollment to 3.6/100 PY for those with newly diagnosed retinitis who subsequently experienced immune recovery. The rates of visual loss to < 20/40 and to ≤ 20/200 were 7.9/100 EY and 3.4/100 EY, respectively; they varied from 6.1/100 EY and 2.7/100 EY for those with previously diagnosed retinitis and immune recovery to 11.8/100 EY and 5.1/100 EY for those with newly diagnosed retinitis. Although the event rates tended to decline with time, in general, at no time did they reach zero. CONCLUSIONS Despite the availability of HAART, patients with AIDS and CMV retinitis remain at increased risk for mortality, retinitis progression, complications of the retinitis, and visual loss over a 5-year period. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
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Affiliation(s)
- Douglas A Jabs
- Department of Ophthalmology, the Mount Sinai School of Medicine, New York, New York, USA.
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Holland GN, Kappel PJ, Van Natta ML, Palella FJ, Lyon AT, Shah KH, Pavan PR, Jabs DA. Association between abnormal contrast sensitivity and mortality among people with acquired immunodeficiency syndrome. Am J Ophthalmol 2010; 149:807-16. [PMID: 20399927 PMCID: PMC4121666 DOI: 10.1016/j.ajo.2009.12.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Revised: 12/14/2009] [Accepted: 12/15/2009] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate the relationship between contrast sensitivity (CS) and mortality among people with acquired immunodeficiency syndrome (AIDS); and to explore the hypothesis that abnormal CS is a marker of systemic, life-threatening microvascular disease. DESIGN Longitudinal, observational cohort study. METHODS We evaluated 3395 eyes of 1706 individuals enrolled in the Longitudinal Study of the Complications of AIDS (1998-2008). CS was evaluated as a risk factor for death, and was compared to the presence of systemic diseases characterized by microvasculopathy (diabetes, cardiovascular disease, stroke, renal disease) and to laboratory markers of those diseases. Abnormal CS was defined as logCS <1.5 (lower 2.5th percentile for a normal control population). RESULTS CS was abnormal in 284 of 1691 (16.8%) study participants at enrollment. There was a positive relationship between the presence of abnormal CS at study entry and mortality (relative risk 2.0, 95% confidence interval 1.7-2.3, P < .0001). Abnormal CS was related to the presence of cardiovascular disease, stroke, and renal disease (all P values CONCLUSIONS Abnormal CS among people with AIDS is associated with increased mortality, and is independent of other risk factors for death that are monitored routinely. The relationship may indicate life-threatening microvascular disease in other organs.
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Affiliation(s)
- Gary N Holland
- Ocular Inflammatory Disease Center, Jules Stein Eye Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-7003, USA.
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Abstract
Cytomegalovirus (CMV) retinitis is the most common cause of vision loss in patients with acquired immunodeficiency syndrome (AIDS). CMV retinitis afflicted 25% to 42% of AIDS patients in the pre-highly active antiretroviral therapy (HAART) era, with most vision loss due to macula-involving retinitis or retinal detachment. The introduction of HAART significantly decreased the incidence and severity of CMV retinitis. Optimal treatment of CMV retinitis requires a thorough evaluation of the patient's immune status and an accurate classification of the retinal lesions. When retinitis is diagnosed, HAART therapy should be started or improved, and anti-CMV therapy with oral valganciclovir, intravenous ganciclovir, foscarnet, or cidofovir should be administered. Selected patients, especially those with zone 1 retinitis, may receive intravitreal drug injections or surgical implantation of a sustained-release ganciclovir reservoir. Effective anti-CMV therapy coupled with HAART significantly decreases the incidence of vision loss and improves patient survival. Immune recovery uveitis and retinal detachments are important causes of moderate to severe loss of vision. Compared with the early years of the AIDS epidemic, the treatment emphasis in the post- HAART era has changed from short-term control of retinitis to long-term preservation of vision. Developing countries face shortages of health care professionals and inadequate supplies of anti-CMV and anti-HIV medications. Intravitreal ganciclovir injections may be the most cost effective strategy to treat CMV retinitis in these areas.
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Affiliation(s)
- Michael W Stewart
- Department of Ophthalmology, Mayo School of Medicine, Jacksonville, FL, USA.
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