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Tillmann A, Ceklic L, Dysli C, Munk MR. Gender differences in retinal diseases: A review. Clin Exp Ophthalmol 2024; 52:317-333. [PMID: 38348562 DOI: 10.1111/ceo.14364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/05/2024] [Accepted: 01/26/2024] [Indexed: 04/18/2024]
Abstract
Gender medicine is a medical specialty that addresses gender differences in health and disease. Traditionally, medical research and clinical practice have often been focused on male subjects and patients. As a result, gender differences in medicine have been overlooked. Gender medicine considers the biological, psychological, and social differences between the genders and how these differences affect the development, diagnosis, treatment, and prevention of disease. For ophthalmological diseases epidemiological differences are known. However, there are not yet any gender-based ophthalmic treatment approaches for women and men. This review provides an overview of gender differences in retinal diseases. It is intended to make ophthalmologists, especially retinologists, more sensitive to the topic of gender medicine. The goal is to enhance comprehension of these aspects by highlighting fundamental gender differences. Integrating gender medicine into ophthalmological practice helps promote personalized and gender-responsive health care and makes medical research more accurate and relevant to the entire population.
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Affiliation(s)
- Anne Tillmann
- Augenarzt-Praxisgemeinschaft Gutblick, Pfäffikon, Switzerland
| | - Lala Ceklic
- Department of Ophthalmology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Bern Photographic Reading Center, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Chantal Dysli
- Department of Ophthalmology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Bern Photographic Reading Center, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Marion R Munk
- Augenarzt-Praxisgemeinschaft Gutblick, Pfäffikon, Switzerland
- Department of Ophthalmology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Bern Photographic Reading Center, Inselspital, University Hospital Bern, Bern, Switzerland
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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2
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Ali AA, Anasseri S, Abou-Ghaida J, Walker L, Barber T. Cytomegalovirus Esophagitis in an Immunocompromised Patient. Cureus 2023; 15:e45634. [PMID: 37868477 PMCID: PMC10588989 DOI: 10.7759/cureus.45634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/20/2023] [Indexed: 10/24/2023] Open
Abstract
Cytomegalovirus (CMV) can present with end-organ disease (EOD), particularly in patients with a CD4 cell count <50/mm3. While EOD in immunocompromised patients commonly presents as CMV retinitis (30%) and CMV colitis (5-10%), CMV esophagitis is rare. CMV is the third most common infectious esophagitis following Candida and Herpes Simplex. CMV esophagitis presents with odynophagia, dysphagia, and abdominal pain. Endoscopic exam may reveal large, linear distal esophageal ulcers. Histopathology or serology studies are diagnostic, though serology may be unreliable in the extremely immunosuppressed. Current treatment consists of antivirals such as ganciclovir and valganciclovir. Esophageal disease due to CMV carries a poor prognosis in the immunocompromised. We present the case of a 56-year-old male with a medical history of HIV/AIDS and stage III rectal squamous cell cancer who presented with shortness of breath, weakness, and chronic diarrhea. His HIV was previously well-controlled on antiretroviral therapy. However, due to his malignancy, he was undergoing treatment with chemotherapy and radiation. Initial labs revealed a CD4 count of 42. His clinical course consisted of Escherichia coli septicemia, new-onset atrial fibrillation with a rapid ventricular response, worsening pneumonia, possible metastasis, progressive diarrhea, and potential oropharyngeal candidiasis. Despite several broad-spectrum antimicrobial regimens, he remained symptomatic with new complaints of dysphagia and odynophagia. Eventually, the appearance of vesicular lesions on the lips and a repeat CD4 count of 13 garnered a suspicion of HSV or CMV. This complicated case highlights the necessity for a high index of suspicion of rare manifestations of CMV EOD in an immunocompromised patient presenting with confounding clinical symptoms and extensive diagnoses.
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Affiliation(s)
- Adya A Ali
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Sheela Anasseri
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Jaafar Abou-Ghaida
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Leslie Walker
- Family Medicine, Broward Health Medical Center, Fort Lauderdale, USA
| | - Tye Barber
- Family Medicine, Broward Health Medical Center, Fort Lauderdale , USA
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3
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Bogoni G, Lucas Júnior RM, Reis Schneider GA, Castanheira de Souza NF, Carvalho MK, Marcusso RM, Vidal JE. Cytomegalovirus retinitis in hospitalized people living with HIV in the late antiretroviral therapy era in São Paulo, Brazil. Int J STD AIDS 2023; 34:48-53. [PMID: 36259434 DOI: 10.1177/09564624221135294] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND There is scarce information on AIDS-related cytomegalovirus (CMV) retinitis in middle-income countries. The objectives of this study were to identify the prevalence of active CMV retinitis in severely immunosuppressed people living with HIV (PLWHIV) and to describe its main features. METHODS This retrospective cohort study was carried out at a tertiary center in São Paulo, Brazil. We included hospitalized adults PLWHIV with CD4 count ≤100 cells/μL, ≥ one quantitation of CMV DNA in plasma, and indirect ophthalmoscopy evaluation. RESULTS Thirty-eight (21.6%) of 176 participants had at least an ophthalmoscopy diagnosis and only 3 (1.7%) individuals presented active CMV retinitis. All these participants were male, and retinitis was asymptomatic in 2 cases. Two participants had extraocular end-organ CMV disease and detectable CMV DNA in plasma. CONCLUSIONS These results show a low prevalence of active CMV retinitis in the evaluated population. However, 2 of 3 participants had asymptomatic active CMV retinitis and a fifth of participants had at least one ophthalmoscopy diagnosis, suggesting the need for routine ophthalmologic evaluation in hospitalized severely immunosuppressed PLWHIV. The profile of participants with active CMV retinitis was similar to that described in the pre-ART era and quantitation of CMV DNA in plasma was variable.
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Affiliation(s)
- Giuliane Bogoni
- Departamento de Infectologia, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil
| | | | | | | | - Maria Kassab Carvalho
- Departamento de Infectologia, Pontifícia Universidade Católica de Campinas, São Paulo, Brazil
| | - Rosa Maria Marcusso
- Departamento de Neurologia, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil
| | - José Ernesto Vidal
- Departamento de Neurologia, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil.,Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Laboratório de Investigação Médica (LIM 49) da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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4
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Voznesenskiy S, Ermak T, Emerole K, Samotolkina Е, Klimkova P, Abramova E, Kozhevnikova G. Coexistence of Competing Opportunistic Pathogens in Critically ill Patients with Advanced AIDS: A Case Report and Literature Review. Open AIDS J 2022. [DOI: 10.2174/18746136-v16-e2208040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction:
Opportunistic infections (OIs) are the leading causes of morbidity and mortality among HIV-infected individuals. The incidence of OIs is greater in antiretroviral treatment (ART) naive patients. As of 30 June 2021, 28.2 (73%) people with HIV/AIDS (PLWHA) were accessing antiretroviral therapy (ART) globally, leaving the remaining 27% PLWHA without ART at risk for OIs. Multiple opportunistic infections are caused due to the coexistence of competing opportunistic pathogens that confound clinical manifestations, investigative procedures, and management protocols.
Case Presentation:
In this report, we describe the case of a critically ill HIV female patient admitted to the ICU. The patient was diagnosed with multiple opportunistic infections and subsequently died after her illness progressed. Due to the paucity of information on the subject, we conducted a retrospective study of 1440 case records of HIV/AIDS critically ill patients to determine the incidence and spectrum of multiple opportunistic infections. We performed a review of the available medical literature relevant to the subject.
Conclusion:
Knowledge of such events would guide and enhance the physician's diagnostic and management strategies, especially in resource limited regions.
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Pharmacokinetics of fluconazole and ganciclovir as combination antimicrobial chemotherapy on ECMO: a case report. Int J Antimicrob Agents 2021; 58:106431. [PMID: 34520832 DOI: 10.1016/j.ijantimicag.2021.106431] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 08/27/2021] [Accepted: 08/28/2021] [Indexed: 11/24/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) can affect antimicrobial pharmacokinetics. This case report describes a 33-year-old male with newly diagnosed acquired immunodeficiency syndrome presenting in acute severe type 1 respiratory failure. On investigation, the patient had positive cultures for Candida albicans from respiratory specimens and high blood cytomegalovirus titres, and required venovenous ECMO therapy for refractory respiratory failure. Intravenous fluconazole (6 mg/kg, 24-h) and ganciclovir (5 mg/kg, 12-h) was commenced. Pre-oxygenator, post-oxygenator and arterial blood samples were collected after antibiotic administration, and were analysed for total fluconazole and ganciclovir concentrations. Although there was a 40% increase in the volume of distribution for fluconazole relative to healthy volunteers, the pharmacodynamic targets for prophylaxis were still met. The area under the curve exposure of ganciclovir (50.78 mg•h/L) achieved target thresholds. The ECMO circuit had no appreciable effect on achievement of therapeutic exposures of fluconazole and ganciclovir.
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Abstract
BACKGROUND The pharmacokinetic (PK) data of ganciclovir (GCV), a first-line antiviral treatment for cytomegalovirus infections, in critically ill patients are limited. This study aimed at characterizing GCV population PK and interindividual variability (IIV) in intensive care unit (ICU) patients. Secondary objectives were to identify patient characteristics responsible for IIV and simulate GCV exposure for different dosing regimens. METHOD In this retrospective observational study, clinical data and serum GCV levels were collected from ICU patients on intravenous GCV. PK modeling, covariate analyses, and explorative Monte Carlo dosing simulations (MCS) were performed using nonlinear mixed-effects modeling. Bootstrap and visual predictive checks were used to determine model adequacy. RESULTS In total, 128 GCV measurements were obtained from 34 patients. GCV PK conformed to a 1-compartment model with first-order elimination. After multivariate analyses, only the estimated glomerular filtration rate calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula (P < 0.001) was included as a covariate. In the final model, the estimated clearance (CL) and volume of distribution (V1) were 2.3 L/h and 42 L, respectively, for a patient with the median CKD-EPI of the population (65 mL/min per 1.73 m). The association between CKD-EPI and CL decreased the residual variability from 0.56 to 0.43 and V1-IIV from 114% to 80%, whereas CL-IIV changed from 43% to 47%. MCS revealed that a substantial number of patients may not achieve the GCV PK/pharmacodynamic target trough level (>1.5 mg/L) when administering the label-recommended dose reductions for patients with CKD-EPI <50 mL/min. CONCLUSIONS A large IIV was observed in GCV PK among ICU patients. CKD-EPI could partially explain the IIV, although a large part of the variability remains unclear. MCS suggested that recommended dose reductions for CKD-EPI <50 mL/min may lead to subtherapeutic plasma GCV levels in these patients.
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7
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Moschos MM, Margetis I, Markopoulos I, Moschos MN. Optical coherence tomography and multifocal electroretinogram study in human immunodeficiency virus‐positive children without infectious retinitis. Clin Exp Optom 2021; 94:291-5. [DOI: 10.1111/j.1444-0938.2011.00603.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
| | - Ioannis Margetis
- Evgenidion Hospital, University of Athens, Athens, Greece. E‐mail:
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8
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He XQ, Huang YQ, Zeng YM, Qin YY, Tang SQ, Xu XL, Harypursat V, Lu YQ, Liu M, Yuan J, Chen YK. Timing of antiretroviral therapy for HIV-infected patients with cytomegalovirus retinitis: study protocol of a multi-center prospective randomized controlled trial. Trials 2021; 22:218. [PMID: 33736696 PMCID: PMC7977244 DOI: 10.1186/s13063-021-05159-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: 09/15/2020] [Accepted: 02/27/2021] [Indexed: 11/10/2022] Open
Abstract
Background Cytomegalovirus retinitis (CMVR) is an important opportunistic infection (OI) occurring mainly in patients with acquired immunodeficiency syndrome (AIDS) and has the potential to cause severe visual impairment and blindness among AIDS patients. Subsequent to the adoption and implementation of widespread antiretroviral therapy (ART), the prognosis of AIDS-associated CMVR has been substantially improved. Nevertheless, the equivocal clinical evidence as regards the optimal timing for ART initiation in patients with an established CMVR diagnosis is required. We therefore designed the present study in order to investigate the optimal timing for ART initiation in AIDS/CMVR patients. Methods This will be a prospective, randomized controlled trial to be performed at 17 hospitals in mainland China. A total of 300 participants with CMVR will be randomly assigned to an early ART initiation group (ART initiation within 2 weeks after anti-CMV therapy), or a deferred ART initiation group (initiation of ART more than 2 weeks after anti-CMV therapy) at a 1:1 ratio. All participants will receive 48 weeks of follow-up after anti-CMV therapy initiation. Our primary outcome will be the incidence of visual loss (to a visual acuity worse than 20/40 or 20/200) in the two groups during the 48-week follow-up period. Secondary outcomes will include changes in HIV virological suppression and serum CD4+ T-cell counts, the incidence of mortality, retinitis progression (movement of the peripheral border of a CMV lesion ≥ ½ disc diameter, or occurrence of a new CMV lesion), retinal detachment, immune recovery uveitis (IRU), and other OIs and adverse events between the two study groups during the 48 weeks of follow-up. Discussion The study aims to investigate the optimal timing for ART initiation in AIDS/CMVR patients. We hope to be able to extract robust clinical evidence for use in optimal AIDS/CMVR management should our trial be successful. Trial registration This research was registered as one of the twelve clinical trials under the name of a general project “A study for precision diagnosing and treatment strategies in difficult-to-treat AIDS cases and HIV-infected patients with highly fatal or highly disabling opportunistic infections”, ChiCTR1900021195. Registered on 1 February 2019, http://www.chictr.org.cn/showproj.aspx?proj=35362.
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Affiliation(s)
- Xiao-Qing He
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Yin-Qiu Huang
- National Key Laboratory for Infectious Diseases Prevention and Treatment with Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, 400036, China
| | - Yan-Ming Zeng
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Yuan-Yuan Qin
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Sheng-Quan Tang
- National Key Laboratory for Infectious Diseases Prevention and Treatment with Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, 400036, China
| | - Xiao-Lei Xu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Vijay Harypursat
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Yan-Qiu Lu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Min Liu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Jing Yuan
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Yao-Kai Chen
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China.
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9
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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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10
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Abstract
Great progress has been made in caring for persons with human immunodeficiency virus. However, a significant proportion of individuals still present to care with advanced disease and a low CD4 count. Careful considerations for selection of antiretroviral therapy as well as close monitoring for opportunistic infections and immune reconstitution inflammatory syndrome are vitally important in providing care for such individuals.
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Affiliation(s)
- Nathan A Summers
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, 341 Ponce de Leon Avenue, Atlanta, GA 30308, USA
| | - Wendy S Armstrong
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, 341 Ponce de Leon Avenue, Atlanta, GA 30308, USA.
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Hodowanec AC, Pikis A, Komatsu TE, Sampson MR, Younis IR, O'Rear JJ, Singer ME. Treatment and Prevention of CMV Disease in Transplant Recipients: Current Knowledge and Future Perspectives. J Clin Pharmacol 2018; 59:784-798. [PMID: 30586161 DOI: 10.1002/jcph.1363] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/26/2018] [Indexed: 12/29/2022]
Abstract
This review summarizes the significant impact of cytomegalovirus (CMV) infection on solid organ and hematopoietic stem cell transplant recipients. A discussion of the various CMV prevention and treatment strategies is provided, including a detailed description of each of the available CMV antiviral drugs.
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Affiliation(s)
- Aimee C Hodowanec
- Center for Drug Evaluation and Research, Office of Antimicrobial Products, Division of Antiviral Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Andreas Pikis
- Center for Drug Evaluation and Research, Office of Antimicrobial Products, Division of Antiviral Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Takashi E Komatsu
- Center for Drug Evaluation and Research, Office of Antimicrobial Products, Division of Antiviral Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Mario R Sampson
- Center for Drug Evaluation and Research, Office of Translational Sciences, Office of Clinical Pharmacology, Division of Clinical Pharmacology IV, Food and Drug Administration, Silver Spring, MD, USA
| | - Islam R Younis
- Center for Drug Evaluation and Research, Office of Translational Sciences, Office of Clinical Pharmacology, Division of Clinical Pharmacology IV, Food and Drug Administration, Silver Spring, MD, USA
| | - Julian J O'Rear
- Center for Drug Evaluation and Research, Office of Antimicrobial Products, Division of Antiviral Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Mary E Singer
- Center for Drug Evaluation and Research, Office of Antimicrobial Products, Division of Antiviral Products, Food and Drug Administration, Silver Spring, MD, USA
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12
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Singh SR, Dogra M, Kaur S, Bajgai P, Tigari B, Handa S, Katoch D, Gupta V, Dogra MR, Sharma A, Singh R. Spectrum of Newly Diagnosed Cytomegalovirus Retinitis in a Developing Country in the HAART Era. Ocul Immunol Inflamm 2018; 28:119-125. [PMID: 30395753 DOI: 10.1080/09273948.2018.1538460] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: To characterize the presenting features of cytomegalovirus (CMV) retinitis in HIV-positive patients in a developing country in the HAART era.Methods: Retrospective chart review of all patients with CMV retinitis seen at a tertiary-care referral center between January 2006 to June 2017. Demographic and clinical data were collected to study the presenting features and risk factors for blindness.Results: Fifty-five patients with treatment-naïve CMV retinitis were enrolled; 75% were males. CD4 counts were below 50 cells/µL in 51.1%. Bilateral presentation was seen in 61.5%. Half (50.6%) of the eyes were blind at first examination. Zone 1 involvement was present in 46% of the eyes. Retinal area involvement > 25% was the only factor associated significantly with higher incidence of blindness (p = 0.016).Conclusions: There was extensive and bilateral presentation of CMV retinitis due to delayed presentation. Screening for CMV retinitis, irrespective of CD4 counts, may help in developing nations.
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Affiliation(s)
- Simar Rajan Singh
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Mohit Dogra
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Savleen Kaur
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Priya Bajgai
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Basavaraj Tigari
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sabia Handa
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Deeksha Katoch
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishali Gupta
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Mangat R Dogra
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ramandeep Singh
- Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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13
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AIDS Cholangiopathy Secondary to Cytomegalovirus as Possible Unmasking Immune Reconstitution Inflammatory Syndrome in Human Immunodeficiency Virus-Infected Individual: Case Report and Review of the Literature. Case Rep Infect Dis 2018; 2018:1891030. [PMID: 30147971 PMCID: PMC6083534 DOI: 10.1155/2018/1891030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/10/2018] [Indexed: 11/17/2022] Open
Abstract
We present the first case report of cytomegalovirus (CMV) cholangiopathy as possible immune reconstitution inflammatory syndrome (IRIS) in a human immunodeficiency virus (HIV)-infected individual, within two months of starting effective HAART. The patient presented with abdominal pain, nausea, vomiting, decreased appetite, and jaundice. The patient was diagnosed on ERCP as AIDS cholangiopathy, and biopsy of the ampulla showed acute inflammation with CMV inclusion bodies. The patient underwent sphincterotomy with CBD stenting and HAART continued without use of ganciclovir or valganciclovir. On follow-up, the patient achieved clinical and histopathological cure, which was demonstrated on repeat ampullary biopsy.
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14
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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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15
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Karass M, Grossniklaus E, Seoud T, Jain S, Goldstein DA. Kaposi Sarcoma Inflammatory Cytokine Syndrome (KICS): A Rare but Potentially Treatable Condition. Oncologist 2017; 22:623-625. [PMID: 28424322 DOI: 10.1634/theoncologist.2016-0237] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 12/21/2016] [Indexed: 01/28/2023] Open
Abstract
Kaposi sarcoma inflammatory cytokine syndrome (KICS) is a newly-described condition affecting individuals who are HIV-positive and are infected with human herpesvirus 8 (HHV-8). This is a syndrome that in some ways mimics severe sepsis with associated acute respiratory distress syndrome, possibly requiring a ventilator and vasopressor support. However, unlike severe sepsis, antibiotics provide no benefit. Management of KICS has not been fully elucidated because of its high mortality rate. However, the syndrome has been successfully treated in some cases with immunomodulatory therapy. It is crucial for oncologists to be able to recognize this syndrome and to institute the appropriate therapy. The Oncologist 2017;22:623-625.
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Affiliation(s)
| | | | - Talal Seoud
- American University of Beirut, Beirut, Lebanon
| | - Sanjay Jain
- Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Daniel A Goldstein
- Emory University, Atlanta, Georgia, USA
- Rabin Medical Center, Petach Tikvah, Israel
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Sittivarakul W, Seepongphun U. Incidence Rates and Risk Factors for Vision Loss among AIDS-Related Cytomegalovirus Retinitis Patients in Southern Thailand. Ocul Immunol Inflamm 2017; 26:82-89. [PMID: 28323489 DOI: 10.1080/09273948.2017.1283044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE To describe the incidence of and risk factors for visual acuity (VA) loss in patients with AIDS and cytomegalovirus (CMV) retinitis. METHODS A total of 132 patients were included. The main outcome measurements were the incidences of VA loss to ≤20/50 and ≤20/200. RESULTS The incidences of VA loss to ≤20/50 and ≤20/200 were 0.22/eye-year (EY) and 0.12/EY, respectively. Risk factors for the incidence of VA loss to ≤20/50 were low nadir CD4+ T-cell count (adjusted hazard ratio [aHR], 3.1), large area of retinitis (aHR, 3.7), and no immune recovery (IR) (aHR, 13.9). Risk factors for the incidence of VA loss to ≤20/200 were not receiving highly active antiretroviral therapy (HAART) (aHR, 4.4) and large retinitis area (aHR, 2.1). CONCLUSIONS The incidence of VA loss in eyes affected by CMV retinitis was high. The use of HAART, particularly with subsequent immune recovery, substantially reduced the incidence of VA loss.
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Affiliation(s)
- Wantanee Sittivarakul
- a Department of Ophthalmology, Faculty of Medicine , Prince of Songkla University , Hat Yai , Thailand
| | - Usanee Seepongphun
- a Department of Ophthalmology, Faculty of Medicine , Prince of Songkla University , Hat Yai , Thailand
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Jirawison C, Yen M, Leenasirimakul P, Chen J, Guadanant S, Kunavisarut P, Patikulsila D, Watanachai N, Ausayakhun S, Heiden D, Holland GN, Margolis TP, Keenan JD. Telemedicine screening for cytomegalovirus retinitis at the point of care for human immunodeficiency virus infection. JAMA Ophthalmol 2015; 133:198-205. [PMID: 25412344 DOI: 10.1001/jamaophthalmol.2014.4766] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Cytomegalovirus (CMV) retinitis is a leading cause of blindness in many developing countries, likely the result of inadequate screening. Telemedicine screening for CMV retinitis instituted at the point of care for human immunodeficiency virus (HIV) infection may allow for earlier detection. OBJECTIVES To determine the diagnostic accuracy of retinal photography in detecting CMV retinitis at the point of HIV care and to characterize the clinical manifestations of CMV retinitis detected through the screening program. DESIGN, SETTING, AND PARTICIPANTS We enrolled 103 participants from a population of 258 patients with HIV and a CD4 level of less than 100/μL treated at an HIV clinic in Thailand from June 2010 through June 2012. We captured mosaic fundus photographs through a dilated pupil using a digital fundus camera. An experienced on-site ophthalmologist masked to the results of the fundus images subsequently examined each eye with indirect ophthalmoscopy and recorded the clinical findings on a standardized form. Three remote graders evaluated each image for CMV retinitis. INTERVENTION Fundus photography and indirect ophthalmoscopy. MAIN OUTCOMES AND MEASURES Sensitivity and specificity of telemedicine relative to indirect ophthalmoscopy for diagnosis of CMV retinitis and clinical features of CMV retinitis lesions. RESULTS Sixteen patients (15.5%) were diagnosed as having CMV retinitis, of whom 5 (31%) had bilateral disease. Of the 21 eyes (10.2%) with CMV retinitis, 7 (33%) had visual symptoms. Retinitis lesions occupied less than 10% of the total retinal surface area in 13 of 21 eyes (62%) and did not involve the posterior pole (ie, zone 1) in 15 of 21 eyes (71%). Mean logMAR visual acuity in affected eyes was 0.41 (95% CI, 0.11-0.71; Snellen equivalent, 20/50 [95% CI, 20/25-20/100]). The mean sensitivity for the 3 remote graders in detecting CMV retinitis on fundus photography was 30.2% (95% CI, 10.5%-52.4%), and mean specificity was 99.1% (95% CI, 97.8%-100.0%). The CMV retinitis lesions missed by the remote graders (false-negative findings) were more likely to be small (P = .001) and located in the peripheral retina (P = .04). CONCLUSIONS AND RELEVANCE Patients undergoing screening at a clinic for HIV treatment had less extensive retinitis than patients in recent reports from an ophthalmology clinic. Retinal photography with the camera used in this study was not highly sensitive in detecting CMV retinitis but may identify disease with an immediate threat to vision. Improved accuracy will require a camera that can more easily image the peripheral retina.
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Affiliation(s)
- Choeng Jirawison
- Department of Ophthalmology, Nakornping Hospital, Chiang Mai, Thailand
| | - Michael Yen
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco3currently a medical student, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Jenny Chen
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco4Ocular Inflammatory Disease Center, Jules Stein Eye Institute, University of California, Los Angeles5Department of Ophthalmology, David Geffen School of M
| | - Siripim Guadanant
- Department of Ophthalmology, Nakornping Hospital, Chiang Mai, Thailand
| | - Paradee Kunavisarut
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Direk Patikulsila
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nawat Watanachai
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Somsanguan Ausayakhun
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - David Heiden
- Department of Ophthalmology, California Pacific Medical Center, San Francisco
| | - Gary N Holland
- Ocular Inflammatory Disease Center, Jules Stein Eye Institute, University of California, Los Angeles
| | - Todd P Margolis
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco8Department of Ophthalmology, University of California, San Francisco9currently with the Department of Ophthalmology and Visual Sciences, Washington Univer
| | - Jeremy D Keenan
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco8Department of Ophthalmology, University of California, San Francisco
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Yen M, Chen J, Ausayakhun S, Kunavisarut P, Vichitvejpaisal P, Ausayakhun S, Jirawison C, Shantha J, Holland GN, Heiden D, Margolis TP, Keenan JD. Retinal detachment associated with AIDS-related cytomegalovirus retinitis: risk factors in a resource-limited setting. Am J Ophthalmol 2015; 159:185-92. [PMID: 25448999 DOI: 10.1016/j.ajo.2014.10.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 10/10/2014] [Accepted: 10/10/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine risk factors predictive of retinal detachment in patients with cytomegalovirus (CMV) retinitis in a setting with limited access to ophthalmic care. DESIGN Case-control study. METHODS Sixty-four patients with CMV retinitis and retinal detachment were identified from the Ocular Infectious Diseases and Retina Clinics at Chiang Mai University. Three control patients with CMV retinitis but no retinal detachment were selected for each case, matched by calendar date. The medical records of each patient were reviewed, with patient-level and eye-level features recorded for the clinic visit used to match cases and controls, and also for the initial clinic visit at which CMV retinitis was diagnosed. Risk factors for retinal detachment were assessed separately for each of these time points using multivariate conditional logistic regression models that included 1 eye from each patient. RESULTS Patients with a retinal detachment were more likely than controls to have low visual acuity (odds ratio [OR], 1.24 per line of worse vision on the logMAR scale; 95% confidence interval [CI], 1.16-1.33) and bilateral disease (OR, 2.12; 95% CI, 0.92-4.90). Features present at the time of the initial diagnosis of CMV retinitis that predicted subsequent retinal detachment included bilateral disease (OR, 2.68; 95% CI, 1.18-6.08) and lesion size (OR, 2.64 per 10% increase in lesion size; 95% CI, 1.41-4.94). CONCLUSION Bilateral CMV retinitis and larger lesion sizes, each of which is a marker of advanced disease, were associated with subsequent retinal detachment. Earlier detection and treatment may reduce the likelihood that patients with CMV retinitis develop a retinal detachment.
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Drye LT, Casper AS, Sternberg AL, Holbrook JT, Jenkins G, Meinert CL. The transitioning from trials to extended follow-up studies. Clin Trials 2014; 11:635-47. [PMID: 25115882 PMCID: PMC4229418 DOI: 10.1177/1740774514547396] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Investigators may elect to extend follow-up of participants enrolled in a randomized clinical trial after the trial comes to its planned end. The additional follow-up may be initiated to learn about longer term effects of treatments, including adverse events, costs related to treatment, or for reasons unrelated to treatment such as to observe the natural course of the disease using the established cohort from the trial. PURPOSE We examine transitioning from trials to extended follow-up studies when the goal of additional follow-up is to observe longer term treatment effects. METHODS We conducted a literature search in selected journals from 2000 to 2012 to identify trials that extended follow-up for the purpose of studying longer term treatment effects and extracted information on the operational and logistical issues in the transition. We also draw experience from three trials coordinated by the Johns Hopkins Coordinating Centers that made transitions to extended follow-up: the Alzheimer's Disease Anti-inflammatory Prevention Trial, Multicenter Uveitis Steroid Treatment trial, and Childhood Asthma Management Program. RESULTS Transitions are not uncommon in multicenter clinical trials, even in trials that continued to the planned end of the trial. Transitioning usually necessitates new participant consents. If study infrastructure is not maintained during the transition, participants will be lost and re-establishing the staff and facilities will be costly. Merging data from the trial and follow-up study can be complicated by changes in data collection measures and schedules. LIMITATIONS Our discussion and recommendations are limited to issues that we have experienced in transitions from trials to follow-up studies. DISCUSSION We discuss issues such as maintaining funding, institutional review board and consent requirements, contacting participants, and combining data from the trial and follow-up phases. We conclude with a list of recommendations to facilitate transitions from a trial to an extended follow-up study.
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Affiliation(s)
- Lea T Drye
- Department of Epidemiology, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA
| | - Anne S Casper
- Department of Epidemiology, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA
| | - Alice L Sternberg
- Department of Epidemiology, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA
| | - Janet T Holbrook
- Department of Epidemiology, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA
| | - Gabrielle Jenkins
- Department of Epidemiology, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA
| | - Curtis L Meinert
- Department of Epidemiology, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA
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Kempen JH, Sugar EA, Varma R, Dunn JP, Heinemann MH, Jabs DA, Lyon AT, Lewis RA. Risk of cataract among subjects with acquired immune deficiency syndrome free of ocular opportunistic infections. Ophthalmology 2014; 121:2317-24. [PMID: 25109932 PMCID: PMC4252252 DOI: 10.1016/j.ophtha.2014.06.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 02/14/2014] [Accepted: 06/11/2014] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To evaluate the risk of cataract in the setting of AIDS. DESIGN Prospective cohort study. PARTICIPANTS Subjects with AIDS free of ocular opportunistic infections throughout catamnesis. METHODS From 1998 through 2008, subjects 13 years of age or older were enrolled. Demographic characteristics and clinical characteristics were documented at enrollment and semiannually. MAIN OUTCOME MEASURES Cataract was defined as high-grade lens opacity observed by biomicroscopy judged to be the cause of a best-corrected visual acuity worse than 20/40. Eyes that underwent cataract surgery during follow-up were considered to have developed cataract before the first visit when pseudophakia or aphakia was observed. RESULTS Among 1606 participants (3212 eyes) at enrollment, 1.9% (95% confidence interval [CI]: 1.3%-2.7%) were observed to have cataract or prior cataract surgery. Among the 2812 eyes initially free of cataract and followed longitudinally (median follow-up, 4.6 years), the incidence of cataract was 0.37%/eye-year (95% CI: 0.26%-0.53%). In addition to age, significant cataract risk factors included prior cataract in the contralateral eye (adjusted hazard ratio [aHR], 21.6; 95% CI: 10.4-44.8), anterior segment inflammation (aHR, 4.40; 95% CI: 1.64-11.9), prior retinal detachment (aHR, 4.94; 95% CI: 2.21-11.0), and vitreous inflammation (aHR, 7.12; 95% CI: 2.02-25.0), each studied as a time-updated characteristic. Detectable human immunodeficiency virus RNA in peripheral blood was associated with lower risk of cataract at enrollment (adjusted odds ratio, 0.32; 95% CI: 0.12-0.80) but not of incident cataract (aHR, 1.58; 95% CI: 0.90-2.76). After adjustment for other factors, neither the then-current absolute CD4+ T-cell count nor antiretroviral therapy status showed consistent association with cataract risk, nor did an additive diagnosis of other comorbidities. Compared with the available population-based studies that used similar definitions of cataract, the age-specific prevalence of cataract in our cohort was higher than in 1 of 2 such studies, and the age-specific incidence of cataract surgery was higher. CONCLUSIONS Our results suggest cataract may occur earlier among patients with AIDS free of ocular opportunistic infections than in the general population. Cataract risk was associated most strongly with age and with other ocular morbidity in this population. With improved survival, the burden of cataract likely will increase for persons with the human immunodeficiency virus or AIDS.
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Affiliation(s)
- John H Kempen
- Department of Ophthalmology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
| | - Elizabeth A Sugar
- Department of Biostatistics, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Rohit Varma
- Doheny Eye Institute, Department of Ophthalmology, University of Southern California, Los Angeles, California
| | - James P Dunn
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Murk-Hein Heinemann
- Ophthalmic Oncology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Ophthalmology, Cornell University Medical College, New York, New York
| | - Douglas A Jabs
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alice T Lyon
- Department of Ophthalmology, Northwestern University, Chicago, Illinois
| | - Richard A Lewis
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
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Dunn JP. An overview of current and future treatment options for patients with cytomegalovirus retinitis. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.945906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sen HN, Davis J, Ucar D, Fox A, Chan CC, Goldstein DA. Gender disparities in ocular inflammatory disorders. Curr Eye Res 2014; 40:146-61. [PMID: 24987987 DOI: 10.3109/02713683.2014.932388] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Ocular inflammatory disorders disproportionately affect women, and the majority of affected women are of childbearing age. The role of sex or reproductive hormones has been proposed in many other inflammatory or autoimmune disorders, and findings from non-ocular autoimmune diseases suggest a complex interaction between sex hormones, genetic factors and the immune system. However, despite the age and sex bias, factors that influence this disparity are complicated and unclear. This review aims to evaluate the gender disparities in prevalence, incidence and severity of the most common infectious and non-infectious ocular inflammatory disorders.
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Affiliation(s)
- Hatice Nida Sen
- National Eye Institute, National Institutes of Health , Bethesda, MD , USA
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Sex and reproduction in the transmission of infectious uveitis. J Ophthalmol 2014; 2014:683246. [PMID: 25105020 PMCID: PMC4106153 DOI: 10.1155/2014/683246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 06/16/2014] [Indexed: 12/17/2022] Open
Abstract
Current data permit only speculations regarding sex differences in the prevalence of infectious uveitis between women and men because uveitis case surveys do not uniformly report gender data. Differences in prevalence that are reported in the literature could relate to simple differences in the number of women and men at risk for infection or to biological differences between men and women. Compared to other types of uveitis, infectious uveitis may be directly related to occupational exposures or sexual behaviors, which differ between women and men, and may mask actual biological differences in susceptibility to ocular manifestations of the infection and its prognosis. In infectious uveitis for which there is no element of sexual transmission and data is available, prevalence of ocular disease is roughly equal between women and men. Women also have a unique relationship with infectious uveitis in their role as mothers. Vertical transmission of infections such as herpes simplex, toxoplasmosis, and cytomegalovirus can produce severe chorioretinitis in neonates.
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Bittencourt MG, Agbedia OO, Liu HT, Annam R, Sepah YJ, Leder HA, Sophie R, Ibrahim M, Akhtar A, Akhlaq A, Do DV, Nguyen QD. Ocular complications of HIV/AIDS in the era of HAART. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.12.65] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Eid AJ, Razonable RR. Valganciclovir for the treatment of cytomegalovirus retinitis in patients with AIDS. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.2.3.351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Xiao J, Gao G, Li Y, Zhang W, Tian Y, Huang Y, Su W, Han N, Yang D, Zhao H. Spectrums of opportunistic infections and malignancies in HIV-infected patients in tertiary care hospital, China. PLoS One 2013; 8:e75915. [PMID: 24204583 PMCID: PMC3808390 DOI: 10.1371/journal.pone.0075915] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 08/19/2013] [Indexed: 11/18/2022] Open
Abstract
Background HIV-related opportunistic infections (OIs) and malignancies continued to cause morbidity and mortality in Chinese HIV-infected individuals. The objective for this study is to elucidate the prevalence and spectrums of OIs and malignancies in HIV-infected patients in the Beijing Ditan Hospital. Methods The evaluation of the prevalence and spectrums of OIs and malignancies was conducted by using the clinical data of 834 HIV-infected patients admitted in the Beijing Ditan hospital from January 1, 2009, to November 30, 2012. Results The prevalence and spectrums of OIs and malignancies varied contingent on geographic region, transmission routes, and CD4 levels. We found that tuberculosis was most common OI and prevalence was 32.5%, followed by candidiasis(29.3%), Pneumocystis pneumonia(PCP)(22.4%), cytomegalovirus(CMV) infection(21.7%), other fungal infections(16.2%), mycobacterium avium complex(MAC)(11.3%), cryptococcosis(8.0%), progressive multifocal leukoencephalopathy(PML)(4.4%), Cerebral Toxoplasmosis(3.5%) and Penicillium marneffei infection(1.4%); while Lymphoma(2.9%), Kaposi’s sarcoma(0.8%) and cervix carcinoma(0.3%) were emerged as common AIDS-defining malignancies. Pulmonary OI infections were the most prevalent morbidity and mortality in patients in the AIDS stage including pulmonary tuberculosis (26.6%) and PCP (22.4%). CMV infection(21.7%) was most common viral infection; Fungal OIs were one of most prevalent morbidity in patients in the AIDS stage, including oral candidiasis (29.3%), other fungal infection (16.2%), Cryptococcosis (8.0%) and Penicillium marneffei infection (1.4%). We found the low prevalence of AIDS-defining illnesses in central neural system in this study, including progressive multifocal leukoencephalopathy (4.4%), cerebral toxoplasmosis (3.5%), tuberculosis meningitis (3.2%), cryptococcal meningitis (2.4%) and CMV encephalitis (1.1%). In-hospital mortality rate was 4.3 per 100 person-years due to severe OIs, malignancies, and medical cost constraints. Conclusions The prevalence and spectrums of OIs, malignancies and co-infections were discussed in this study. It would help increase the awareness for physicians to make a diagnosis and empirical treatment sooner and plan good management strategies, especially in resource limited regions.
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Affiliation(s)
- Jiang Xiao
- Center for Infectious Diseases, Ditan Hospital, Capital Medical University, Beijing, the People’s Republic of China
| | - Guiju Gao
- Center for Infectious Diseases, Ditan Hospital, Capital Medical University, Beijing, the People’s Republic of China
| | - Yanmei Li
- Center for Infectious Diseases, Ditan Hospital, Capital Medical University, Beijing, the People’s Republic of China
| | - Wen Zhang
- Center for Infectious Diseases, Ditan Hospital, Capital Medical University, Beijing, the People’s Republic of China
| | - Yunfei Tian
- Center for Infectious Diseases, Ditan Hospital, Capital Medical University, Beijing, the People’s Republic of China
| | - Yinxiu Huang
- Center for Infectious Diseases, Ditan Hospital, Capital Medical University, Beijing, the People’s Republic of China
| | - Wenjing Su
- Center for Infectious Diseases, Ditan Hospital, Capital Medical University, Beijing, the People’s Republic of China
| | - Ning Han
- Center for Infectious Diseases, Ditan Hospital, Capital Medical University, Beijing, the People’s Republic of China
| | - Di Yang
- Center for Infectious Diseases, Ditan Hospital, Capital Medical University, Beijing, the People’s Republic of China
| | - Hongxin Zhao
- Center for Infectious Diseases, Ditan Hospital, Capital Medical University, Beijing, the People’s Republic of China
- * E-mail:
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Shah JM, Leo SW, Pan JC, Yong VK, Wong EP, Lim TH, Teoh SC. Telemedicine Screening for Cytomegalovirus Retinitis Using Digital Fundus Photography. Telemed J E Health 2013; 19:627-31. [DOI: 10.1089/tmj.2012.0233] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jinesh M. Shah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Seo W. Leo
- Dr Leo Adult & Paediatric Eye Specialist, Singapore
- National Healthcare Group Eye Institute, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore
| | - James C. Pan
- National Healthcare Group Eye Institute, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore
- Nobel Eye & Vision Centre, Singapore
| | - Vernon K. Yong
- National Healthcare Group Eye Institute, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore
| | - Elizabeth P. Wong
- National Healthcare Group Eye Institute, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore
| | - Tock H. Lim
- National Healthcare Group Eye Institute, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore
| | - Stephen C. Teoh
- National Healthcare Group Eye Institute, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore
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Luo J, Jing D, Kozak I, Huiming Z, Siying C, Yezhen Y, xin Q, Luosheng T, Adelman RA, Forster SH. Prevalence of Ocular Manifestations of HIV/AIDS in the Highly Active Antiretroviral Therapy (HAART) Era: A Different Spectrum in Central South China. Ophthalmic Epidemiol 2013; 20:170-5. [DOI: 10.3109/09286586.2013.789530] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Gangaputra S, Drye L, Vaidya V, Thorne JE, Jabs DA, Lyon AT. Non-cytomegalovirus ocular opportunistic infections in patients with acquired immunodeficiency syndrome. Am J Ophthalmol 2013; 155:206-212.e5. [PMID: 23068916 PMCID: PMC4164649 DOI: 10.1016/j.ajo.2012.07.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 07/13/2012] [Accepted: 07/16/2012] [Indexed: 11/21/2022]
Abstract
PURPOSE To report the incidence and clinical outcomes of non-cytomegalovirus (non-CMV) ocular opportunistic infections in patients with acquired immunodeficiency syndrome (AIDS) in the era of highly active antiretroviral therapy. DESIGN Multicenter, prospective, observational study of patients with AIDS. METHODS Medical history, ophthalmologic examination, and laboratory tests were performed at enrollment and every 6 months subsequently. Once an ocular opportunistic infection was diagnosed, patients were seen every 3 months for outcomes. RESULTS At enrollment, 37 non-CMV ocular opportunistic infections were diagnosed: 16 patients, herpetic retinitis; 11 patients, toxoplasmic retinitis; and 10 patients, choroiditis. During the follow-up period, the estimated incidences (and 95% confidence intervals [CI]) of these were: herpetic retinitis, 0.007/100 person-years (PY) (95% CI 0.0004, 0.039); toxoplasmic retinitis, 0.007/100 PY (95% CI 0.004, 0.039); and choroiditis, 0.014/ 100 PY (95% CI 0.0025, 0.050). The mortality rates appeared higher among those patients with newly diagnosed or incident herpetic retinitis and choroiditis (rates = 21.7 deaths/100 PY [P = .02] and 12.8 deaths/100 PY [P = .04]), respectively, than those for patients with AIDS without an ocular opportunistic infection (4.1 deaths/100 PY); toxoplasmic retinitis did not appear to be associated with greater mortality (6.4/100 PY, P = .47). Eyes with newly diagnosed herpetic retinitis appeared to have a poor visual prognosis, with high rates of visual impairment (37.9/100 PY) and blindness (17.5/100 PY), whereas those outcomes in eyes with choroiditis appeared to be lower (2.3/100 PY and 0/100 PY, respectively). CONCLUSIONS Although uncommon, non-CMV ocular opportunistic infections may be associated with high rates of visual loss and/or mortality.
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Affiliation(s)
- Sapna Gangaputra
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, Wisconsin, 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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Kozak I, Ahuja A, Gangaputra S, Van Natta ML, Thorne JE, Freeman WR. Optic nerve head morphology and visual field function in patients with AIDS and without infectious retinitis. Ocul Immunol Inflamm 2012; 20:342-8. [PMID: 22697270 PMCID: PMC4164231 DOI: 10.3109/09273948.2012.694552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To evaluate morphology of the optic nerve head and visual field in AIDS patients without retinitis. METHODS One randomly selected eye from 246 patients with AIDS without retinitis was evaluated from prospective multicenter Longitudinal Studies of Ocular Complications of AIDS. Stereo fundus photographs of OHN and serial VF data over 5-years were analyzed. Main outcomes included vertical cup-to-disc ratio (CDR), mean deviation, and pattern standard deviation scores on VF testing. RESULTS The median CDR was 0.39 at enrollment and 0.40 at 5-year follow-up. An unadjusted linear regression model revealed a mean change in CDR of 0.004 after 5-years (P = 0.04). After adjustment for practice effect, there were no statistically significant changes in VF performance observed during the 5 years of follow-up. CONCLUSIONS We detected clinically minimal, but statistically significant changes in ONH morphology and no change in VF performance among eyes of patients with AIDS and without retinitis.
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Affiliation(s)
- Igor Kozak
- Department of Ophthalmology, University of California San Diego, Jacobs Retina Center at Shiley Eye Center, La Jolla, California 92037, USA.
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Kempen JH, Sugar EA, Lyon AT, Lewis RA, Jabs DA, Heinemann MH, Dunn JP. Risk of cataract in persons with cytomegalovirus retinitis and the acquired immune deficiency syndrome. Ophthalmology 2012; 119:2343-50. [PMID: 22853972 DOI: 10.1016/j.ophtha.2012.05.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 05/24/2012] [Accepted: 05/24/2012] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate cataract risk in eyes of patients with AIDS and cytomegalovirus (CMV) retinitis and to identify risk factors. DESIGN Prospective cohort study. PARTICIPANTS Patients with AIDS and CMV retinitis. METHODS Patients 13 years of age and older were enrolled between 1998 and 2008. Demographic and clinical characteristics, slit-lamp biomicroscopy findings, and dilated ophthalmoscopy results were documented at quarterly visits. Cataract status was determined at the initial visit (prevalence) and at follow-up visits (incidence). MAIN OUTCOME MEASURES For cataract, a high grade of lens opacity by biomicroscopy to which best-corrected visual acuity worse than 20/40 was attributed. Eyes that had undergone cataract surgery before enrollment or between visits also were counted as having cataract. RESULTS Seven hundred twenty-nine eyes of 489 patients diagnosed with CMV retinitis were evaluated. Higher prevalence was observed for patients with bilateral versus unilateral CMV retinitis (adjusted odds ratio [aOR], 2.74; 95% confidence interval [CI], 1.76-4.26) and, among unilateral CMV retinitis cases, for eyes with retinitis versus without retinitis (15% vs. 1.4%; P<0.0001). The age-adjusted prevalence of cataract among CMV retinitis cases was higher than that in a population-based sample (P<0.0001). Cataract prevalence increased with age (aOR, 11.77; 95% CI, 2.28-60.65 for age ≥ 60 years vs. younger than 40 years) and longer duration of retinitis (aOR, 1.36; 95% CI, 1.20-1.54 per year). Among eyes with CMV retinitis initially free of cataract, the cataract incidence was 8.1%/eye-year (95% CI, 6.7%-10.0%). Prior retinal detachment was associated with higher cataract risk (if repaired with silicone oil: adjusted hazard ratio [aHR], 10.37; 95% CI, 6.51-16.52; otherwise: aHR, 2.90; 95% CI, 1.73-4.87). Large CMV retinitis lesions also were associated with higher risk of cataract (for involvement of 25-49% retinal area: aHR, 2.30; 95% CI, 1.51-3.50; for ≥ 50% involvement: aHR, 3.63; 95% CI, 2.18-6.04), each with respect to ≤ 24% involvement, as were anterior segment inflammation (aHR, 2.27; 95% CI, 1.59-3.25) and contralateral cataract (aHR, 2.52; 95% CI, 1.74-3.66). CONCLUSIONS Cytomegalovirus retinitis is associated with a high absolute and relative risk of cataract. Among several risk factors, large retinal lesion size and use of silicone oil in retinal detachment repair are potentially modifiable, albeit not in all cases. Cataract is likely to be an increasingly important cause of visual morbidity in this population.
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Affiliation(s)
- John H Kempen
- Department of Ophthalmology, and the Center for Clinical Epidemiology and Biostatistics, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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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: 68] [Impact Index Per Article: 5.7] [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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Clinical features of newly diagnosed cytomegalovirus retinitis in northern Thailand. Am J Ophthalmol 2012; 153:923-931.e1. [PMID: 22265148 DOI: 10.1016/j.ajo.2011.10.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Revised: 10/06/2011] [Accepted: 10/07/2011] [Indexed: 11/20/2022]
Abstract
PURPOSE To characterize the clinical manifestations of cytomegalovirus (CMV) retinitis in northern Thailand. DESIGN Prospective, observational, cross-sectional study. METHODS We recorded characteristics of 52 consecutive patients newly diagnosed with CMV retinitis at a tertiary university-based medical center in northern Thailand. Indirect ophthalmoscopy by experienced ophthalmologists was supplemented with fundus photography to determine the proportion of eyes with various clinical features of CMV retinitis. RESULTS Of the 52 patients with CMV retinitis, 55.8% were female. All were HIV-positive. The vast majority (90.4%) had started antiretroviral therapy. CMV retinitis was bilateral in 46.2% of patients. Bilateral visual acuity worse than 20/60 was observed in 23.1% of patients. Of 76 eyes with CMV retinitis, 61.8% had zone I disease and 21.6% had lesions involving the fovea. Lesions larger than 25% of the retinal area were observed in 57.5% of affected eyes. CMV retinitis lesions commonly had marked or severe border opacity (47.4% of eyes). Vitreous haze often was present (46.1% of eyes). Visual impairment was more common in eyes with larger retinitis lesions. Retinitis lesion size, used as a proxy for duration of disease, was associated with fulminant appearance (odds ratio, 1.24; 95% confidence interval, 1.01 to 1.51) and marked or severe border opacity (odds ratio, 1.36; 95% confidence interval, 1.11 to 1.67). Based on lesion size, retinitis preceded antiretroviral treatment in each patient. CONCLUSIONS Patients seeking treatment at a tertiary medical center in northern Thailand had advanced CMV retinitis, possibly because of delayed diagnosis. Earlier screening and treatment of CMV retinitis may limit progression of disease and may prevent visual impairment in this population.
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Wang Z, Jia R, Ge S, He T, Zhang Y, Yang Y, Wang Y, Shi W, Ji Y, Ye F, Chen P, Lu J, Sun J, Xu X, Zhou Y, Gu P, Luo M, Lu H, Fan X. Ocular complications of human immunodeficiency virus infection in eastern china. Am J Ophthalmol 2012; 153:363-369.e1. [PMID: 21982101 DOI: 10.1016/j.ajo.2011.07.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 07/29/2011] [Accepted: 07/30/2011] [Indexed: 11/15/2022]
Abstract
PURPOSE To investigate ocular complications in patients with HIV/AIDS in eastern China during the time of highly active antiretroviral therapy (HAART). DESIGN Prospective study. METHODS This study was carried out from August 1, 2009 to July 31, 2010. Recruited HIV/AIDS patients underwent a series of surveys and ophthalmologic and laboratory examinations (including CD4 level) at enrollment. RESULTS In this study, all 787 HIV/AIDS patients (1574 eyes) had a history of HAART. Of these patients, 28.72% (95% CI = 0.26-0.32) had a history of systemic disease and 26.30% (95% CI = 0.23-0.29) had ocular complications. Of these ocular complications, cytomegalovirus retinitis (CMVR) had the highest prevalence (10.6%, 83/787) and ocular microangiopathy had the second-highest prevalence (9.4%, 74/787). Among the patients with CMVR, 16.9% (14/83) suffered from immune recovery uveitis (IRU). Furthermore, 3.4% (27/787) of the recruited AIDS patients had neuro-ophthalmologic disorders. The mean logMAR visual acuity of the group with ocular complications was 0.47 ± 0.64, which was significantly different from the asymptomatic group (0.17 ± 0.39, P < .001). The median CD4 T-cell count of the group with ocular complications is 43 cells/μL, which was significantly different from the asymptomatic group (116.5 cells/μL, P < .001). CONCLUSIONS The study shows a high rate of treatable ocular complications among patients with HIV/AIDS in eastern China. HIV/AIDS treatment programs in China must be prepared to identify ocular complications and refer patients to the correct treatment facilities.
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Affiliation(s)
- Zhiliang Wang
- Department of Ophthalmology, Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, PR China
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Clinical Guidelines for the Treatment and Prevention of Opportunistic Infections in HIV-infected Koreans. Infect Chemother 2012. [DOI: 10.3947/ic.2012.44.3.93] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Kumar P, Vats DP, Mishra S, Makkar A, Banarji A, Patyal S, Gurunadh VS. CD4 counts: a strong indicator of retinal and ocular lesions in HIV disease. Med J Armed Forces India 2011; 67:354-7. [PMID: 27365846 PMCID: PMC4920618 DOI: 10.1016/s0377-1237(11)60083-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Accepted: 07/22/2011] [Indexed: 11/30/2022] Open
Affiliation(s)
- Poninder Kumar
- Associate Professor, Department of Ophthalmology, AFMC, Pune – 40
| | - DP Vats
- Former Commandant, AFMC, Pune, Chairman, Haryana Public Service Commission
| | - Sanjay Mishra
- Classified Specialist (Ophthalmology), Army Hospital (R&R), Delhi Cantt. – 10
| | - Anuradha Makkar
- Associate Professor, (Microbiology), Army College & Medical Sciences, Delhi
| | | | - Sagarika Patyal
- Associate Professor, Department of Ophthalmology, AFMC, Pune – 40
| | - VS Gurunadh
- Senior Advisor (Ophthalmology), Command Hospital (EC), Kolkata
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Holbrook JT, Colvin R, van Natta ML, Thorne JE, Bardsley M, Jabs DA. Evaluation of the United States public health service guidelines for discontinuation of anticytomegalovirus therapy after immune recovery in patients with cytomegalovirus retinitis. Am J Ophthalmol 2011; 152:628-637.e1. [PMID: 21742304 PMCID: PMC3185165 DOI: 10.1016/j.ajo.2011.04.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 04/11/2011] [Accepted: 04/12/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate United States Public Health Service (USPHS) guidelines for discontinuing anticytomegalovirus (CMV) therapy in patients with AIDS who have immune recovery and quiescent retinitis after initiating highly active antiretroviral therapy. DESIGN Cohort study of patients with CMV retinitis (Longitudinal Study of Ocular Complications of AIDS). METHODS Participants had CMV retinitis and CD4+ T-cell counts of 50 cells/μL or fewer enrolled from 1998 through 2009 who demonstrated sustained immune recovery (2 consecutive CD4+ T-cell counts of 100 cells/μL or more at least 6 months apart) and inactive retinitis. Participants were classified into 2 groups according to anti-CMV treatment after immune recover: (1) continued anti-CMV therapy and (2) discontinued therapy. We evaluated survival, visual acuity, and CMV retinitis activity; we used propensity scores to adjust for confounding factors for these analyses. RESULTS Of 152 participants reviewed, 71 demonstrated immune recovery, 37 of whom discontinued therapy and 34 of whom continued therapy. At immune recovery, participants continuing therapy tended to be older (44 vs 40 years; P = .09), have bilateral retinitis (53% vs 32%; P = .10), and have lower CD4+ T-cell counts (148 vs 207 cells/μL; P < .001). There were no statistical differences in any of the clinical outcomes (death, retinitis progress, visual acuity, or incidence of bilateral retinitis). Both groups lost visual acuity during follow-up, on average 1.2 letters per year (P < .01). CONCLUSIONS Discontinuation of anti-CMV therapy after immune recovery did not increase the risk of poor outcomes. These results support the current guidelines for discontinuation of anti-CMV therapy after achievement of sustained immune recovery.
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Affiliation(s)
- Janet T Holbrook
- Center for Clinical Trials, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland 21232, USA.
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Mitchell SM, Shiew MMF, Nelson M. 5 Ocular infections. HIV Med 2011. [DOI: 10.1111/j.1468-1293.2011.00944_6.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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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: 92] [Impact Index Per Article: 7.1] [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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Abdollahi A, Heidari-Bateni G, Zarei R, Kheirandish P, Malekmadani M, Mohraz M, Abdollahi M, Rajabi MT. Clinical spectrum of 15 patients with HIV-related ocular involvement in Tehran. Int J Ophthalmol 2010; 3:331-6. [PMID: 22553586 DOI: 10.3980/j.issn.2222-3959.2010.04.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Accepted: 11/30/2010] [Indexed: 11/02/2022] Open
Abstract
AIM To determine the frequency of HIV-related ocular involvement and to describe the characteristics of involvement in a special clinic in Tehran. METHODS In this cross sectional study, 141 patients (125 male and 16 female, 282 eyes) of HIV-infected patients with various stages of HIV infection that were referred to Center of behavioral diseases were evaluated during a period of 7 months. Every patient had a complete profile including demographic data, method of HIV transmission, recent CD4 T cell lymphocyte count, serological studies for common sexual or blood-born viruses and toxoplasmosis, history of antiretroviral therapy, and associated systemic disease. RESULTS A total of 141 patients were evaluated. HIV-related ocular involvement was detected in 15 patients (10.6%), including 3 mycobacterium tuberculosis-related choroiditis, 2 cytomegalovirus retinitis, 2 retinal toxoplasmosis, 2 herpes simplex virus-related lesions, 1 HIV-associated retinopathy, 1 herpes zoster ophthalmicus, 1 undetermined vitritis, and 3 cases of cranial nerve involvement including 2 cases of gaze palsy and 1 case of papilitis. In our study, mean CD4 T cell lymphocyte count was fewer in patients with ocular involvement than in patients without ocular involvement (204.7±123.8 vs 403.7±339.7, P=0.029), but there was no difference in other possible associated factors between two groups. CONCLUSION Mycobacterium tuberculosis-related choroiditis and neurophthalmic lesions are the most common HIV-related ocular involvements in Tehran that is different from those of recent publications in developed countries.
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Affiliation(s)
- Ali Abdollahi
- Department of Ophthalmology, Eye Research Center, Farabi Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Thorne JE, Van Natta ML, Jabs DA, Duncan JL, Srivastava SK. Visual field loss in patients with cytomegalovirus retinitis. Ophthalmology 2010; 118:895-901. [PMID: 21146225 DOI: 10.1016/j.ophtha.2010.09.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 09/17/2010] [Accepted: 09/17/2010] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To describe visual field (VF) loss among patients with cytomegalovirus (CMV) retinitis and the risk factors for such loss. DESIGN Multicenter, prospective, observational study. PARTICIPANTS A total of 476 patients with AIDS and CMV retinitis, and VF data. METHODS Follow-up every 3 months with medical history, ophthalmologic examination, Goldmann visual fields, and laboratory testing. MAIN OUTCOME MEASURES Incidence of VF loss in eyes affected with CMV retinitis and characteristics associated with such VF loss. RESULTS Over a median follow-up of 4 years (range, 0.5-9 years), the incidence rates of VF loss to 75% and 50% of normal were 0.22/eye-year (EY, 95% confidence interval [CI], 0.20-0.25) and 0.08/EY (95% CI, 0.06-0.10), respectively. The observed rates were 6- to 7-fold less than those observed rates of VF loss in the era before highly active antiretroviral therapy (HAART). Decreased CD4+ T-cell count, whether measured at enrollment or over follow-up time, was associated with increased rates of VF loss for all VF outcomes in a dose-dependent fashion. Risk factors for VF loss included lower CD4+ T-cell count, CMV lesion size >25% of the total retinal area, and active CMV retinitis after controlling for potential confounding. Highly active antiretroviral therapy use and immune recovery (CD4+ T-cell count >100 cells/μL) were associated with reduced risk of VF loss in multiple regression models. Immune recovery was statistically significantly associated with a lower risk of VF loss to 75% of normal (relative risk [RR] = 0.63; 95% CI, 0.49-0.86; P = 0.003) and to 50% of normal (RR = 0.60; 95% CI, 0.44-0.82; P = 0.001) after controlling for demographic characteristics, HIV viral load, HAART use, CMV lesion location and size, and retinitis activity. CONCLUSIONS Cytomegalovirus retinitis was associated with a substantial risk of incident VF loss, but the incidence is approximately 6-fold lower than that observed in the pre-HAART era. Those who have HAART-induced immune recovery have approximately 40% lower risk of VF loss for both outcomes after controlling for confounding.
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Affiliation(s)
- Jennifer E Thorne
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Sezgin E, Jabs DA, Hendrickson SL, Van Natta M, Zdanov A, Lewis RA, Smith MW, Troyer JL, O'Brien SJ. Effect of host genetics on the development of cytomegalovirus retinitis in patients with AIDS. J Infect Dis 2010; 202:606-13. [PMID: 20617924 PMCID: PMC2932829 DOI: 10.1086/654814] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) retinitis is a common opportunistic infection among patients with AIDS and still causes visual morbidity despite the wide spread usage of highly active antiretroviral therapy (HAART). The ubiquitous CMV pathogen contains a human interleukin-10 (IL-10) homolog in its genome and utilizes it to evade host immune reactions through an IL-10 receptor mediated immune-suppression pathway. METHODS Effects of IL-10R1, IL-10 and previously described AIDS restriction gene variants are investigated on the development of CMV retinitis in the Longitudinal Study of the Ocular Complications of AIDS (LSOCA) cohort (N = 1284). RESULTS In European Americans (n = 750), a haplotype carrying an amino acid changing variation in the cytoplasmic domain (S420L) of IL-10R1 can be protective (OR, 0.14; 95% CI, 0.02-0.94; P = .04) against, whereas another haplotype carrying an amino acid changing variation in the extracellular domain (I224V) of IL-10R1 can be more susceptible (OR, 6.21; 95% CI, 1.22- 31.54; P = .03) to CMV retinitis. In African Americans (n = 534), potential effects of IL-10 variants are observed. CONCLUSION Host genetics may have a role in the occurrence of CMV retinitis in patients infected with HIV.
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Affiliation(s)
- Efe Sezgin
- Laboratory of Genomic Diversity, SAIC-Frederick, National Cancer Institute, Frederick, Maryland 21702-1201, USA.
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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: 39] [Impact Index Per Article: 2.8] [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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Moayedi S. Head, Neck and Ophthalmologic Manifestations of HIV in the Emergency Department. Emerg Med Clin North Am 2010; 28:265-71. [DOI: 10.1016/j.emc.2010.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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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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Viral retinitis after intravitreal triamcinolone injection in patients with predisposing medical comorbidities. Am J Ophthalmol 2010; 149:433-40.e1. [PMID: 20172069 DOI: 10.1016/j.ajo.2009.10.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Revised: 10/15/2009] [Accepted: 10/15/2009] [Indexed: 11/20/2022]
Abstract
PURPOSE To review the cases of viral retinitis after intravitreal steroid administration at a single center, to estimate the incidence, and to propose risk factors for its occurrence. DESIGN Retrospective, observational case series. METHODS Seven hundred thirty-six intravitreal triamcinolone (IVTA) injections were administered in the clinic and operating room by 3 retina specialists at a single academic medical center between September 2002 and November 2008. Inclusion criteria were simply a history of 1 or more IVTA injections during the period. The overall incidence of viral retinitis after IVTA injection was calculated. Subsequently, a chart audit was performed to estimate the number of patients with immune-altering conditions who had received IVTA during the period, and the incidence within this subgroup was calculated. RESULTS Viral retinitis developed after IVTA injection in 3 patients, yielding an overall incidence of 3 in 736 or 0.41%. An estimated 334 injections were administered to patients with an immune-altering condition, including diabetes. All 3 of the patients in whom viral retinitis developed after IVTA injection possessed abnormal immune systems, yielding an incidence rate of 3 in 334 or 0.90% within this subgroup. CONCLUSIONS Our high reported incidence for this potentially devastating complication can be attributed to multiple factors, including coexisting medical immunocompromising comorbidities, a higher dose with a longer duration of local immunosuppression in the vitreous, multiple injections, as well as previous viral retinitis. Caution with a high index of clinical suspicion and frequent follow-up is advised in patients receiving IVTA injection with potentially immune-altering conditions, even after apparent immune recovery.
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