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Rodrigues Alves N, Barão C, Mota C, Costa L, Proença RP. Immune recovery uveitis: a focus review. Graefes Arch Clin Exp Ophthalmol 2024:10.1007/s00417-024-06415-y. [PMID: 38381160 DOI: 10.1007/s00417-024-06415-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 12/23/2023] [Accepted: 02/11/2024] [Indexed: 02/22/2024] Open
Abstract
Immune recovery uveitis (IRU) is an intraocular inflammation that typically occurs as part of immune reconstitution inflammatory syndrome (IRIS) in the eye. Typically, it affects human immunodeficiency virus (HIV)-infected patients with recognized or unrecognized cytomegalovirus (CMV) retinitis who are receiving highly active antiretroviral therapy (HAART). IRU is a common cause of new vision loss in these patients, and it manifests with a wide range of symptoms and an increased risk of inflammatory complications, such as macular edema. Recently, similar IRU-like responses have been observed in non-HIV individuals with immune reconstitution following immunosuppression of diverse etiologies, posing challenges in diagnosis and treatment. This review provides an updated overview of the current literature on the epidemiology, pathophysiology, biomarkers, clinical manifestations, diagnosis, differential diagnosis, and treatment strategies for IRU.
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Affiliation(s)
- Nuno Rodrigues Alves
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal.
| | - Catarina Barão
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal
| | - Catarina Mota
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal
| | - Lívio Costa
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal
- NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Rita Pinto Proença
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal
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Akhavanrezayat A, Uludag Kirimli G, Matsumiya W, Khojasteh H, Or C, Karaca I, Pham B, Ongpalakorn P, Lajevardi S, Lam B, Hwang JJ, Than NTT, Park S, Yavari N, Bazojoo V, Mobasserian A, Khatri A, Halim MS, Thng ZX, Ghoraba H, Do DV, Tugal-Tutkun I, Gupta V, de Smet M, Nguyen QD. The Role of Corticosteroids and Immunomodulatory Therapy in the Management of Infectious Uveitis. Ocul Immunol Inflamm 2024:1-12. [PMID: 38330155 DOI: 10.1080/09273948.2023.2296032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/11/2023] [Indexed: 02/10/2024]
Abstract
PURPOSE The index review aims to provide an update on the role of corticosteroids and steroid-sparing immunomodulatory therapy (IMT) in managing patients with infectious uveitis. METHOD Narrative literature review. RESULTS Corticosteroids and immunomodulatory therapy (IMT) focus on the host defense system instead of the pathogen, adjusting exaggerated inflammatory reactions to reduce potential harm to ocular tissues. Systemic or local corticosteroids are primarily selected as adjunctive medication for infectious uveitis. Concomitant corticosteroids have also been used in cases of paradoxical worsening in ocular tuberculosis and immune recovery uveitis in cytomegalovirus (CMV) retinitis. While there is no well-established evidence to support the use of IMT in infectious uveitis, it is occasionally used in clinical settings to treat persistent inflammation following resolution of infection such as cases of ocular tuberculosis and ocular syphilis where an insufficient response is observed with corticosteroids. CONCLUSION There is no consensus on the position of immunomodulatory therapy in the management of infectious uveitis with different etiologies. The index review provides an overview of available adjunctive corticosteroids and IMT options to assist clinicians in managing such disease entities more efficiently.
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Affiliation(s)
- Amir Akhavanrezayat
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Gunay Uludag Kirimli
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Wataru Matsumiya
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hassan Khojasteh
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Christopher Or
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Irmak Karaca
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Brandon Pham
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | | | - Sherin Lajevardi
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Brandon Lam
- Department of Ophthalmology, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Jaclyn Joyce Hwang
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ngoc Trong Tuong Than
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - SungWho Park
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Negin Yavari
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Vahid Bazojoo
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Azadeh Mobasserian
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Anadi Khatri
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Muhammad Sohail Halim
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Zheng Xian Thng
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Hashem Ghoraba
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Diana V Do
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
- Bayrampasa Eye Hospital, Eye Protection Foundation, Istanbul, Turkey
| | - Vishali Gupta
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Marc de Smet
- Department of Ophthalmology, MicroInvasive Ocular Surgery Clinic (MIOS), Lausanne, Switzerland
| | - Quan Dong Nguyen
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
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Rahman EZ, Beck KD, Wong RW, Sohn JH, Diaz-Rohena RD, Harper CA. Bilateral Combined Rhegmatogenous and Tractional Retinal Detachments Due to Persistent High-Titer Syphilis. Ophthalmic Surg Lasers Imaging Retina 2024; 55:46-50. [PMID: 38189796 DOI: 10.3928/23258160-20231023-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
A 23-year-old man developed bilateral rhegmatogenous retinal detachments secondary to high-titer ocular syphilis. The patient's titer increased four-fold after completing a 14-day course of intravenous penicillin (IVP). He underwent bilateral pars plana vitrectomy with silicone oil fill in both eyes. In this article, the authors propose an updated treatment method for patients with advanced ocular syphilis that includes oral doxycycline for 30 days following 14 days of IVP to optimally minimize the patient's infectious burden. Following surgery and this new treatment regime, this patient's best-corrected visual acuity 10 weeks postoperatively measured 20/50 in the right eye and 20/30 in the left eye. This case highlights a rare but devastating complication of ocular syphilis. We suggest the addition of oral doxycycline to IVP for patients with syphilis titers ≥ 1:256, HIV co-infection, and presence of posterior retinitis. [Ophthalmic Surg Lasers Imaging Retina 2024;55:46-50.].
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Yuen YS, Holder GE, Lingam G, Shen TYT. Diffuse retinal dysfunction following immune reconstitution uveitis in patients with prior cytomegalovirus retinitis: a novel observation. Doc Ophthalmol 2023; 147:139-145. [PMID: 37639171 DOI: 10.1007/s10633-023-09947-6] [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: 12/14/2022] [Accepted: 08/01/2023] [Indexed: 08/29/2023]
Abstract
PURPOSE To report continuing diffuse retinal dysfunction following resolution of immune reconstitution uveitis (IRU) in patients with cytomegalovirus retinitis (CMVR). METHODS Retrospective case series describing two patients with IRU following CMVR who underwent serial fundus photography and macular optical coherence tomography. One patient had serial electrophysiology. RESULTS Both patients had CMVR successfully treated with antiviral medication. The affected eyes later developed IRU that resolved with steroids. However, following resolution, chronic retinal damage was evidenced by ellipsoid line loss in one case and gradual optic disc cupping in the other. Electrophysiology in both cases revealed generalized retinal dysfunction worse in the eye with more severe IRU and demonstrated objectively the efficacy of treatment intervention in the patient with serial recordings. CONCLUSIONS Patients with IRU following CMV retinitis may have continuing diffuse retinal dysfunction despite apparent recovery and normal visual acuity. An aggressive approach to inflammation control may be warranted in such patients.
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Affiliation(s)
- Yew Sen Yuen
- Department of Ophthalmology, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore.
| | - Graham E Holder
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- UCL Institute of Ophthalmology, London, UK
| | - Gopal Lingam
- Department of Ophthalmology, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore
| | - Tina Yu Ting Shen
- Department of Ophthalmology, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore
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Jayadev C, Sanjay S, Handa A, Agrawal S. Human immunodeficiency virus retinopathy with presumed cytomegalovirus retinitis with macular oedema in a diabetic. BMJ Case Rep 2023; 16:e252710. [PMID: 37024150 PMCID: PMC10083806 DOI: 10.1136/bcr-2022-252710] [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] [Indexed: 04/08/2023] Open
Abstract
A man in his early 50s on regular follow-up for a stable non-proliferative diabetic retinopathy (NPDR) presented with decreased vision, worsening of retinal pathology and macular oedema in both eyes. His corrected distance visual acuity (CDVA) was 6/9 in the right eye and 6/15 in the left eye and fundus examination showed multiple intraretinal haemorrhages in all quadrants. His systemic workup revealed a severe thrombocytopaenia, which prompted a further detailed systemic evaluation revealing him to be positive for HIV with retinopathy complicating the pre-existing NPDR. Given the significant inflammation and macular oedema, a cocktail of intravitreal bevacizumab, ganciclovir and dexamethasone was administered. The retinopathy and macular oedema resolved and the CDVA improved to 6/6 in both eyes over a 6-month follow-up period. Any sudden worsening of fundus findings in a patient with diabetes necessitates immediate and detailed ocular and systemic evaluation, especially when the immune status is unknown.
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Affiliation(s)
- Chaitra Jayadev
- Vitreoretina Department, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Srinivasan Sanjay
- Uveitis and Ocular Immunology, Narayana Nethralaya, Bangalore, Karnataka, India
| | - Ashit Handa
- Vitreoretina Department, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Sameeksha Agrawal
- Vitreoretina Department, Narayana Nethralaya, Bengaluru, Karnataka, India
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Human Immunodeficiency Virus and Uveitis. Viruses 2023; 15:v15020444. [PMID: 36851658 PMCID: PMC9962278 DOI: 10.3390/v15020444] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/31/2023] [Accepted: 02/03/2023] [Indexed: 02/09/2023] Open
Abstract
Uveitis is one of the most common ocular complications in people living with the Human immunodeficiency virus (HIV) and can be classified into HIV-induced uveitis, co-infection related uveitis, immune recovery uveitis, and drug-induced uveitis. The introduction of antiretroviral therapy has considerably changed the incidence, diagnosis, and treatment of different types of HIV-related uveitis. Furthermore, the specific immune condition of patients infected with HIV makes diagnosing HIV-related uveitis difficult. Recent studies have focused on the growing prevalence of syphilis/tuberculosis co-infection in uveitis. Simultaneously, more studies have demonstrated that HIV can directly contribute to the incidence of uveitis. However, the detailed mechanism has not been studied. Immune recovery uveitis is diagnosed by exclusion, and recent studies have addressed the role of biomarkers in its diagnosis. This review highlights recent updates on HIV-related uveitis. Furthermore, it aims to draw the attention of infectious disease physicians and ophthalmologists to the ocular health of patients infected with HIV.
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Huynh E, Chronopoulos A, Schutz JS, Claus B, Erwemi M, Krastel H, Hattenbach L. Frosted branch angiitis as an immune recovery response in newly diagnosed acquired immunodeficiency syndrome and systemic cytomegalovirus infection. Clin Case Rep 2023; 11:e6895. [PMID: 36762146 PMCID: PMC9896155 DOI: 10.1002/ccr3.6895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 02/05/2023] Open
Abstract
Frosted branch angiitis (FBA) is an uncommon form of severe retinal perivasculitis associated with systemic inflammatory/infectious diseases. In this report, we describe a case of FBA and macular edema as a result of immune recovery response in a patient newly diagnosed with HIV infection and cytomegalovirus viremia.
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Affiliation(s)
- Elisa Huynh
- Department of OphthalmologyLudwigshafen HospitalLudwigshafen am RheinGermany
| | | | - James Scott Schutz
- Department of OphthalmologyLudwigshafen HospitalLudwigshafen am RheinGermany
| | - Bernd Claus
- Department of Internal Medicine ALudwigshafen HospitalLudwigshafen am RheinGermany
| | - Marwa Erwemi
- Department of Ophthalmology, Medical Faculty MannheimRuprecht‐Karls‐University HeidelbergMannheimGermany
| | - Hermann Krastel
- Department of Ophthalmology, Medical Faculty MannheimRuprecht‐Karls‐University HeidelbergMannheimGermany
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Yavuz Saricay L, Baldwin G, Leake K, Johnston A, Shah AS, Patel NA, Gonzalez E. Cytomegalovirus retinitis and immune recovery uveitis in a pediatric patient with leukemia. J AAPOS 2023; 27:52-55. [PMID: 36521818 DOI: 10.1016/j.jaapos.2022.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/17/2022] [Accepted: 10/31/2022] [Indexed: 12/14/2022]
Abstract
Immune recovery uveitis (IRU) is an ocular form of immune reconstitution inflammatory syndrome, which is rare in the pediatric population. We report a case of IRU in an 11-year-old girl with a history of cytomegalovirus (CMV) retinitis in the setting of acute leukemia, who developed uveitis, vitritis, retinitis, and vasculitis during immune reconstitution. She was found to have negative CMV antigenemia, and the disease occurred during concurrent systemic antiviral therapy. Anterior chamber tap confirmed the absence of the CMV in the eye, and recurrent blood samples continued to reveal absent CMV viral particles systemically while her lymphocyte count was steadily increasing. The patient responded to oral steroids, leading to resolution of active retinitis. Tapering the steroids caused a mild reactivation of the ocular immune response.
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Affiliation(s)
- Leyla Yavuz Saricay
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | | | - Katelyn Leake
- Harvard Medical School, Boston, Massachusetts; Department of Infectious Disease, Boston Children's Hospital, Boston, Massachusetts
| | - Alicia Johnston
- Harvard Medical School, Boston, Massachusetts; Department of Infectious Disease, Boston Children's Hospital, Boston, Massachusetts
| | - Ankoor S Shah
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Ophthalmology, Massachusetts Eye & Ear, Boston, Massachusetts
| | - Nimesh A Patel
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Ophthalmology, Massachusetts Eye & Ear, Boston, Massachusetts
| | - Efren Gonzalez
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Ophthalmology, Massachusetts Eye & Ear, Boston, Massachusetts.
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Hernanz I, Alvear-Torres A, Serrano Del Castillo C, Sánchez-Pernaute O, Recuero S, Romero-Bueno F, Muñoz N, Carreño E. Non-infectious Uveitis as a Manifestation of the Immune Reconstitution Inflammatory Syndrome in Patients Infected by HIV. Ocul Immunol Inflamm 2022; 30:1599-1603. [PMID: 33908843 DOI: 10.1080/09273948.2021.1919310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To describe a retrospective review of HIV patients with noninfectious uveitis. Data collected included: demographics, anatomic classification and phenotypic diagnosis of the uveitis, systemic immune-mediated disorders (IMD), time from HIV diagnosis to uveitis, CD4 count, viral load, treatment and complications of treatment and time of follow-up. RESULTS Twenty patients (18 males) were included. The time lag between HIV diagnosis and the onset of uveitis was 9 ± 8.5 years. Mean CD4 count was 670 ± 294 cells/ml. Viral load was undetectable in 14 out of 18 cases. In 6 patients IMD was diagnosed prior to or concurring with the uveitis diagnosis. The use of immunosuppressive therapies was necessary in 6 patients (including biologics in 4 cases). The mean follow-up was 42.2 months. CONCLUSIONS noninfectious uveitis could be the first manifestation of IMD in patients with well-controlled HIV infection. Immunosuppression appeared to be a safe therapeutic option in our cohort of patients.
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Affiliation(s)
- Ines Hernanz
- Ophthalmology Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Andrea Alvear-Torres
- Rheumatology Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | | | | | - Sheila Recuero
- Rheumatology Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | | | - Nelida Muñoz
- Ophthalmology Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Ester Carreño
- Ophthalmology Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
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Di Y, Yu W, Ye J. Temporal trends in ocular manifestations of HIV/AIDS patients in the past 18 years in a tertiary hospital in China. Graefes Arch Clin Exp Ophthalmol 2022; 260:2807-2818. [PMID: 35460364 DOI: 10.1007/s00417-022-05660-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 03/30/2022] [Accepted: 04/08/2022] [Indexed: 11/04/2022] Open
Abstract
PURPOSE To investigate the ocular manifestation changes in human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) patents in a tertiary eye clinic in China over the past 18 years. METHODS In this retrospective cross-sectional study, 264 HIV/AIDS patients (528 eyes) were recruited at the Department of Ophthalmology, Peking Union Medical College Hospital, from 2001 to 2018. Patients underwent ophthalmic examinations, including best-corrected visual acuity (BCVA), slit-lamp microscopy, and indirect ophthalmoscopy, and completed a registration form including demographic characteristics, medical history, and immune status data. Kruskal-Wallis test or Mann-Whitney test was used to compare continuous variables, and Pearson's chi-squared test or Fisher's exact test was performed to compare categorical variables. RESULTS Regarding demographic characteristics, there was a significant increasing trend in male patients, sexual transmission, and HIV/AIDS-syphilis coinfection (all P < 0.001). For systemic features, more patients received cART, and fewer patients had systemic syndromes after 2003 (P < 0.001). For ocular manifestations, there were no significant changes between time intervals in CMVR and HIV retinopathy patients (P = 0.149, P = 0.643), but the proportion of patients with uveitis increased from 1.14% to 19.32% (P < 0.001). CONCLUSION CMVR was the most common ocular compilation in HIV/AIDS patients, followed by uveitis and HIV retinopathy. The proportion of patients with CMVR and HIV retinopathy was stable over time, but the proportion of patients with uveitis showed a significant increasing trend. Therefore, immediate ophthalmic examination should be performed at the point of care or as soon as possible after entry into the health care system.
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Affiliation(s)
- Yu Di
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.,Key Laboratory of Ocular Fundus Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Weihong Yu
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.,Key Laboratory of Ocular Fundus Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Junjie Ye
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China. .,Key Laboratory of Ocular Fundus Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
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Manouchehri N, Steinman L, Stuve O. Biological Significance of Anti-SARS-CoV-2 Antibodies: Lessons Learned From Progressive Multifocal Leukoencephalopathy. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:e935. [PMID: 33361386 PMCID: PMC7768959 DOI: 10.1212/nxi.0000000000000935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/09/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To discuss the pathogenic and diagnostic relevance of cellular and humoral immune responses against severe acute respiratory syndrome novel coronavirus (SARS-COV-2) and pertinent observations made in progressive multifocal leukoencephalopathy (PML). METHODS Review of pertinent literature. RESULTS: There is at least 1 precedent for an antibody response against a viral pathogen that fails to provide host protection in the absence of immune-competent CD4+ T cells. PML is an infection of the CNS caused by JC virus (JCV), which commonly occurs during treatment with the therapeutic monoclonal antibody natalizumab. In this context, the humoral immune response fails to prevent JCV reactivation, and elevated anti-JCV serum indices are associated with a higher PML incidence. The more relevant immune-competent cells in host defense against JCV appear to be T cells. T cell-mediated responses are also detectable in convalescing patients with SARS-COV-2 irrespective of the humoral immune response. CONCLUSION Based on pathogenic lessons learned from PML under natalizumab therapy, we suggest the incorporation of functional assays that determine neutralizing properties of SARS-CoV-2-specific antibodies. In addition, we outline the potential role of T-cell detection assays in determining herd immunity in a given population or in studying therapeutic responses to vaccines.
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Affiliation(s)
- Navid Manouchehri
- From the Department of Neurology (N.M.), the University of Texas Southwestern Medical Center, Dallas; Departments of Pediatrics and Neurology and Neurological Sciences (L.S.), Stanford University, CA; and Neurology Section (O.S.), VA North Texas Health Care System, Medical Service Dallas, VA Medical Center
| | - Lawrence Steinman
- From the Department of Neurology (N.M.), the University of Texas Southwestern Medical Center, Dallas; Departments of Pediatrics and Neurology and Neurological Sciences (L.S.), Stanford University, CA; and Neurology Section (O.S.), VA North Texas Health Care System, Medical Service Dallas, VA Medical Center
| | - Olaf Stuve
- From the Department of Neurology (N.M.), the University of Texas Southwestern Medical Center, Dallas; Departments of Pediatrics and Neurology and Neurological Sciences (L.S.), Stanford University, CA; and Neurology Section (O.S.), VA North Texas Health Care System, Medical Service Dallas, VA Medical Center
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12
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Human Immunodeficiency Virus Infection Increases the Risk of Incident Uveitis Among People Living With HIV/AIDS. J Acquir Immune Defic Syndr 2019; 79:149-157. [PMID: 30212432 DOI: 10.1097/qai.0000000000001782] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Case reports indicated that HIV itself may be a direct cause of uveitis. However, the association of HIV with incident uveitis has not been extensively studied. This nationwide cohort study determined the association of HIV with incident uveitis. METHODS Since January 1, 2003, we identified adult people living with HIV/AIDS (PLWHA) from Taiwan Centers for Disease Control HIV Surveillance Database. A control cohort without HIV infection, matched for age and sex, was selected for comparison from the Taiwan National Health Insurance Research Database. The time-dependent Cox proportional hazards model was used to determine the associations of HIV and highly active antiretroviral therapy (HAART) with incident uveitis, while considering death as a competing risk event. RESULTS Of the total 120,430 patients (24,086 PLWHA and 96,344 matched controls), 609 (0.51%) had incident uveitis, including 334 (1.39%) PLWHA and 265 (0.28%) controls. After adjusting for age, sex, and comorbidities, HIV infection was found to be an independent risk factor for incident uveitis [adjusted hazard ratio (AHR), 5.55; 95% confidence interval (CI): 4.67 to 6.59]. Within PLWHA, the risk of incident uveitis was significantly higher in those who received HAART (AHR, 2.46; 95% CI: 1.71 to 3.54). In addition, considering the short- and long-term effects of HAART on incident uveitis, HAART was found to associate with a higher risk of uveitis development within 1 year of treatment (AHR, 3.36; 95% CI: 2.41 to 4.69), but not after 1 year of HAART initiation (AHR, 1.14; 95% CI: 0.76 to 1.72). CONCLUSIONS HIV infection is an independent risk factor for incident uveitis.
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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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Yeo TH, Yeo TK, Wong EP, Agrawal R, Teoh SC. Immune recovery uveitis in HIV patients with cytomegalovirus retinitis in the era of HAART therapy-a 5-year study from Singapore. J Ophthalmic Inflamm Infect 2016; 6:41. [PMID: 27822743 PMCID: PMC5099291 DOI: 10.1186/s12348-016-0110-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 10/27/2016] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this study is to analyse the clinical features of HIV patients with cytomegalovirus retinitis (CMVR) developing immune recovery uveitis (IRU) while on highly active antiretroviral therapy (HAART) and to identify the risk factors, visual outcomes and complications of IRU. Results Majority (n = 26, 86.7 %) of patients were male, with 76.7 % (n = 23) of patients having bilateral disease. Twenty-seven eyes (50.9 %) had both anterior uveitis and vitritis. The median CD4 at IRU was 210 cells/μL (IQR 140–279), with 86.7 % having CD4 >100 cells/μL. The median duration from initiation of HAART to IRU was significantly different between those <50 years old (median 763 days, IQR 174–1872 days) and those ≥50 years old (median 161 days, IQR 84.5–278 days). Fourteen eyes (26.4 %) had loss of one or more Snellen lines visual acuity at 6 months while the rest maintained or improved vision. Complications developed in 21 eyes, with cataract (66.7 %), glaucoma and ocular hypertension (33.3 %) being the most common. The risk of complications was associated with the absolute difference in CD4 counts at IRU and at HAART commencement (p = 0.041). Age was also negatively associated with the duration from HAART to IRU (p = 0.005, Spearman’s rho coefficient = −0.503). Conclusions It is common to have both anterior uveitis and vitritis in IRU. There was a positive association between the increase in CD4 from HIV to IRU diagnoses and the risk of developing complications. Younger patients appeared to develop IRU later than older patients after HAART, suggesting that long-term follow-ups are essential for these patients.
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Affiliation(s)
- Tun Hang Yeo
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, 308433, Singapore.
| | - Tun Kuan Yeo
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, 308433, Singapore
| | - Elizabeth P Wong
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, 308433, Singapore
| | - Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, 308433, Singapore
| | - Stephen C Teoh
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, 308433, Singapore.,Eagle Eye Centre, Singapore, Singapore
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Fife KH, Mugwanya K, Thomas KK, Baeten JM, Celum C, Bukusi E, de Bruyn G, Mujugira A, Vwalika B, Wald A, Lingappa JR. Transient Increase in Herpes Simplex Virus Type 2 (HSV-2)-Associated Genital Ulcers Following Initiation of Antiretroviral Therapy in HIV/HSV-2-Coinfected Individuals. J Infect Dis 2015; 213:1573-8. [PMID: 26704611 DOI: 10.1093/infdis/jiv765] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 12/18/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Immune reconstitution inflammatory syndrome (IRIS) in human immunodeficiency virus (HIV)-infected persons beginning antiretroviral therapy (ART) has been incompletely characterized for herpes simplex virus type 2 (HSV-2). METHODS We evaluated genital ulcer disease (GUD) and HSV-2-associated GUD at quarterly visits or when spontaneously reported at monthly visits in 3381 HIV/HSV-2-coinfected individuals in a placebo-controlled trial of suppressive acyclovir therapy to prevent HIV transmission, 349 of whom initiated ART during the study. Incidence was calculated for months before and after ART initiation, and incidence rate ratios (IRRs) were calculated. RESULTS GUD incidence increased from 15.0 episodes per 100 person-years before ART to 26.9 episodes per 100 person-years in the first full quarter after ART initiation (IRR, 1.83;P= .03), and the incidence of HSV-2-associated GUD increased from 8.1 to 19.0 episodes per 100 person-years (IRR, 2.20;P= .02). Subsequently, the incidence of GUD was similar to that before ART, although the numbers were small. Persons receiving suppressive acyclovir had fewer GUD episodes, but the IRR after beginning ART was similar in the acyclovir and placebo groups. CONCLUSIONS Initiation of ART in HIV/HSV-2-coinfected persons is associated with a transient increase in GUD and HSV-2 GUD. Acyclovir reduces the incidence of GUD but does not prevent an increase in GUD incidence during the first quarter following initiation of ART.
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Affiliation(s)
- Kenneth H Fife
- Department of Medicine Deparment of Microbiology and Immunology Department of Pathology, Indiana University, Indianapolis
| | | | | | - Jared M Baeten
- Department of Epidemiology Department of Global Health Department of Medicine
| | - Connie Celum
- Department of Epidemiology Department of Global Health Department of Medicine
| | - Elizabeth Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi
| | | | | | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, University of Zambia, and Zambia-Emory HIV Research Project, Lusaka
| | - Anna Wald
- Department of Epidemiology Department of Medicine Department of Laboratory Medicine, University of Washington, and Vaccine and Infectious Disease Institute, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jairam R Lingappa
- Department of Global Health Department of Medicine Department of Pediatrics
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Wohl DA, Kendall MA, Owens S, Holland G, Nokta M, Spector SA, Schrier R, Fiscus S, Davis M, Jacobson MA, Currier JS, Squires K, Alston-Smith B, Andersen J, Freeman WR, Higgins M, Torriani FJ. The Safety of Discontinuation of Maintenance Therapy for Cytomegalovirus (CMV) Retinitis and Incidence of Immune Recovery Uveitis Following Potent Antiretroviral Therapy. HIV CLINICAL TRIALS 2015; 6:136-46. [PMID: 16192248 DOI: 10.1310/4j65-4yx1-4et6-e5kr] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Reconstitution of immune function during potent antiretroviral therapy can prompt discontinuation of maintenance cytomegalovirus (CMV) therapy but has also been associated with sight-threatening inflammatory conditions including immune recovery uveitis (IRU). METHOD Patients with inactive CMV retinitis and a CD4+ cell count above 100/mm3, receiving CMV therapy and stable combination antiretroviral therapy, were assigned to one of two groups based on willingness to discontinue CMV therapy. RESULTS Thirty-eight participants were enrolled: 28 discontinued anti-CMV therapy (Group 1) and 10 continued CMV treatment (Group 2). Median on-study follow-up was 16 months. One Group 1 participant who experienced an increase in plasma HIV viral load and a decline in CD4+ cell count developed confirmed progression of CMV retinitis. Progression or reactivation CMV retinitis was not observed among Group 2. IRU was present at study entry in 3 participants. Six participants in Group 1 and 3 participants in Group 2 developed IRU on-study. CMV viremia was not detected in any participants, and urinary shedding of CMV was intermittent. CONCLUSION Recurrence of CMV retinitis following discontinuation of anti-CMV therapy among patients with antiretroviral-induced increases in CD4+ cell count was rare. However, IRU was common in both those who maintained and discontinued anti-CMV therapy.
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Affiliation(s)
- D A Wohl
- University of North Carolina, Chapel Hill, North Carolina 27516-7215, USA.
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Wong MHY, Cheung GCM, Chee SP. Posterior segment findings of ocular cytomegalovirus infection in immunocompetent patients. Graefes Arch Clin Exp Ophthalmol 2014; 252:1811-6. [DOI: 10.1007/s00417-014-2743-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 06/25/2014] [Accepted: 07/08/2014] [Indexed: 12/19/2022] Open
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Immune recovery uveitis: pathogenesis, clinical symptoms, and treatment. Mediators Inflamm 2014; 2014:971417. [PMID: 25089078 PMCID: PMC4096001 DOI: 10.1155/2014/971417] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 06/10/2014] [Indexed: 12/13/2022] Open
Abstract
IRU is the most common form of immune reconstitution inflammatory syndrome in HIV-infected patients with cytomegalovirus retinitis who are receiving highly active antiretroviral therapy (HAART). Among patients with CMV in the HAART era, immune recovery may be associated with a greater number of inflammatory complications, including macular edema and epiretinal membrane formation. Given the range of ocular manifestations of HIV, routine ocular examinations and screening for visual loss are recommended in patients with CD4 counts <50 cells/μL. With the increasing longevity of these patients due to the use of HAART, treatment of IRU may become an issue in the future. The aim of this paper is to review the current literature concerning immune recovery uveitis. The definition, epidemiology, pathophysiology, clinical findings, complications, diagnosis, and treatment are presented.
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Kozak I, Vaidya V, Van Natta ML, Pak JW, May KP, Thorne JE. The prevalence and incidence of epiretinal membranes in eyes with inactive extramacular CMV retinitis. Invest Ophthalmol Vis Sci 2014; 55:4304-12. [PMID: 24925880 DOI: 10.1167/iovs.14-14479] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To determine the prevalence and incidence of epiretinal membranes (ERM) in eyes with inactive extramacular cytomegalovirus (CMV) retinitis in patients with acquired immune deficiency syndrome (AIDS). METHODS A case-control report from a longitudinal multicenter observational study by the Studies of the Ocular Complications of AIDS (SOCA) Research Group. A total of 357 eyes of 270 patients with inactive CMV retinitis and 1084 eyes of 552 patients with no ocular opportunistic infection (OOI) were studied. Stereoscopic views of the posterior pole from fundus photographs were assessed at baseline and year 5 visits for the presence of macular ERM. Generalized estimating equations (GEE) logistic regression was used to compare the prevalence and 5-year incidence of ERM in eyes with and without CMV retinitis at enrollment. Crude and adjusted logistic regression was performed adjusting for possible confounders. Main outcome measures included the prevalence, incidence, estimated prevalence, and incidence odds ratios. RESULTS The prevalence of ERM at enrollment was 14.8% (53/357) in eyes with CMV retinitis versus 1.8% (19/1084) in eyes with no OOI. The incidence of ERM at 5 years was 18.6% (16/86) in eyes with CMV retinitis versus 2.4% (6/253) in eyes with no OOI. The crude odds ratio (OR) (95% confidence interval, CI) for prevalence was 9.8 (5.5-17.5) (P < 0.01). The crude OR (95% CI) for incidence was 9.4 (3.2-27.9) (P < 0.01). CONCLUSIONS A history of extramacular CMV retinitis is associated with increased prevalence and incidence of ERM formation compared to what is seen in eyes without ocular opportunistic infections in AIDS patients.
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Affiliation(s)
- Igor Kozak
- King Khaled Eye Specialist Hospital, Vitreoretinal Division, Riyadh, Kingdom of Saudi Arabia University of California-San Diego, Jacobs Retina Center, La Jolla, California, United States
| | - Vijay Vaidya
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Mark L Van Natta
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Jeong W Pak
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, Wisconsin, United States
| | - K Patrick May
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Jennifer E Thorne
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
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Ruiz-Cruz M, Alvarado-de la Barrera C, Ablanedo-Terrazas Y, Reyes-Terán G. Proposed clinical case definition for cytomegalovirus-immune recovery retinitis. Clin Infect Dis 2014; 59:298-303. [PMID: 24771331 DOI: 10.1093/cid/ciu291] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) retinitis has been extensively described in patients with advanced or late human immunodeficiency virus (HIV) disease under ineffective treatment of opportunistic infection and antiretroviral therapy (ART) failure. However, there is limited information about patients who develop active cytomegalovirus retinitis as an immune reconstitution inflammatory syndrome (IRIS) after successful initiation of ART. Therefore, a case definition of cytomegalovirus-immune recovery retinitis (CMV-IRR) is proposed here. METHODS We reviewed medical records of 116 HIV-infected patients with CMV retinitis attending our institution during January 2003-June 2012. We retrospectively studied HIV-infected patients who had CMV retinitis on ART initiation or during the subsequent 6 months. Clinical and immunological characteristics of patients with active CMV retinitis were described. RESULTS Of the 75 patients under successful ART included in the study, 20 had improvement of CMV retinitis. The remaining 55 patients experienced CMV-IRR; 35 of those developed CMV-IRR after ART initiation (unmasking CMV-IRR) and 20 experienced paradoxical clinical worsening of retinitis (paradoxical CMV-IRR). Nineteen patients with CMV-IRR had a CD4 count of ≥50 cells/µL. Six patients with CMV-IRR subsequently developed immune recovery uveitis. CONCLUSIONS There is no case definition for CMV-IRR, although this condition is likely to occur after successful initiation of ART, even in patients with high CD4 T-cell counts. By consequence, we propose the case definitions for paradoxical and unmasking CMV-IRR. We recommend close follow-up of HIV-infected patients following ART initiation.
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Affiliation(s)
- Matilde Ruiz-Cruz
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Claudia Alvarado-de la Barrera
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Yuria Ablanedo-Terrazas
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Gustavo Reyes-Terán
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
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Willemot P, Klein MB. Prevention of HIV-associated opportunistic infections and diseases in the age of highly active antiretroviral therapy. Expert Rev Anti Infect Ther 2014; 2:521-32. [PMID: 15482218 DOI: 10.1586/14787210.2.4.521] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since the introduction of highly active antiretroviral therapy (HAART), the rates of opportunistic infections have decreased markedly as has overall morbidity and mortality from HIV infection in developed countries. However, opportunistic infections remain the most important cause of death in HIV-infected people due to both late presentation of HIV infections and failure of HAART to adequately restore cell-mediated immunity in all individuals. While prophylaxis may be discontinued in patients who have responded to HAART with sustained increases of their CD4 counts above risk thresholds, for those patients who fail HAART, those who are unable to tolerate it, or whose treatments are interrupted, opportunistic-infection prophylaxis remains essential. Some HIV-associated diseases, such as anogenital human papilloma virus-induced neoplasia and hepatitis C infection, have not decreased in frequency with the advent of HAART. For these conditions, effective screening and treatment programs will be necessary to prevent ongoing morbidity. This review will provide an update on HIV-associated opportunistic infections and their prevention in the age of HAART, as well as discuss novel presentations of opportunistic illnesses, such as immune restoration syndromes.
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Affiliation(s)
- Patrick Willemot
- Royal Victoria Hospital, McGill University Health Center, Montreal, Quebec H2X 2P4, Canada.
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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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Sudharshan S, Kaleemunnisha S, Banu AA, Shrikrishna S, George AE, Babu BR, Devaleenal B, Kumarasamy N, Biswas J. Ocular lesions in 1,000 consecutive HIV-positive patients in India: a long-term study. J Ophthalmic Inflamm Infect 2013; 3:2. [PMID: 23514612 PMCID: PMC3589206 DOI: 10.1186/1869-5760-3-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 09/12/2012] [Indexed: 11/16/2022] Open
Abstract
Background Ocular lesions in patients on highly active antiretroviral therapy (HAART) have shown changes in disease prevalence and pattern. Although they have been described in the Western population, there are not many such studies in the HAART era from India. This study aims to present the clinical profile, systemic correlation, and visual outcome in HIV-positive patients in relation to HAART in comparison with pre-HAART Indian studies and current Western data. Ocular findings and systemic correlation in 1,000 consecutive patients with HIV seen at a tertiary eye care center were analyzed. This study uses a prospective observational case series design. Results Age range of the patients was 1.5 to 75 years. Ocular lesions were seen in 68.5% of the patients (cytomegalovirus (CMV) retinitis was the commonest). The commonest systemic disease was pulmonary TB. Mean interval between HIV diagnosis and onset of ocular lesions was 2.43 years. CD4 counts range from 2 to 1,110 cells/mm3. Immune recovery uveitis (IRU) was seen in 17.4%. Interval between HAART initiation and IRU was 4 months to 2.5 years. Recurrence of ocular infection was seen in 2.53% (post-HAART) and > 20% (pre-HAART). Overall visual outcome showed improvement in about 14.3% and was maintained in 71.6% of the patients. Conclusions CMV retinitis is the commonest ocular opportunistic infection in India, even in the HAART era. Newer manifestations of known diseases and newer ocular lesions are being seen. In contrast to Western studies, in our patients on HAART, ocular lesions do not always behave as in immunocompetent individuals. Ocular TB needs to be kept in mind in India, as well as other neuro-ophthalmic manifestations related to cryptococci, especially in gravely ill patients. Occurrence and frequency of various ocular opportunistic infections in developing nations such as India have significant variations from those reported in Western literature and need to be managed accordingly.
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Affiliation(s)
- Sridharan Sudharshan
- Medical Research Foundation, 18, College Road, Sankara Nethralaya, Chennai, 600006, India.
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Meintjes G, Scriven J, Marais S. Management of the immune reconstitution inflammatory syndrome. Curr HIV/AIDS Rep 2012; 9:238-50. [PMID: 22752438 DOI: 10.1007/s11904-012-0129-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The immune reconstitution inflammatory syndrome (IRIS) is a frequent early complication of antiretroviral therapy (ART) in patients with advanced HIV. Because there is no confirmatory diagnostic test, the diagnosis is based on clinical presentation and exclusion of alternative causes for deterioration, such as antimicrobial drug resistance. Opportunistic infection treatment should be optimized. Mild cases may require symptomatic therapy alone or nonsteroidal anti-inflammatory drugs. Corticosteroids have been used to treat more severe cases of IRIS associated with mycobacterial and fungal infections. There is evidence from a randomized controlled trial that prednisone reduces morbidity and improves symptoms in paradoxical tuberculosis (TB)-IRIS. Neurological TB-IRIS is potentially life-threatening; high-dose corticosteroids are indicated and ART interruption should be considered if level of consciousness is depressed. When considering corticosteroid treatment clinicians should be aware of their side effects and only use them when the diagnosis of IRIS is certain. In viral forms of IRIS corticosteroids are generally avoided.
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Affiliation(s)
- Graeme Meintjes
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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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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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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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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Chern KC, Meisler DM. Less Common Viral Corneal Infections. Cornea 2011. [DOI: 10.1016/b978-0-323-06387-6.00088-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
Immune reconstitution inflammatory syndrome (IRIS) must be considered in the differential diagnosis for any patient infected with HIV who has begun ART in the preceding months. Distinguishing between manifestations of IRIS and active infection is of paramount importance and poses a diagnostic challenge to the provider in the acute care setting. Presentations of IRIS are often atypical for the precipitating pathogen, and novel presentations are likely. Of the diseases associated with IRIS, mycobacteria and cryptococcal infections are commonly encountered, as are dermatologic symptoms in general. The most clinically significant complications of IRIS are those involving the central nervous system, lungs, and eye, and in many of these scenarios systemic steroids may be of benefit. Management should rarely include interruption of ART, except possibly in severe, life-threatening complications.
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Affiliation(s)
- George W Beatty
- Positive Health Program at San Francisco General Hospital, University of California San Francisco, Building 80, Ward 84, 995 Potrero Avenue, San Francisco, CA 94110, USA.
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Affiliation(s)
- Aliza Jap
- Division of Ophthalmology, Changi General Hospital, 2 Simei Street 3, Singapore
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Abstract
PURPOSE OF REVIEW The aim of this article is to review the current literature concerning immune reconstitution inflammatory syndrome in relation to the eye. The definition, epidemiology, pathophysiology, risk factors, clinical features, diagnosis and treatment are discussed. RECENT FINDINGS Immune reconstitution inflammatory syndrome affecting the eye has been documented in association with cytomegalovirus retinitis following the introduction of highly active antiretroviral therapy in a large number of patients. This syndrome is referred to as immune recovery uveitis, which is presumed to be mediated by recovery of immune responses specific to residual cytomegalovirus antigen located in the eye. In addition to improved immunity itself, risk factors include a low CD4 T count at the time of initiation of highly active antiretroviral therapy and involvement of a larger proportion of retina. Immune recovery uveitis is a major cause of visual loss and morbidity among patients with AIDS who are receiving highly active antiretroviral therapy. SUMMARY Immune recovery uveitis is the most common form of immune reconstitution inflammatory syndrome in HIV-infected patients with cytomegalovirus retinitis who are receiving highly active antiretroviral therapy. Clear clinical definitions are required for ocular immune reconstitution inflammatory syndromes to avoid misclassification of other inflammatory conditions. A multidisciplinary approach is important in the diagnosis and management of immune recovery uveitis.
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Lin YC, Yang CH, Lin CP, Yang CM, Chen MS, Chen MY, Sheng WH, Hung CC, Chang SC. Cytomegalovirus Retinitis and Immune Recovery Uveitis in AIDS Patients Treated with Highly Active Antiretroviral Therapy in Taiwanese. Ocul Immunol Inflamm 2009; 16:83-7. [DOI: 10.1080/09273940802056307] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Thorne JE, Shah KH, Brown DM, Holland GN, Jabs DA. ORIGINAL ARTICLE Posterior Intracorneal Opacities in Patients with HIV Infection. Ocul Immunol Inflamm 2009; 13:25-31. [PMID: 15804766 DOI: 10.1080/09273940590909176] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To describe a keratopathy in patients with the human immunodeficiency virus (HIV) infection. METHODS Retrospective review of ophthalmic and medical records, including laboratory evaluations, of seven patients with HIV infection and posterior intracorneal opacities. RESULTS Each patient had a bilateral peripheral keratopathy located at the level of the Descemet membrane that was unassociated with intraocular inflammation. All patients were receiving highly active antiretroviral therapy (HAART). All patients had elevations in their CD4+ T-lymphocyte counts due to HAART prior to presenting with the corneal opacities. Five of the seven patients had elevated serum cholesterol, triglycerides, or both. Best-corrected visual acuity was 20/25 or better in six of the seven patients at the time of diagnosis, and vision remained stable through the follow-up period in all patients (median follow-up: 25 months; range: 14-82 months). The corneal opacities remained unchanged in all seven over the follow-up period. CONCLUSION These patients have a bilateral keratopathy that appears to be non-progressive and has no effect on visual acuity.
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Affiliation(s)
- Jennifer E Thorne
- Department of Ophthalmology, The Wilmer Eye Institute, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA.
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Haemorrhagic hypertensive hypopyon uveitis in early immune reactivation uveitis. Eye (Lond) 2009; 24:383. [PMID: 19407838 DOI: 10.1038/eye.2009.100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Alp MN, Baykam N, Kural G. Immune recovery uveitis associated with highly active antiretroviral therapy in a patient with CMV retinitis and AIDS despite a low CD4+ T cell count: case report and a review of the literature. Int Ophthalmol 2009; 30:183-9. [PMID: 19198761 DOI: 10.1007/s10792-009-9303-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Accepted: 01/20/2009] [Indexed: 11/26/2022]
Abstract
An unusual case of CMV retinitis and AIDS who developed immune recovery uveitis (IRU) despite a low CD4+ T cell count achieved during HAART is reported. A 36-year-old female complained of blurred vision in both eyes six months after initiation of anti-CMV retinitis therapy and HAART. Ocular examination revealed a substantial intraocular inflammation causing a dense vitreous haze and frosted branch angiitis. Consecutive CD4+ T cell counts were 20 cells/mm(3) or less and plasma HIV mRNA was undetectable. The laboratory test for Cytomegalovirus was positive whereas those for infections known to cause uveitis were negative. The inflammatory reaction resolved with treatment, but she developed retinal detachment just before she died of pulmonary complications. A review of the literature led us to propose that our patient developed an intraocular inflammation which may probably be a form of IRU and it might be appropriate to employ additional criteria in the definition and the diagnosis of IRU.
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Affiliation(s)
- Mehmet Numan Alp
- Department of Ophthalmology, Numune Training and Research Hospital, Dr Mediha Eldem Sokak 69/10, 06640, Ankara, Turkey.
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Khurana RN, Javaheri M, Rao N. Ophthalmic manifestations of immune reconstitution inflammatory syndrome associated with Cryptococcus neoformans. Ocul Immunol Inflamm 2008; 16:185-90. [PMID: 18716955 DOI: 10.1080/09273940802204550] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE To describe the ophthalmic manifestations of immune reconstitution inflammatory syndrome (IRIS) associated with Cryptococcus neoformans. METHODS Four HIV-positive patients on highly active anti-retroviral therapy (HAART) presented with marked optic disk swelling. RESULTS Three months after the episode of IRIS, 2 of the patients maintained 20/20 visual acuity whose elevated intracranial pressure (ICP) was successfully managed, while 2 patients visual acuities were worse than 20/400 whose ICP was persistently elevated. CONCLUSION Cryptococcus is another opportunistic infectious organism associated with IRIS with ophthalmic manifestations. Ophthalmologists have the opportunity to play a key role in the early diagnosis and management to prevent serious visual loss.
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Affiliation(s)
- Rahul N Khurana
- Uveitis & Ocular Pathology, Dohney Eye Institute, Los Angeles, California 90033, USA
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Sudharshan S, Biswas J. Introduction and immunopathogenesis of acquired immune deficiency syndrome. Indian J Ophthalmol 2008; 56:357-62. [PMID: 18711263 PMCID: PMC2636143 DOI: 10.4103/0301-4738.42411] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2007] [Accepted: 03/18/2008] [Indexed: 11/21/2022] Open
Abstract
India has a large number of patients with acquired immune deficiency syndrome (AIDS), the third largest population of this group in the world. This disease was first described in patients with Pneumocystis pneumonia in 1981. Ocular lesions can occur at any stage of the disease but are more commonly seen at the late stages. Human immunodeficiency virus (HIV), the causative agent of AIDS is a retrovirus with RNA genome and a unique 'Reverse transcriptase enzyme' and is of two types, HIV-1 and 2. Most human diseases are caused by HIV-1. The HIV-1 subtypes prevalent in India are A, B and C. They act predominantly by reducing the CD4+ cells and thus the patient becomes susceptible to opportunistic infections. High viral titers in the peripheral blood during primary infection lead to decrease in the number of CD4+ T lymphocytes. Onset of HIV-1-specific cellular immune response with synthesis of HIV-1 specific antibodies leads to the decline of plasma viral load and chronification of HIV-1 infection. However, the asymptomatic stage of infection may lead to persistent viral replication and a rapid turnover of plasma virions which is the clinical latency. During this period, there is further decrease in the CD4+ counts which makes the patient's immune system incapable of controlling opportunistic pathogens and thus life-threatening AIDS-defining diseases emerge. Advent of highly active antiretroviral treatment (HAART) has revolutionized the management of AIDS though there is associated increased development of immune recovery uveitis in a few of these patients.
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Affiliation(s)
- S Sudharshan
- Medical and Vision Research Foundations, Sankara Nethralaya, 18, College Road, Chennai - 600 006, Tamil Nadu, India
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Miró JM. Prevención de las infecciones oportunistas en pacientes adultos y adolescentes infectados por el VIH en el año 2008. Enferm Infecc Microbiol Clin 2008; 26:437-64. [DOI: 10.1157/13125642] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Jeng BH, Holland GN, Lowder CY, Deegan WF, Raizman MB, Meisler DM. Anterior Segment and External Ocular Disorders Associated with Human Immunodeficiency Virus Disease. Surv Ophthalmol 2007; 52:329-68. [PMID: 17574062 DOI: 10.1016/j.survophthal.2007.04.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The eye is a common site for complications of human immunodeficiency virus (HIV) infection. Although cytomegalovirus retinitis remains the most prevalent of the blinding ocular disorders that can occur in individuals with the acquired immunodeficiency syndrome (AIDS), several important HIV-associated disorders may involve the anterior segment, ocular surface, and adnexae. Some of these entities, such as Kaposi sarcoma, were well described, but uncommon, before the HIV epidemic. Others, like microsporidial keratoconjunctivitis, have presentations that differ between affected individuals with HIV disease and those from the general population who are immunocompetent. The treatment of many of these diseases is challenging because of host immunodeficiency. Survival after the diagnosis of AIDS has increased among individuals with HIV disease because of more effective antiretroviral therapies and improved prophylaxis against, and treatment of, opportunistic infections. This longer survival may lead to an increased prevalence of anterior segment and external ocular disorders. In addition, the evaluation and management of disorders such as blepharitis and dry eye, which were previously overshadowed by more severe, blinding disorders, may demand increased attention, as the general health of this population improves. Not all individuals infected with HIV receive potent antiretroviral therapy, however, because of socioeconomic or other factors, and others will be intolerant of these drugs or experience drug failure. Ophthalmologists must, therefore, still be aware of the ocular findings that develop in the setting of severe immunosuppression. This article reviews the spectrum of HIV-associated anterior segment and external ocular disorders, with recommendations for their evaluation and management.
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Affiliation(s)
- Bennie H Jeng
- The Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Affiliation(s)
- Lucia Sobrin
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Boston, MA 02114, USA
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Riedel DJ, Pardo CA, McArthur J, Nath A. Therapy Insight: CNS manifestations of HIV-associated immune reconstitution inflammatory syndrome. ACTA ACUST UNITED AC 2006; 2:557-65. [PMID: 16990829 DOI: 10.1038/ncpneuro0303] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Accepted: 08/03/2006] [Indexed: 11/09/2022]
Abstract
The introduction of combination antiretroviral therapy for HIV infection has prolonged the lives of patients with AIDS. It is increasingly being recognized, however, that following initiation of this therapy some patients can develop a paradoxical neurological deterioration, despite dramatic improvements in HIV viral load and CD4+ T-cell counts. This immune reconstitution inflammatory syndrome (IRIS) in the CNS is emerging as an important neurological complication, particularly as antiretroviral therapy is now becoming readily available worldwide. Currently, there are no guidelines for prevention, diagnosis or treatment of the CNS manifestations of IRIS. Even in patients with an acute presentation, the diagnosis can be challenging. Furthermore, it is possible that more-chronic forms of the syndrome exist but remain unrecognized. Here, we review the various clinical presentations of CNS IRIS, and discuss options for their management.
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Thorne JE, Jabs DA, Kempen JH, Holbrook JT, Nichols C, Meinert CL. Incidence of and Risk Factors for Visual Acuity Loss among Patients with AIDS and Cytomegalovirus Retinitis in the Era of Highly Active Antiretroviral Therapy. Ophthalmology 2006; 113:1432-40. [PMID: 16766032 DOI: 10.1016/j.ophtha.2006.03.021] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Revised: 03/21/2006] [Accepted: 03/21/2006] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To describe the incidence of and risk factors for visual acuity loss among patients with AIDS and cytomegalovirus (CMV) retinitis in the era of highly active antiretroviral therapy (HAART). DESIGN Multicenter prospective observational study. PARTICIPANTS Three hundred seventy-nine patients with AIDS and CMV retinitis (494 eyes). METHODS Follow-up every 3 months with medical history, ophthalmologic examination, and laboratory testing. MAIN OUTCOME MEASURES Incidence of visual acuity loss to 20/50 or worse, to 20/200 or worse, and of doubling of the visual angle in eyes affected with CMV retinitis. RESULTS Among the 494 eyes with CMV retinitis, the baseline frequencies of visual acuity loss to 20/50 or worse and to 20/200 or worse were 29% and 15%, respectively. Over a median follow-up period of 3.1 years, the incidences of visual acuity loss to 20/50 or worse, to 20/200 or worse, and of doubling of the visual angle were 0.10/eye-year (EY), 0.06/EY, and 0.13/EY, respectively. Immune recovery was associated with a 42% reduction in vision loss to 20/50 or worse and with a 61% reduction in vision loss to 20/200 or worse after adjusting for confounding. Of the patients with immune recovery at baseline, 17% had immune recovery uveitis (IRU). In these patients, the incidence rate of 20/50 or worse vision was similar to that observed in patients without immune recovery (0.17/EY vs. 0.16/EY), but the incidence of 20/200 or worse vision was similar to that observed among patients with immune recovery (0.04/EY vs. 0.04/EY). CONCLUSIONS Cytomegalovirus retinitis is associated with a substantial risk of incident vision loss in the era of HAART. Those who have HAART-induced immune recovery have approximately 50% lower risk of visual acuity loss. Presence of IRU at baseline attenuated the protective effect of immune recovery for moderate vision loss but not for blindness.
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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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Thorne JE, Jabs DA, Kempen JH, Holbrook JT, Nichols C, Meinert CL. Causes of Visual Acuity Loss among Patients with AIDS and Cytomegalovirus Retinitis in the Era of Highly Active Antiretroviral Therapy. Ophthalmology 2006; 113:1441-5. [PMID: 16781775 DOI: 10.1016/j.ophtha.2006.03.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Revised: 03/20/2006] [Accepted: 03/20/2006] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To quantitate the frequencies of the common causes of visual acuity loss for patients with AIDS and cytomegalovirus (CMV) retinitis in the era of highly active antiretroviral therapy (HAART). DESIGN Multicenter prospective observational study. PARTICIPANTS Three hundred seventy-nine patients (494 eyes) with CMV retinitis. METHODS Follow-up every 3 months with medical history, ophthalmologic examination, and laboratory testing. MAIN OUTCOME MEASURES Loss of visual acuity across the 20/50 or worse and 20/200 or worse thresholds and doubling of the visual angle; frequencies of causes of such vision loss. RESULTS Overall, involvement of the posterior pole with CMV retinitis (zone 1 retinitis) accounted for approximately one half of incident visual acuity loss of 20/50 or worse, 20/200 or worse, and of doubling of the visual angle. Cataract and retinitis-related retinal detachment were the second and third most common causes of vision loss, accounting for 22% to 33% and 13% to 20% of vision loss for the 3 outcomes, respectively. In subset analysis, cataract and cystoid macular edema (CME) accounted for approximately 50% of incident vision loss in eyes of patients with longstanding CMV retinitis and immune recovery at baseline, but these complications accounted for <10% of incident vision loss in eyes of patients with newly diagnosed CMV retinitis at baseline. Of eyes that had a vision-threatening complication of CMV retinitis, eyes that developed retinal detachment had the highest risk of vision loss, with 100% of eyes developing visual impairment (20/50 or worse vision) and 42% of eyes developing legal blindness (20/200 or worse vision) at 12 months after diagnosis of the retinal detachment. CONCLUSIONS In the HAART era, zone 1 involvement and retinal detachment remain the most common causes of visual acuity loss among patients with CMV retinitis. Cataract and CME also are common causes of loss of visual acuity, primarily in those patients with HAART-induced immune recovery.
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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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Steininger C, Puchhammer-Stöckl E, Popow-Kraupp T. Cytomegalovirus disease in the era of highly active antiretroviral therapy (HAART). J Clin Virol 2006; 37:1-9. [PMID: 16675299 DOI: 10.1016/j.jcv.2006.03.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2006] [Accepted: 03/23/2006] [Indexed: 10/24/2022]
Abstract
Cytomegalovirus (CMV) infection was one of the most important opportunistic infections in HIV-infected patients before the introduction of highly active antiretroviral therapy (HAART), i.e. the combination of at least three antiretroviral drugs of different classes. Thereafter, life expectancy and quality of life increased dramatically with the persistent suppression of HIV viremia and a significant reduction in incidence of CMV disease. Nevertheless, evidence for a multitude of direct and indirect effects of CMV on HIV progression is accumulating. Even in the era of HAART, a considerable number of HIV-infected patients have a CD4 cell count below <100 mm(-3), which involves a high risk for CMV disease. The focus of the present review is on interpretation of test results, their predictive value for CMV disease, and guidance for the rational use of diagnostic assays in HIV-infected patients. Identification of patients at immediate risk for CMV disease may be accomplished by detection of CMV-DNA in leucocytes or plasma. Evidence is growing that CMV genotypes may be also relevant for the risk of CMV disease. Diagnosis of CMV disease requires in most instances demonstration of virus in biopsy specimen from the affected organ because presence of CMV in blood may not be causally related to symptoms observed. Clinical symptoms and patient characteristics are essential in the interpretation of laboratory test results and may guide the rational collection of clinical specimen and use of laboratory assays. As a consequence, a reliable diagnosis of CMV disease and early identification of patients at high risk for CMV disease requires an integrated interpretation of clinical and virological information.
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Affiliation(s)
- Christoph Steininger
- Department of Internal Medicine I, Division of Infectious Diseases, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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