Cytomegalovirus retinitis in a young homosexual male with acquired immunodeficiency

Synthetic DNA approach to cytomegalovirus vaccine/immune therapy

There is no licensed vaccine or cure for human cytomegalovirus (CMV), a ubiquitous β-herpes virus that infects 60-95 % of adults worldwide. Infection is a major cause of congenital abnormalities in newborns, contributes to development of childhood cerebral palsy and medulloblastoma, can result in severe disease in immunocompromised patients, and is a major impediment during successful organ transplantation. While CMV has been increasingly associated with numerous inflammatory diseases and cancers, only recently has it been correlated with increased risk of heart disease in adults, the number-one killer in the USA. These data, among others, suggest that subclinical CMV infection, or microinfection, in healthy individuals may play more of a causative role than an epiphenomenon in development of CMV-associated pathologies. Due to the myriad of diseases and complications associated with CMV, an efficacious vaccine would be highly valuable in reducing human morbidity and mortality as well as saving billions of dollars in annual health-care costs and disability adjusted life years (DALY) in the developing world. Therefore, the development of a safe efficacious CMV vaccine or immune therapy is paramount to the public health. This review aims to provide a brief overview on aspects of CMV infection and disease and focuses on current vaccine strategies. The use of new synthetic DNA vaccines might offer one such approach to this difficult problem.

Role of human cytomegalovirus genotype polymorphisms in AIDS patients with cytomegalovirus retinitis

Although several host factors have been identified to influence the course of HCMV infection, it still remains unclear why in AIDS patients without highly active antiretroviral therapy human cytomegalovirus (HCMV) retinitis is one of the most common opportunistic infections, whereas in other immunosuppressed individuals it has a low incidence. It was suggested that HCMV glycoprotein B strains may be suitable as marker for virulence and HCMV retinitis. Moreover, UL144 ORF, a member of the TNF-α receptor superfamily, may play a crucial role in innate defences and adaptive immune response of HCMV infection. Furthermore, sequence analyses of HCMV genes UL128, UL130, and UL131A as major determinants of virus entry and replication in epithelial and other cell types were performed. To evaluate the association of sequence variability of depicted viral genes with HCMV retinitis and in vitro growth properties in retinal pigment epithelial cells (RPE) and human foreskin fibroblasts (HFF), we compared 14 HCMV isolates obtained from vitreous fluid and urine of AIDS patients with clinically proven HCMV retinitis. Isolates were analyzed by PCR cycle sequencing and phylogenetic analysis. In addition, sequences of HCMV strains AF1, U8, U11, VR1814, and its cell culture adapted derivates were included. Sequence analysis of gB yielded three genetic subtypes (gB type 1 (5 isolates), gB type 2 (12 isolates), and gB type 3 (5 Isolates)), whereas sequence analysis of UL144 showed a greater diversity (7 isolates type 1A, 2 isolates type 1C, 7 isolates type 2, and 3 isolates type 3). In contrast, the UL128, UL130, and UL131A genes of all low-passage isolates were highly conserved and showed no preferential clustering. Moreover, in HFF and RPE cells, all of our HCMV isolates replicated efficiently independently of their genetic subtype. In conclusion, beside a possible link between the gB subtype 2 and HCMV retinitis, our study found no direct evidence for a connection between UL144/UL128/UL130/UL131A genotypes and the incidence of HCMV retinitis in AIDS patients.

Immune-based therapies for cytomegalovirus infection

Immune fitness is critical in the pathogenesis and outcome of cytomegalovirus (CMV) infection. CMV disease is seen almost exclusively among individuals with an immature or defective immune system, such as patients with AIDS, transplant recipients and the developing fetus. These observations have generated interest in immune-based strategies for the management of CMV disease. Among the immune-based therapies that have been investigated in experimental and clinical settings are: passive immunotherapy with immunoglobulin; CMV vaccination; adoptive CMV-specific T-cell immunotherapy; and immune reconstitution strategies (HAART in AIDS patients, and a reduction in pharmacologic immunosuppression among transplant recipients). However, except for immune reconstitution strategies, there is no widely accepted immune-based strategy that is proven to be highly effective for CMV disease management. The benefits of immunoglobulins remain debated in an era when antiviral therapy is widely available. CMV vaccination and adoptive immunotherapy, on the other hand, remain experimental, but have had encouraging preliminary results.

Cytomegalovirus infection with MRI signal abnormalities affecting the optic nerves, optic chiasm, and optic tracts

A 49-year-old woman who had been immunosuppressed after a renal transplant developed bilateral severe visual loss. Visual acuities were finger counting and hand movements in the two eyes. Both optic nerves were pale. There were no other ophthalmic abnormalities. Brain MRI disclosed marked signal abnormalities involving the optic nerves, optic chiasm, and optic tracts. Cerebrospinal fluid polymerase chain reaction (PCR) was positive for cytomegalovirus. Treatment did not restore vision. Such extensive clinical and imaging involvement of the anterior visual pathway, which has been previously reported with other herpes viruses, illustrates the propensity for this family of viruses to track along axons.

Intravitreal ganciclovir for cytomegalovirus retinitis in patients with AIDS

OBJECTIVE

To assess the evolution of cytomegalovirus (CMV) retinitis and evaluate the possible complications associated with the use of intravitreal injections to treat this disease.

DESIGN

A nonrandomized, retrospective study with case series was performed. The study took place over 34 months.

SETTING

The study included patients with AIDS who developed CMV retinitis, and who were treated in the hospital, as outpatients, or both.

PATIENTS

Twelve patients with AIDS and CMV retinitis diagnosed between June 1990 through April 1993 were included in the study. MAIN PATIENT PARAMETERS AND OUTCOME MEASURES: For each patient, the following data were recorded: age, risk factors, other systemic findings, dates of AIDS and CMV retinitis diagnoses, stage of AIDS, extent of the retinitis, CD4 lymphocyte count at the time of diagnosis of retinitis, visual acuity, clinical evolution of the ocular infection, therapy, complications caused by the treatment, development on nonocular CMV, and the use of zidovudine or didanosine during the study period.

RESULTS

Vision improved or remained stable in nine patients and worsened in three. Two patients developed optic neuritis. The retinitis progressed to the other eye in only one of the eight patients who had unilateral involvement. The rate of relapse with maintenance therapy was 8.3% (n = 1) within the first 8 weeks. Treatment was well tolerated. There was no evidence of toxicity after a total of 226 intravitreal ganciclovir injections. All patients were able to tolerate zidovudine or didanosine concomitantly with intravitreal ganciclovir.

CONCLUSIONS

Intravitreal ganciclovir appears to be an effective alternate to systemic ganciclovir in patients with severe neutropenia and in patients who choose to continue receiving systemic zidovudine or didanosine. Early treatment and long-term maintenance therapy is essential for preserving sight.

Ocular toxoplasmosis misdiagnosed as cytomegalovirus retinopathy in immunocompromised patients

BACKGROUND

Cytomegalovirus (CMV) and Toxoplasma gondii both cause necrotizing retinopathy in immunosuppressed hosts. Because of the high prevalence of serum antibodies to these agents in the general population and the risks associated with retinal biopsies, diagnosis of these infections is usually based on clinical findings alone, but the two infections can be confused with one another because of similar clinical features. Accurate diagnosis is critical, however, because both diseases are treatable but require different medical therapies.

METHODS

Case histories were reviewed for five immunosuppressed patients with necrotizing retinopathy, which was initially diagnosed incorrectly as CMV retinopathy but was subsequently found to be toxoplasmic retinochoroiditis. Correct diagnosis was based on retinal biopsy (2 cases) or rapid response to antiparasitic drug therapy (3 cases). Factors were sought that might help differentiate toxoplasmic retinochoroiditis from CMV retinopathy at presentation.

RESULTS

In all cases, the character of retinal opacification (densely opaque, thick) and the appearance of lesion borders (smooth, nongranular) was different from that typically seen with CMV retinopathy. These cases also were characterized by prominent anterior chamber and vitreous inflammatory reactions (four of five cases) and relative lack of retinal hemorrhage. One patient subsequently developed CMV retinopathy; characteristics of the two lesions in the same eye highlighted the differences between these two infections.

CONCLUSION

Clinicians should consider ocular toxoplasmosis as a cause of necrotizing retinopathy in immunosuppressed patients and consider an empiric course of antiparasitic therapy for lesions with features described in this report.

Systemic viral infections and their retinal and choroidal manifestations

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

Foscarnet and Ganciclovir in the treatment of CMV retinitis in AIDS patients: a randomised comparison

Ganciclovir and Foscarnet were compared in an open randomised trial as treatment and secondary prophylaxis of cytomegalovirus (CMV) retinitis in patients with AIDS. Patients responded more rapidly to Ganciclovir than to Foscarnet although eventual response rates were similar with both drugs. During maintenance therapy there were trends towards more delayed reactivation of CMV and fewer adverse events requiring changes in therapy, in the Ganciclovir group. However, these patients had more line infections and a higher blood transfusion requirement.

Severe visual loss related to isolated peripapillary retinal and optic nerve head cytomegalovirus infection

We examined ten patients from a consecutive series of 73 patients with either isolated cytomegalovirus papillitis or limited cytomegalovirus retinitis contiguous with the optic disk. Patients with peripheral retinitis and other areas of retinitis were excluded. All patients were treated with ganciclovir. Two distinct types of cytomegalovirus infection of the peripapillary area were identified. Type I was characterized by spread of limited retinitis to the optic disk margin, good central visual acuity, and permanent arcuate and altitudinal visual field defects that enlarged and became more complete as the retinitis progressed toward the disk. Type II appeared to be a true cytomegalovirus infection of the optic nerve characterized by primary, isolated papillitis with peripapillary retinitis, an early afferent pupillary defect, and good initial visual acuity, which rapidly deteriorated despite prompt antiviral therapy. Peripapillary cytomegalovirus retinitis appears to be an important and underreported cause of visual morbidity in patients with AIDS.

Long-term outpatient treatment of CMV retinitis with ganciclovir in AIDS patients

Cytomegaloviral retinitis was diagnosed in nine eyes of seven patients with acquired immune deficiency syndrome (AIDS) on the basis of the characteristic ocular findings and a positive culture for cytomegalovirus (CMV) obtained systemically. Treatment with ganciclovir was begun on a protocol which provided two weeks of inpatient therapy at daily doses of 2.5 to 10 mg/kg followed by outpatient therapy at a reduced dosage three to six days per week. Outpatient maintenance dosage ranged from 15 mg/kg per week to 30 mg/kg per week. In seven eyes of six patients the treatment decreased retinal inflammation and stabilised the margins of the lesions. Six patients have tolerated long term maintenance therapy for 10-30 weeks. Six of seven patients (85%) in this study developed side effects from ganciclovir which required periods of a reduction in dosage or interruption of therapy. The side effects from ganciclovir included neutropenia, thrombocytopenia, drug fever, and neuropathy. Physicians using ganciclovir in AIDS patients must watch for the signs of drug toxicity and adjust treatment accordingly. Ganciclovir appears to be a promising therapy for CMV retinitis, but further work is necessary to determine the best regimen for optimal efficacy with minimal side effects.

Atypical presumed CMV retinitis

Cytomegalovirus (CMV) retinitis is a common and one of the most serious ophthalmic manifestations of the acquired immunodeficiency syndrome (AIDS). Early recognition is essential in the proper management of this necrotizing and progressive infection. We discuss an unusual presentation of CMV retinitis which appeared initially only in the foveal region.

Cytomegalovirus retinitis

Cytomegalovirus retinitis is a frequent and serious complication of various conditions, including diseases characterized by impaired immunity, such as the acquired immunodeficiency syndrome. Due to recent advances in the treatment of cytomegalovirus retinitis, accurate diagnosis and management have become increasingly important. In this review, the authors present the epidemiology, clinical features, diagnostic testing, treatment with complications, and prognosis of cytomegalovirus retinitis. A differential diagnosis is presented and the characteristic ocular lesions are illustrated.

The spectrum of optic nerve disease in human immunodeficiency virus infection

We studied four patients with HIV-associated optic neuropathies. One had syphilitic optic perineuritis, which responded promptly and completely to penicillin therapy. The second had cytomegalovirus papillitis and visual acuity subsequently deteriorated to no light perception. The third showed varicella zoster optic neuritis, which improved after intravenous acyclovir treatment. The fourth patient developed cryptococcal retrobulbar neuritis and died shortly thereafter. Optic neuropathy was among the initial symptoms of HIV infection in two of the four cases.

Brainstem ocular motility defects and AIDS

Ocular motility manifestations of focal brainstem dysfunction were the initial clinical features in three patients with human immunodeficiency virus (HIV) infection. These included conjugate gaze palsy with ipsilateral facial paresis, bilateral abducens palsy and a gaze paresis, and homolateral internuclear ophthalmoplegia and abducens nerve paresis. Two patients had focal brainstem lesions as evidenced on neuroimaging. The third showed concurrent infection with Treponema pallidum.

Atypical retinitis in patients with the acquired immunodeficiency syndrome

We examined three patients with AIDS who had large, sharply demarcated areas of thinned retina consistent with inactive cytomegalovirus retinitis and who were not treated with ganciclovir. These lesions appeared identical to clinically inactive areas of cytomegalovirus retinitis after effective antiviral treatment. All patients were receiving azidothymidine or ribavirin, or both, which have activity against the human immunodeficiency virus and which may improve immune function. All patients also received oral acyclovir at doses ineffective against cytomegalovirus retinitis.

Intravitreal ganciclovir in the treatment of AIDS-associated cytomegalovirus retinitis

Ganciclovir (BW B759U, DHPG, dihydroxy propoxymethyl guanine) was injected directly into the vitreous in 14 eyes of 11 patients with severe acquired immune deficiency syndrome (AIDS)-associated cytomegalovirus (CMV) retinitis. All 11 patients either demonstrated serious myelosuppression which precluded the continuation of intravenous ganciclovir therapy (5 patients) or were experiencing progressive CMV retinitis despite therapy with maximum-tolerable dosages of intravenous ganciclovir (6 patients). Suppression of the retinitis was observed in 11 (78%) of the 14 treated eyes. Three eyes (22%) showed no improvement after the initial intravitreal injection. One rhegmatogenous retinal detachment (RD) occurred during an injection. There were no other complications, and no intraocular drug toxicity was observed. Reactivation of CMV retinitis necessitated repeated injections in 9 (64%) of the 14 eyes. The authors' experience with these 30 intravitreal injections indicates that the procedure is safe and effective both as an alternative to intravenous ganciclovir therapy in myelosuppressed patients and as a supplement to intravenous therapy in uncontrolled CMV retinitis.

Viral infections in the acquired immunodeficiency syndrome

The following communication is a tripartite synopsis of the role of viral infection in the acquired immunodeficiency syndrome (AIDS). The first section describes the impact of viral opportunistic infection in AIDS; for each virus, clinical presentation and diagnosis, laboratory diagnostic approaches (with emphasis on electron microscopy), and therapeutic interventions attempted to date are discussed. The second segment explores current theories on the pathogenesis of AIDS, and describes diagnostic and therapeutic approaches to the syndrome itself. The final section catalogues ultrastructural anomalies in the cells of AIDS patients, many of which have been mistakenly identified as etiologic agents.

Uveitis: a strategy for diagnosis

Uveitis may be the first presentation of a wide variety of underlying ocular and systemic diseases. It is important for the ophthalmologist to make a specific diagnosis in order to instigate specific therapy and give an accurate prognosis. The ability to recognise the clinical patterns of uveitis and to initiate appropriate investigations should form the basis of the ophthalmologist's management of the condition. To this end, we have considered uveitis under four major patterns of presentation--anterior uveitis, intermediate uveitis, posterior uveitis, and panuveitis--with subclasses within each of these four groups. We have outlined both the investigations which facilitate diagnosis of the possible underlying causes of inflammation and the interpretation of the results of such investigations.

Ganciclovir for the treatment and suppression of serious infections caused by cytomegalovirus

Ganciclovir is a congener of acyclovir with in vitro activity against cytomegalovirus. Ninety-seven patients with the acquired immune deficiency syndrome (AIDS) and a serious cytomegalovirus infection received ganciclovir, 3.0 to 15 mg/kg per day. Viremia cleared during drug therapy in 88 percent of patients. Viral shedding from urine and throat ceased or became inapparent during treatment in 78 percent and 68 percent of patients, respectively. Among patients with cytomegalovirus retinitis, 87 percent of evaluable patients had improvement in (30 of 60) or stabilization (22 of 60) of their disease. However, when the drug was discontinued, progression or recurrence of disease always occurred. Long-term suppressive therapy with ganciclovir, 5.0 mg/kg five to seven times weekly, prevented the recurrence of cytomegalovirus disease (p less than 0.001). The drug was eliminated by renal excretion, and in patients without renal impairment (creatinine clearance rates of more than 60 ml/minute/1.73 m2), ganciclovir has a mean half-life of 4.2 hours. Significant neutropenia and leukopenia occurred in 55 percent and 32 percent of patients, respectively.

Treatment of cytomegalovirus retinopathy with ganciclovir

Ganciclovir is an experimental antiviral drug with activity against human cytomegalovirus (CMV). Forty patients with acquired immune deficiency syndrome (AIDS) and CMV retinopathy were treated with ganciclovir on a compassionate protocol basis. Initial treatment doses ranged from 5.0 to 14.0 mg/kg/day for 9 to 26 days. Signs of drug response were a halt to enlargement of lesions, decreased opacification of retinal tissue, and resolution of hemorrhage and vasculitis. Complete response was seen in 88% of patients and incomplete response was seen in 9%. Vision improved or remained stable in 88% of patients. Initial treatment did not eradicate live virus from the eye. To prevent reactivation of disease, 26 patients received low-dose maintenance therapy ranging from 1.5 to 7.5 mg/kg/day, once or twice daily, 3 to 7 days per week. Reactivation of disease developed for unknown reasons in 50% of patients on continuous, uninterrupted maintenance therapy for longer than 3 weeks. Reversible neutropenia, requiring cessation of treatment, developed in 30% of patients on initial treatment and in 38% of patients on maintenance therapy. Rhegmatogenous retinal detachment was a late complication in seven patients. By reducing or delaying visual loss, ganciclovir appears to be useful in the management of CMV retinopathy in patients with AIDS.

Combined short- and long-term therapy for the treatment of cytomegalovirus retinitis using ganciclovir (BW B759U)

A total of 66 eyes in 41 patients were treated for cytomegalovirus (CMV) retinitis with a new acyclic nucleoside, ganciclovir (BW B759U). At the completion of the short-term therapy period of 21 days, 87.7% of eyes had stabilized or improved. Seventy-two percent of eyes stabilized or improved during long-term home maintenance therapy. Leukopenia and increased liver function abnormalities were the most common adverse drug reactions seen in this series. Ganciclovir dramatically improved the quality of life in these patients, but clinical evidence suggests that it is a virostatic medication requiring indefinite long-term maintenance therapy.

Neurological complications in AIDS

Neurological complications in the acquired immunodeficiency syndrome (AIDS) are an important aspect of this new infectious disease and occur frequently. The existence of neurotropic variants of the human immunodeficiency virus (HIV), the causative agent of AIDS, is probable. Direct infection of the nervous system with HIV leads to a variety of HIV-induced neurological syndromes, the AIDS dementia complex being its most important representative. In addition, a large number of opportunistic infections and malignancies of the nervous system may complicate the disease. Major aspects of the clinical pictures, rational diagnostic approaches and treatment options of the most important sequels of HIV infection of the nervous system are discussed.

Bone-marrow transplantation and toxoplasmic retinochoroiditis

A 33-year-old woman underwent bone-marrow transplantation following radiation and chemotherapy for chronic myelocytic leukemia (CML); immunosuppressive therapy was continued for graft-versus-host disease. Five months after successful transplantation, she developed necrotizing retinitis in both eyes with rapid progression over the following weeks. Due to her immunosuppressed state the patient developed pneumonia and died. Postmortem evaluation of the retinal lesions in both eyes disclosed infection by Toxoplasma gondii, which was also found in the brain and myocardium. Multiple viable toxoplasmic cysts were observed at the transition zone from a necrotic to a normal retina. Additionally, cysts of Toxoplasma gondii a normal retina. Additionally, cysts of Toxoplasma gondii were seen in the adjacent intact retina and in areas of necrosis with almost complete absence of retinal or choroidal inflammation. Toxoplasmosis should therefore be considered along with fungi and viruses in the differential diagnosis of necrotizing retinochoroiditis in immunocompromised patients.

Antiviral therapy with ganciclovir for cytomegalovirus retinitis and bilateral exudative retinal detachments in an immunocompromised child

A child with bilateral cytomegalovirus (CMV) retinitis, vitritis, and exudative retinal detachments, who was in remission from stage IV neuroblastoma and status post-chemotherapy and autologous bone marrow transplantation, was treated with ganciclovir. The drug is a new acyclic nucleoside antiviral drug with potent antiCMV activity. There was bilateral retinal reattachment, clearing of vitritis and regression of retinal exudates and hemorrhages, with concomitant resolution of viral shedding in urine and blood, on ganciclovir 7.5 mg/kg per day. There was recurrence of exudative detachments, vitritis and retinitis when the dose was reduced to 2.5 mg/kg per day, and regression of these findings when the dose was again increased to 7.5 mg/kg per day. Despite continued therapy at this dose, a relapse occurred. When the dose of drug was doubled to 15 mg/kg per day, there initially was a partial therapeutic response, followed by a subsequent relapse. No further response was seen when the dose was increased to 19.5 mg/kg per day. This patient was treated with ganciclovir for a total of 192 days. No adverse reactions to ganciclovir were seen. On the last day of drug administration, there were persistent bilateral exudative retinal detachments and progressive optic nerve head involvement with optic disc pallor, despite quiescence of the retinitis.

Varicella zoster virus is a cause of the acute retinal necrosis syndrome

We studied two blind eyes enucleated during the active phase of the acute retinal necrosis syndrome. Both eyes showed similar histopathologic findings of necrotizing retinitis, retinal arteritis, and optic neuropathy. A virus morphologically consistent with a herpes group virus was found on electron microscopy and immunocytopathologic stains showed this virus to be varicella zoster in both cases. Varicella zoster virus was cultured from the vitreous of one of the eyes. We conclude that varicella zoster virus retinal infection is a cause of the acute retinal necrosis syndrome.

Management of opportunistic infections complicating the acquired immunodeficiency syndrome

Therapy of opportunistic infection in patients with the acquired immunodeficiency syndrome is frustrating, and there is no convincing evidence that aggressive treatment and/or prophylaxis other than for Pneumocystis infection can significantly prolong life. While much clinical effort is expended on treating sequential life-threatening infections, the overall course is usually progressively downhill. Thus, any real impact on the disease should be aimed at the causative viral agent, because it is destruction of a critical component of the immune system that predisposes to opportunistic infections.

Antiviral therapy for cytomegalovirus retinitis in AIDS with dihydroxy propoxymethyl guanine

Six patients (all male, five homosexual and one bisexual, 23 to 48 years old) with the acquired immune deficiency syndrome (AIDS) who had cytomegalovirus retinitis were treated with a new antiviral drug as a part of a prospective open-labeled trial for serious cytomegalovirus infections. The drug, 9-[2-hydroxy-1-(hydroxymethyl)ethoxymethyl] guanine (referred to as dihydroxy propoxymethyl guanine), a new acyclic nucleoside antiviral agent similar in structure to acyclovir, produced positive results. These patients treated with dihydroxy propoxymethyl guanine (2.5 mg/kg of body weight every eight hours) showed regression and often disappearance of the lesions of cytomegalovirus retinitis during and for several weeks after therapy, usually with concomitant resolution of viral shedding. The cytomegalovirus retinitis recurred in four patients (the other two were lost to follow-up), but retreatment usually led to remission. Adverse drug toxicity (reversible granulocytopenia) occurred in two patients.

Central nervous system involvement in patients with acquired immune deficiency syndrome (AIDS)

Central nervous system involvement occurred in 28 of 121 patients with acquired immune deficiency syndrome (AIDS). The major risk factor in this AIDS population was intravenous drug abuse (64%). A neurologic symptom or disability was the principal reason for hospitalization in 16 cases (57%). Three patients had primary lymphoma of the brain and the remainder had opportunistic infections. Patients with focal neurological features usually had toxoplasmosis. Progressive headache and meningeal signs occurred with cryptococcosis. A progressive subacute dementia was probably due to cytomegalovirus. Other infections included atypical mycobacteria, candida, herpes zoster and possible progressive multifocal leukoencephalopathy.

Immunocytologic localization of herpes simplex type 1 viral antigens in herpetic retinitis and encephalitis in an adult

An immunoperoxidase technique was utilized to identify herpes simplex type I viral antigens in the retina, optic nerve and brain of an adult with herpetic retinitis and encephalitis. Viral antigens were demonstrated in all layers of retina, retinal pigment epithelium and to a lesser extent, in choroid. Oligodendroglia in the right optic nerve and neuronal and glial cells in the grey and white matter of the left frontal, inferior parietal and temporal lobes of the brain also expressed herpes simplex antigens. The sensitive immunoperoxidase method allowed detection of viral antigens in many cells without intranuclear inclusions or surrounding inflammation, and thereby added valuable information regarding the anatomic and cellular localization of herpetic infection. The clinicopathologic features that characterize herpes simplex retinitis in the adult are compared to cytomegalovirus retinopathy.

The acute retinal necrosis syndrome. Possible herpes simplex retinitis

The acute retinal necrosis (ARN) syndrome is a severe necrotic peripheral retinitis with vasculitis and vitritis. It attacks healthy people and carries a poor visual prognosis. Five patients with ARN were seen. Two showed interesting clinical features. One patient developed the ARN syndrome in both eyes but with a 14-year hiatus separating the two episodes, each being preceded by an infectious illness. A second patient had a possible recurrence of the ARN syndrome in the same eye, one year after the original episode. Each episode was preceded by an upper respiratory infection and ipsilateral vesicular skin lesions on the face. Biopsy of one lesion yielded herpes simplex virus (HSV) in culture. These associations, although not definitive, do lend support to the hypothesis that HSV may be the cause of the ARN syndrome.

Concurrent herpes simplex and cytomegalovirus retinitis and encephalitis in the acquired immune deficiency syndrome (AIDS)

We present a case of bilateral herpes simplex and cytomegalovirus retinitis and concurrent encephalitis following acyclovir therapy in a homosexual male with the acquired immune deficiency syndrome (AIDS). At autopsy, herpes simplex virus antigens were readily detected in all retinal layers, retinal pigment epithelium, and choriocapillaris, using an immunoperoxidase technique, whereas herpes simplex antigens in the brain were localized in restricted foci of vascular and subependymal parenchymal cells. Cytomegalovirus antigens were identified in cells in all layers of retina, in retinal pigment epithelium, and in subependymal parenchymal cells in the brain. No cytomegalovirus antigens were detected in any vascular endothelium, in choroid, or anterior to the ora serrata. The widespread expression of herpes simplex virus antigens in this patient's retinas is in marked contrast to the restricted foci of herpes simplex antigens limited to the subependymal region of the brain, and is similar to that seen in murine models of herpes simplex retinitis produced by acyclovir-resistant viral mutants.

Cytomegalovirus retinitis in the acquired immunodeficiency syndrome (AIDS). Light-microscopical, ultrastructural and immunohistochemical examination of a case

The light-microscopical, ultrastructural and immunohistochemical findings in the first reported European case of ocular changes in the acquired immuno-deficiency syndrome (AIDS) are presented. The syndrome occurred in a 31-year-old homosexual man who died of Kaposi sarcoma in the skin and internal organs, cytomegalovirus (CMV) infection of the larynx, the lungs and the small intestine, and mycobacterial infection of the lungs, the lymph nodes and the spleen. A right-sided necrotizing retinitis was shown to be caused by CMV and was clinically and histopathologically similar to previously described changes in CMV retinitis. CMV was cultured from the left eye where no ophthalmoscopic changes were observed. It is stressed that in these cases regular ophthalmological examination is advisable, even if no ocular complaints are present.

A prospective study of the ophthalmologic findings in the acquired immune deficiency syndrome

A prospective evaluation of ophthalmologic findings in 26 patients (25 men and one woman) with the acquired immune deficiency syndrome disclosed that 19 patients had significant ocular abnormalities. These included isolated retinal hemorrhages, cotton-wool spots, cytomegalovirus retinitis, acute retinal necrosis, cranial nerve palsies, and orbital Kaposi's sarcoma. Hemorrhages and cotton-wool spots appeared and disappeared spontaneously. Cytomegalovirus retinitis and acute retinal necrosis were progressive and destructive. The fundus findings did not correlate with the patient's general clinical status.

Herpes simplex chorioretinitis in a healthy adult

A previously healthy 20-year-old man developed bilateral chorioretinitis that included mild anterior uveitis, vitreous cells, multifocal chorioretinitis, and optic nerve swelling that progressed to severe optic neuropathy in one eye. Chorioretinal biopsy specimens cultured herpes simplex type 1 from separate chorioretinal and vitreous samples. Although the visual acuity of one eye remained at light perception, sight in the second eye was saved when treatment with systemic acyclovir and corticosteroids led to resolution of the inflammation. A recurrence was successfully treated with acyclovir alone and the patient shows no evidence of active disease.

Opportunistic toxoplasmic retinochoroiditis following chemotherapy for systemic lymphoma. A light and electron microscopic study

After a prolonged period of chemotherapy for a disseminated nodular lymphoma, a 51-year-old woman developed a white lesion in the left macular region, in the absence of any overt lymphomatous disease elsewhere. The initial retinal diagnosis was nonetheless a lymphomatous infiltrate. Due to her severely immunocompromised state, the patient developed pneumonia and died. The involved left eye was examined postmortem by light and electron microscopy. The retinal lesion was discovered to be caused by infection with Toxoplasma gondii, which on postmortem evaluation was also found in the brain together with subclinical lymphomatous disease and multifocal leucoencelphalopathy. Many viable and intact cysts were observed floating within the necrotic retina as well as lodged within recognizable retinal cells. Most of the organisms were encysted bradyzoites, although a rare tachyzoite was discovered in the extracellular space. Unusual features examined ultrastructurally were a preretinal membrane formed exclusively by glial cells, residual proliferating glial cells within the retina that were frequently related to surviving capillaries, and a multilaminar spindle cell placoid proliferation of pigment epithelial cells, assuming almost pseudo-sarcomatous proportions. Banded extracellular membrane material was focally observed between the proliferating pigment epithelial cells. No neoplastic lymphoreticular cells were discovered within the choroid, but a curious feature was the production of basement membranes by the surviving choroidal melanocytes. Toxoplasmosis should therefore be considered along with fungi and viruses in the differential diagnosis of white retinal lesions appearing in immunocompromised patients.

Acquired immune deficiency syndrome. Ocular manifestations

The acquired immune deficiency syndrome (AIDS) is a recently described disorder of cellular immunity in homosexuals, intravenous drug abusers, and Haitians. Manifestations include Kaposi's sarcoma, Pneumocystis carinii pneumonia, and other opportunistic infections. Ophthalmic and autopsy examinations of 30 patients at UCLA revealed frequent ocular abnormalities. Findings included cotton-wool spots (16 patients), cytomegalovirus retinitis (eight patients), conjunctivitis and keratitis (four patients), conjunctival Kaposi's sarcoma (three patients), Mycobacterium avium intracellulare choroidal granulomas (one patient), and retinal periphlebitis (one patient). We feel that the presence of cotton-wool spots in patients with this syndrome indicates a poor prognosis. Immunologic and electronmicroscopic studies of cotton-wool spots revealed no infectious agents or immunoglobulin deposition. Cytomegalovirus retinitis always was associated with a fatal outcome. The retinitis was characterized by an acute inflammatory reaction in 50% of patients. Ophthalmologists should be aware of the syndrome and its ocular manifestations.