Management of Ganciclovir Resistant Cytomegalovirus Retinitis in a Solid Organ Transplant Recipient: A Review of Current Evidence and Treatment Approaches

Refractory anti-viral resistant CMV retinitis in an immunological nonresponder person living with HIV

Cytomegalovirus (CMV) retinitis caused by drug-resistant viruses poses a major challenge in immunocompromised patients. We present the case of a patient living with HIV with persistently low CD4+ T cells count despite effective antiretroviral therapy, who experienced multiple episodes of CMV retinitis associated with iterative acquisition of resistance. The failure of ganciclovir and foscarnet treatments led us to implement a combined therapy of intravenous cidofovir, high-dose ganciclovir, and anti-CMV immunoglobulin as well as intravitreal injections of ganciclovir. This triple therapy was successful but resulted in significant myelotoxicity. Furthermore, the relapse of CMV retinitis and/or CMV viremia with each therapeutic de-escalation reflects the high level of immunodeficiency in our patient, despite sustained control of HIV viremia for several months. This case report highlights the need for a particular management of CMV infection in patients living with HIV who are immunological nonresponders.

Cytomegalovirus chronic retinal necrosis with ganciclovir resistance: a case report

BACKGROUND

Cytomegalovirus (CMV) chronic retinal necrosis (CRN) is a rare viral retinal infection that occurs in mildly immunocompromised people. It shares some features with both acute retinal necrosis and CMV retinitis. It is typically treated with combination intravitreal and systemic ganciclovir. We discuss the management of a case of CMV CRN with ganciclovir resistance.

CASE PRESENTATION

An 80-year-old female presented with one month of blurry vision in the left eye. She was being treated with abatacept, methotrexate, and prednisone for rheumatoid arthritis. Examination revealed anterior chamber and vitreous cell along with peripheral retinal whitening. Fluorescein angiogram showed diffuse retinal non-perfusion. Aqueous fluid PCR testing returned positive for CMV. The retinitis was initially controlled with oral and intravitreal ganciclovir, but then recurred and progressed despite these therapies. Ganciclovir resistance was suspected and the patient was switched to intravitreal foscarnet injections, along with oral letermovir and leflunomide, which lead to resolution of the retinitis. The patient has now continued with letermovir and leflunomide for approximately 2.5 years without reactivation of the retinitis or need for further intravitreal anti-viral injections and with adequate control of her rheumatoid arthritis.

CONCLUSION

The incidence of CMV CRN may increase in the future as the use of non-cytotoxic immunosuppressive therapies that result in relatively mild immunosuppression also increases. Treatment with ganciclovir is effective but frequently leads to resistance, as in our case. In this situation, combination therapy with letermovir and leflunomide, particularly in the setting of rheumatoid arthritis where leflunomide can also have an anti-inflammatory effect, can be considered.

Cytomegalovirus Retinitis: Clinical Manifestations, Diagnosis and Treatment

Cytomegalovirus (CMV) retinitis is the most common eye disease associated with CMV infection in immunocompromised individuals. The CMVR may initially be asymptomatic; however, relatively mild vitreous inflammation at the onset may be an important differential point from other diseases in HIV patients. Fundus photography, CD4 T-cell count, and telemedicine could be used to screen and monitor the high-risk population, particularly in resource-limited regions. Retinitis generally starts in the peripheral retina and advances toward the posterior pole, which could develop to the characteristic "pizza pie" appearance marked by central retinal necrosis and intraretinal hemorrhage. CMVR causes vision loss if left untreated, and early antiviral therapy significantly reduces the risk of vision loss. Alongside traditional antiviral treatments, immunotherapies including CMV-specific adoptive T-cell therapy and CMV immunoglobulin (CMVIG) are emerging as promising treatment options due to their favorable tolerability and reduced mortality. This review comprehensively examines CMV retinitis, encompassing the clinical features, differential diagnosis, laboratory tests, and updated treatment strategies to inform clinical management.

Nonsurgical Management of Severe Viral Keratitis with Hypopyon and Retrocorneal Plaques: A Case Series

INTRODUCTION

Severe viral keratitis with hypopyon and retrocorneal plaques is easily misdiagnosed as it mimics fungal or bacterial keratitis and is more likely to undergo emergency therapeutic penetrating keratoplasty (TPK) in the presence of active infection, resulting in poor outcomes. This case series offers some important insights for the management strategy of severe viral keratitis.

METHODS

This retrospective case series involved five patients with unilateral severe infectious keratitis with hypopyon over 3 mm and retrocorneal endothelial plaques. Testing for corneal sensation, microscopy, culture, and anterior segment optical coherence tomography (ASOCT) were performed.

RESULTS

At presentation, all five cases had visual acuity of counting fingers (CF) or worse, large centrally located ulcer with clean ulcer surface, hypopyon, and retrocorneal plaques with reduced corneal sensation. ASOCT demonstrated the presence of retrocorneal plaques with clear space between corneal endothelium and plaques. All cases received systemic and topical ganciclovir and topical steroids. Two patients received intravenous immunoglobulin (IVIG) weekly for 2 weeks. Complete resolution was achieved in all cases except one patient who underwent TPK because of diffuse anterior synechiae of the iris, with recurrence of infection after 10 days. The patients who received IVIG showed resolution earlier compared to the other patients.

CONCLUSIONS

Evaluation of characteristics of retrocorneal plaques by ASOCT and reduced corneal sensation are valuable aids in diagnosis of complicated viral keratitis. Conservative medical management may be a viable option even in severe cases. IVIG may have a role in speedy resolution of severe cases, but more research is needed to confirm this.

Unforeseen cytomegalovirus retinopathy following high dose thiotepa and proton irradiation in a pediatric patient with high-risk medulloblastoma: A case report

In immunocompetent individuals, cytomegalovirus (CMV) infection is usually mild but may cause severe complications such as retinitis, pneumonitis, and encephalitis in immunocompromised individuals. So far, cases of CMV retinitis in patients with medulloblastoma undergoing chemotherapy and radiotherapy, have not been reported. We herein report the case of a pediatric patient with high-risk medulloblastoma who experienced an unexpected CMV retinopathy and leukoencephalopathy following high dose thiotepa and proton irradiation. The patient underwent a four-course induction therapy (1st cycle: methotrexate and vinorelbine; 2nd cycle: etoposide and hematopoietic stem cells apheresis; 3rd cycle: cyclophosphamide and vinorelbine; 4th cycle: carboplatin and vinorelbine) and then a consolidation phase consisting in high dose thiotepa followed by autologous HSC transplant and proton cranio-spinal irradiation plus boost to the primary tumor site and pituitary site with concomitant vinorelbine. After two months of maintenance treatment with lomustine and vinorelbine, the patient showed complete blindness and leukoencephalopathy. A diagnosis of CMV retinopathy was made and oral valganciclovir was administered. CMV retinopathy was judged to be possibly related to the use of high dose thiotepa worsened by radiotherapy. This case report suggests that in pediatric patients undergoing immunosuppressive chemo-radiotherapy, CMV reactivation should be carefully monitored to prevent serious complications such as retinopathy and visual loss.

Cytomegaloviral Retinitis in a Heart Transplant Patient: Case Report and Review of the Literature

Cytomegalovirus (CMV) poses a significant threat to solid organ transplant recipients (SOTR). The incidence of CMV disease in SOTR varies according to immunosuppressive therapy, antiviral prophylaxis, donor and recipient serologic compatibility, and the transplanted organ: 9% to 23%, 22% to 29% and 8% to 32% after heart, liver and kidney transplant, respectively. CMV retinitis (CMVR) is a rare manifestation of CMV with a high risk of blindness. Infection may vary in severity, from initially clinically silent cases to full-blown advanced changes involving the eye. The most characteristic effects are changes in the retina, which usually begin at the retina's periphery and are asymptomatic, then these changes spread toward the center as the disease progresses and impairs vision. We describe CMV vitritis and retinitis in a 74-year-old patient after heart transplantation conducted in 1992. The first symptom of the disease was low vision in the left eye. Initially no blood viremia was observed; then the CMV viral load in the blood and vitreous body of the right eye was 2454 and 26 million IU/mL.Despite the initiation of treatment (intravitreal and then intravenous ganciclovir), the inflammatory process progressed rapidly and vision in the left eye was lost, although functional visual acuity in the right eye was maintained. Systemic antiviral therapy with intravenous ganciclovir lasted 6 weeks until the eradication of CMV viremia. The patient was on prophylactic therapy with oral valganciclovir for 12 months. A clinically silent course of CMVR delays diagnosis and therapy. Therefore, it is recommended that all SOTR undergo periodic ophthalmologic control to avoid delayed diagnosis.

Progress and Challenges in the Prevention, Diagnosis, and Management of Cytomegalovirus Infection in Transplantation

Hosts with compromised or naive immune systems, such as individuals living with HIV/AIDS, transplant recipients, and fetuses, are at the highest risk for complications from cytomegalovirus (CMV) infection. Despite substantial progress in prevention, diagnostics, and treatment, CMV continues to negatively impact both solid-organ transplant (SOT) and hematologic cell transplant (HCT) recipients. In this article, we summarize important developments in the field over the past 10 years and highlight new approaches and remaining challenges to the optimal control of CMV infection and disease in transplant settings.