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Agrawal R, Gunasekeran DV, Xu Y, Leo YS, Ng OT, Wong CS, Testi I, Ding J, Banu I, Teoh SC. Clinical Features and CD4+ T Cells Count in AIDS Patients with CMV Retinitis: Correlation with Mortality. Ocul Immunol Inflamm 2020; 30:42-47. [PMID: 32644842 DOI: 10.1080/09273948.2020.1772312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To explore the all-cause mortality in patients with acquired immune deficiency syndrome (AIDS) and Cytomegalovirus (CMV) retinitis. METHODS A retrospective cohort study of patients with CMV retinitis (CMVR) presented to a tertiary referral center in Singapore from January 1, 2004, through December 31, 2015. RESULTS A total of 144 patients were studied (87 survived, 11 lost to follow up, 46 died). Patients with bilateral CMVR and six-month follow up CD4 + T cell count < 50 cells/mm3 have shorter time to mortality, compared to patients with CD4 + T cell count > 50 cells/mm3 (p < .001) and unilateral disease (p = .043). Baseline CD4 + T cell count, size and zone of initial primary retinitis lesions, recurrences of retinitis, and timing of combined antiretroviral therapy (cART) are not significantly associated with mortality. CONCLUSION Bilateral ocular involvement and lack of immune recovery in patients with AIDS and CMVR are associated with shorter survival time.
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Affiliation(s)
- Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore.,Moorfields Eye Hospital, National Health Service Foundation Trust, London, UK
| | - Dinesh V Gunasekeran
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yanping Xu
- Department of Ophthalmology, Ng Teng Fong Hospital, Singapore, Singapore
| | - Yee-Sin Leo
- National Centre for Infectious Disease, Tan Tock Seng Hospital, Singapore, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Oon T Ng
- National Centre for Infectious Disease, Tan Tock Seng Hospital, Singapore, Singapore
| | - Chen Seong Wong
- National Centre for Infectious Disease, Tan Tock Seng Hospital, Singapore, Singapore
| | - Ilaria Testi
- Moorfields Eye Hospital, National Health Service Foundation Trust, London, UK
| | - Jianbin Ding
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Imrana Banu
- National Centre for Infectious Disease, Tan Tock Seng Hospital, Singapore, Singapore
| | - Stephen C Teoh
- Eagle Eye Center, Gleneagles Hospital, Singapore, Singapore
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Ocieczek P, Barnacle JR, Gumulira J, Phiri S, Heller T, Grabska-Liberek I. Cytomegalovirus Retinitis Screening and Treatment in Human Immunodeficiency Virus Patients in Malawi: A Feasibility Study. Open Forum Infect Dis 2019; 6:ofz439. [PMID: 31723570 PMCID: PMC6834087 DOI: 10.1093/ofid/ofz439] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 11/04/2019] [Indexed: 11/13/2022] Open
Abstract
Background Cytomegalovirus retinitis is a treatable cause of blindness in people with human immunodeficiency virus (HIV) typically with CD4 counts <50 cells/mm3. Diagnosis is with indirect fundoscopy, and treatment is with intravitreal ganciclovir injections or systemic therapy. However, diagnosis and treatment are not widely available in Malawi, which has an adult HIV prevalence estimated at 10.6%. This study aimed to establish the prevalence of cytomegalovirus retinitis among people with HIV in Malawi and the feasibility of screening. Methods Patients with CD4 counts <200 cells/mm3 were examined from 2 HIV clinics in Lilongwe and the main government hospital. Data were collected on antiretroviral therapy, ocular symptoms, and visual acuity. Fundoscopy was performed to investigate for features of cytomegalovirus retinitis. Retinal photographs were reviewed by an ophthalmologist. Patients diagnosed with cytomegalovirus retinitis were offered weekly ganciclovir injections, because systemic treatment was not available. Results Five of the 102 people with HIV screened had cytomegalovirus retinitis (4.9%). All affected patients had CD4 counts <50 cells/mm3 (mean, 15 cells/mm3; range, 3-22 cells/mm3). Visual acuity was unhelpful in identifying those with cytomegalovirus retinitis. Symptomatically, only blurred vision was useful. Two patients consented to treatment, 1 of which improved but relapsed after defaulting. Conclusions Cytomegalovirus retinitis screening based on CD4 count is essential to early recognition because visual acuity and symptoms are unreliable. Cytomegalovirus retinitis is a significant yet neglected public health issue in Malawi. Oral valganciclovir is essential to reduce blindness and mortality in those diagnosed but is not yet available. Further screening and advocacy are needed.
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Affiliation(s)
- Paulina Ocieczek
- Department of Ophthalmology, Szpital Klinczny im. Prof. W. Orłowskiego, Warsaw, Poland
| | | | | | - Sam Phiri
- Lighthouse Trust, Lilongwe, Malawi.,Department of Global Health, University of Washington, Seattle, USA.,Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,Department of Public Health, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Malawi
| | | | - Iwona Grabska-Liberek
- Department of Ophthalmology, Szpital Klinczny im. Prof. W. Orłowskiego, Warsaw, Poland
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Ngai JJ, Chong KL, Oli Mohamed S. Cytomegalovirus Retinitis in Primary Immune Deficiency Disease. Case Rep Ophthalmol Med 2018; 2018:8125806. [PMID: 30327738 PMCID: PMC6169215 DOI: 10.1155/2018/8125806] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 09/03/2018] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION To report an unusual case of CMV retinitis in Primary Immune Deficiency Disease (PIDD). CASE REPORT 13-year-old child with combined T and B cell deficiencies was diagnosed of bilateral zone 1 CMV retinitis. Intravitreal injections were unable to be given in a regular and timely manner under general anaesthesia due to her underlying systemic disease. The child was treated with intravenous ganciclovir for 8 weeks until eventual resolution of the retinitis. However, visual acuity deteriorated due to progressive optic nerve involvement. CONCLUSION Paediatric patients often do not notice subtle symptoms of CMV retinitis. Although ocular manifestations are uncommon in PIDD, recognition and high index of suspicion will allow for timely referral, diagnosis, and treatment to be instituted for better visual outcomes.
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Affiliation(s)
- Jia Jeane Ngai
- Department of Ophthalmology, Hospital Bintulu, Sarawak, Malaysia
| | - Ka Lung Chong
- Department of Ophthalmology, Hospital Bintulu, Sarawak, Malaysia
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Shah JM, Leo SW, Lee TL, Tan XL, Pan JC, Wong EP, Yong VK, Lim TH, Teoh SC. A Cytomegalovirus Retinitis Screening Program: Evaluation of Enrollment Criteria for HIV Patients in Singapore. Ocul Immunol Inflamm 2014; 23:362-70. [DOI: 10.3109/09273948.2014.902472] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Jinesh M. Shah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore,
| | - Seo W. Leo
- Dr Leo Adult & Paediatric Eye Specialist, Singapore,
- National Healthcare Group Eye Institute, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, and
| | - Tian L. Lee
- National Healthcare Group Eye Institute, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, and
| | - Xiu L. Tan
- National Healthcare Group Eye Institute, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, and
| | - James C. Pan
- National Healthcare Group Eye Institute, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, and
- Nobel Eye & Vision Centre, Singapore
| | - Elizabeth P. Wong
- National Healthcare Group Eye Institute, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, and
| | - Vernon K. Yong
- National Healthcare Group Eye Institute, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, and
| | - Tock H. Lim
- National Healthcare Group Eye Institute, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, and
| | - Stephen C. Teoh
- National Healthcare Group Eye Institute, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, and
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Lalonde RG, Boivin G, Deschênes J, Hodge WG, Hopkins JJ, Klein AH, Lindley JI, Phillips P, Shafran SD, Walmsley S. Canadian consensus guidelines for the management of cytomegalovirus disease in HIV/AIDS. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2004; 15:327-35. [PMID: 18159510 PMCID: PMC2094992 DOI: 10.1155/2004/369390] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2004] [Accepted: 06/01/2004] [Indexed: 01/11/2023]
Abstract
BACKGROUND The management of HIV-infected patients with cytomegalovirus (CMV) disease has changed significantly with the availability of highly active antiretroviral therapy (HAART). OBJECTIVES These updated guidelines are intended to provide practical help to physicians managing HIV-positive patients with or at risk for CMV disease. METHODS The 10 members of the Canadian CMV Disease in HIV/AIDS Consensus Group were infectious disease specialists, a primary care physician and ophthalmologists with expertise in HIV and CMV infection. Financial support by Hoffmann-La Roche Canada Ltd was unrestricted, and was limited to travel expenses and honoraria. The consensus group met in June and October 2002. Key areas to be considered were identified, and group members selected, reviewed and presented relevant recent literature for their assigned section for the group's consideration. Evidence was assessed based on established criteria, which were expert opinions of the members. Draft documents were circulated to the entire group and modified until consensus was reached. The final guidelines represent the group's consensus agreement. The guidelines were approved by the Canadian Infectious Disease Society. RESULTS AND CONCLUSIONS The guidelines address symptom monitoring, screening for early detection and prevention, and treatment using oral, intravenous and intraocular anti-CMV therapies in conjunction with HAART.
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Affiliation(s)
- Richard G Lalonde
- Division of Infectious Diseases, McGill University Health Centre, Montréal, Quebec
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Verbraak FD, Boom R, Wertheim-van Dillen PM, van den Horn GJ, Kijlstra A, de Smet MD. Influence of highly active antiretroviral therapy on the development of CMV disease in HIV positive patients at high risk for CMV disease. Br J Ophthalmol 1999; 83:1186-9. [PMID: 10502584 PMCID: PMC1722831 DOI: 10.1136/bjo.83.10.1186] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIMS In the pre-HAART era, HIV positive patients with CD4+ cell counts below 50 cells x10(6)/l, and those with detectable cytomegalovirus (CMV) DNA in their peripheral blood, were considered to be at high risk for the development of CMV disease. With the start of highly active antiretroviral therapy (HAART), a restoration of immune function occurred in these patients, and as a consequence patients became less vulnerable to CMV disease. Since it is not exactly known how HAART influences CMV viral load in peripheral blood and the incidence of CMV disease in high risk HIV positive patients a group of patients was followed before and after initiation of HAART. METHODS 29 HIV positive patients, seen in the first 3 months of 1996 at the AIDS clinic of the Academic Medical Centre, at high risk for development of CMV disease (positive CMV DNA assay in blood and/or CD4+ cell count below 50 cells x10(6)/l), not receiving anti-CMV maintenance therapy, were included in a prospective cohort study. HAART was started in the second trimester of 1996. Patients were evaluated for the occurrence of CMV retinitis, or CMV disease elsewhere, comparing the incidence of CMV events before and after the start of HAART. Following the introduction of HAART, CD4+ cell counts and quantitative polymerase chain reaction (PCR) for CMV DNA in blood were monitored in all patients who remained alive and were not receiving anti-CMV maintenance therapy (n=22). Follow up was performed until August 1998; the mean follow up after the start of HAART was 14.9 months (range 8-22 months). RESULTS In the pre-HAART period four patients developed CMV disease, and four died (without clinically manifest CMV disease). After the start of HAART no patient developed CMV disease or died. With HAART, the mean CD4+ cell counts increased from 34 cells x10(6)/l to 194 cells x10(6)/l at the end of follow up. CMV DNA could be detected in the blood of 11 patients. Quantification showed a decline in the amount of detectable DNA during follow up. At the last examination only one patient showed a positive PCR assay. This was the only patient with a CD4+ cell count remaining below 100 cells x10(6)/l. CONCLUSION In HIV positive patients at high risk of CMV retinitis, either with a positive CMV PCR assay in blood and/or with CD4+ cell counts below 50 cell x10(6)/l, HAART causes a dramatic decrease in the occurrence of CMV disease. This decrease is paralleled by an increase in CD4+ cell count, and a decrease in the amount of CMV DNA in the blood, which was below detection levels in all patients with CD4+ cell counts above 100 cells x10(6)/l.
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Affiliation(s)
- F D Verbraak
- Department of Ophthalmology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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