Relationship Between Opacity of Cytomegalovirus Retinitis Lesion Borders and Severity of Immunodeficiency Among People With AIDS

Deep learning system for screening AIDS-related cytomegalovirus retinitis with ultra-wide-field fundus images

Background

Ophthalmological screening for cytomegalovirus retinitis (CMVR) for HIV/AIDS patients is important to prevent lifelong blindness. Previous studies have shown good properties of automated CMVR screening using digital fundus images. However, the application of a deep learning (DL) system to CMVR with ultra-wide-field (UWF) fundus images has not been studied, and the feasibility and efficiency of this method are uncertain.

Methods

In this study, we developed, internally validated, externally validated, and prospectively validated a DL system to detect AIDS-related from UWF fundus images from different clinical datasets. We independently used the InceptionResnetV2 network to develop and internally validate a DL system for identifying active CMVR, inactive CMVR, and non-CMVR in 6960 UWF fundus images from 862 AIDS patients and validated the system in a prospective and an external validation data set using the area under the curve (AUC), accuracy, sensitivity, and specificity. A heat map identified the most important area (lesions) used by the DL system for differentiating CMVR.

Results

The DL system showed AUCs of 0.945 (95 % confidence interval [CI]: 0.929, 0.962), 0.964 (95 % CI: 0.870, 0.999) and 0.968 (95 % CI: 0.860, 1.000) for detecting active CMVR from non-CMVR and 0.923 (95 % CI: 0.908, 0.938), 0.902 (0.857, 0.948) and 0.884 (0.851, 0.917) for detecting active CMVR from non-CMVR in the internal cross-validation, external validation, and prospective validation, respectively. Deep learning performed promisingly in screening CMVR. It also showed the ability to differentiate active CMVR from non-CMVR and inactive CMVR as well as to identify active CMVR and inactive CMVR from non-CMVR (all AUCs in the three independent data sets >0.900). The heat maps successfully highlighted lesion locations.

Conclusions

Our UWF fundus image-based DL system showed reliable performance for screening AIDS-related CMVR showing its potential for screening CMVR in HIV/AIDS patients, especially in the absence of ophthalmic resources.

Analysis of Clinical Characteristics of Patients with Recurrent Cytomegalovirus Retinitis after Hematopoietic Stem Cell Transplantation

OBJECTIVE

To analyze and summarize the clinical and imaging characteristics of patients with cytomegalovirus retinitis (CMVR) relapse after hematopoietic stem cell transplantation (HSCT).

METHODS

This retrospective case series study recruited patients with CMVR after HSCT. The study compared the patients with stable lesions and CMV-negative aqueous humor after treatment with those with relapse lesions and a CMV DNA load in aqueous humor which had increased again after treatment. The observation indexes were basic clinical information, best-corrected visual acuity, wide-angle fundus photography, optical coherence tomography (OCT), blood CD4⁺ T lymphocyte count, and aqueous humor CMV load of the patients. We summarized the data and statistically analyzed the differences between the relapse and non-relapse groups, as well as the correlations of the observed indicators.

RESULTS

The study recruited 52 patients with CMVR (82 eyes) after HSCT, of whom 11 patients (15 eyes) had recurrence after treatment (21.2%). The recurrence interval was 6.4 ± 4.9 months. The final best-corrected visual acuity of recurrent patients was 0.3 ± 0.3. The number of CD4⁺ T lymphocytes in recurrence patients at the time of onset was 126.7 ± 80.2/mm³. The median CMV DNA load detected in aqueous humor at the time of recurrence was 8.63 × 10³ copies/mL. There was a significant difference in the CD4⁺ T lymphocyte count between the recurrence and the non-recurrence groups at onset. The onset of visual acuity in recurrence patients was significantly correlated with final visual acuity and recurrence lesion area. The fundus of recurred CMVR showed increased marginal activity of the original stable lesion. Concurrently, yellow-white new lesions appeared around the stable, atrophic, and necrotic lesions. OCT showed new diffuse hyperreflexic lesions in the retinal neuroepithelial layer near the old lesions. Inflammatory punctate hyperreflexes were observed in the vitreous, with vitreous liquefaction and contraction.

CONCLUSION

This study suggests that the clinical features, fundus manifestations, and imaging features of CMVR recurrence after HSCT are different from those at the initial onset. Patients should be closely followed up after their condition is stable to be alert for CMVR recurrence.

Cytomegalovirus Retinitis with Hypopyon Similar to Bacterial Endophthalmitis in a Patient with non-Hodgkin's Lymphoma

PURPOSE

To report a case of cytomegalovirus retinitis (CMVR) with hypopyon and intense ocular inflammation.

CASE REPORT

An 81-year-old female was referred to our hospital with a suspicion of postoperative endophthalmitis in the left eye. She had been treated with etoposide and prednisolone for non-Hodgkin's lymphoma. Examination revealed mutton-fat keratic precipitates and numerous infiltrating cells in the anterior chamber with hypopyon. The fundus was invisible due to intense vitreous opacity. Systemic and topical administration of antibiotics was started, and vitrectomy was performed. However, the ocular symptoms did not respond to treatment. Vitrectomy was repeated twice, but severe endophthalmitis findings recurred soon after surgery. Finally, a comprehensive viral PCR test using the intraocular fluid detected CMV with 3.34 × 10⁹ copies/ml, leading to a diagnosis of CMV retinitis.

CONCLUSIONS

If the causative agent is not identified in endophthalmitis that develops in immunosuppressive patients, CMV may also be considered as the possible cause.

Unusual global outbreak of monkeypox: what should we do?

Recently, monkeypox has become a global concern amid the ongoing COVID-19 pandemic. Monkeypox is an acute rash zoonosis caused by the monkeypox virus, which was previously concentrated in Africa. The re-emergence of this pathogen seems unusual on account of outbreaks in multiple nonendemic countries and the incline to spread from person to person. We need to revisit this virus to prevent the epidemic from getting worse. In this review, we comprehensively summarize studies on monkeypox, including its epidemiology, biological characteristics, pathogenesis, and clinical characteristics, as well as therapeutics and vaccines, highlighting its unusual outbreak attributed to the transformation of transmission. We also analyze the present situation and put forward countermeasures from both clinical and scientific research to address it.

Cytomegalovirus-Immune Recovery Retinitis After Initiation of Highly Active Antiretroviral Therapy: A Case Series

Purpose

To delineate the characteristics and treatment of cytomegalovirus-immune recovery retinitis (CMV-IRR) in human immunodeficiency virus (HIV) patients with immune recovery under effective highly active antiretroviral therapy (HAART) regimen.

Methods

We reported four patients with HIV who were diagnosed with CMV-IRR soon after effective HAART. Plasma levels of CD4 T cells, HAART regimen, and other clinical and laboratory characteristics of the four patients were described. Patients were monitored for ocular manifestations and clinical signs under effective ocular and systemic anti-cytomegalovirus (CMV) and corticosteroid treatment for 12 months.

Results

With HAART, plasma levels of CD4 T cell counts rose remarkably. The mean baseline CD4 count of the four patients was 14.5 (range from 7 to 33) cells/μl before HAART and 183.25 (range from 153 to 220) cells/μl when diagnosed with CMV-IRR. Ophthalmic examination demonstrated severe vitreous opacities and necrotizing retinitis, intraretinal hemorrhages, and vasculitis. A large number of CMV sequencing was detected by DNA sequencing of vitreous samples. All four patients were recovered from CMV-IRR with anti-CMV and corticosteroid treatment.

Conclusions

Cytomegalovirus-immune recovery retinitis is a new diagnosis of HIV-associated ocular complication under HAART. These findings suggest that the immunological effects of HAART may accelerate the CMV retinitis in patients with very low initial CD4 T cell counts. HIV patients are recommended to have a thorough fundus examination before HAART initiation and a close follow-up especially in those with low CD4 counts to avoid the progression of CMV retinitis.

Automated lesion segmentation and quantification for prediction of paradoxical worsening in patients with tubercular serpiginous-like choroiditis

To develop and evaluate a fully automated pipeline that analyzes color fundus images in patients with tubercular serpiginous-like choroiditis (TB SLC) for prediction of paradoxical worsening (PW). In this retrospective study, patients with TB SLC with a follow-up of 9 months after initiation of anti-tubercular therapy were included. A fully automated custom-designed pipeline was developed which was initially tested using 12 baseline color fundus photographs for assessment of repeatability. After confirming reliability using Bland–Altman plots and intraclass correlation coefficient (ICC), the pipeline was deployed for all patients. The images were preprocessed to exclude the optic nerve from the fundus photo using a single-shot trainable WEKA segmentation algorithm. Two automatic thresholding algorithms were applied, and quantitative metrics were generated. These metrics were compared between PW + and PW- groups using non-parametric tests. A logistic regression model was used to predict probability of PW for assessing binary classification performance and receiver operator curves were generated to choose a sensitivity-optimized threshold. The study included 139 patients (139 eyes; 92 males and 47 females; mean age: 44.8 ± 11.3 years) with TB SLC. Pilot analysis of 12 images showed an excellent ICC for measuring the mean area, intensity, and integrated pixel intensity (all ICC > 0.89). The PW + group had significantly higher mean lesion area (p = 0.0152), mean pixel intensity (p = 0.0181), and integrated pixel intensity (p < 0.0001) compared to the PW- group. Using a sensitivity optimized threshold cut-off for mean pixel intensity, an area under the curve of 0.87 was achieved (sensitivity: 96.80% and specificity: 72.09%). Automated calculation of lesion metrics such as mean pixel intensity and segmented area in TB SLC is a novel approach with good repeatability in predicting PW during the follow-up.

Macular Structure and Microvasculature Changes in AIDS-Related Cytomegalovirus Retinitis Using Optical Coherence Tomography Angiography

Background: Cytomegalovirus retinitis (CMVR) is a crucial blind-causing disease of AIDS-related ocular opportunistic infection. The CMVR lesions produced retinal necrosis. It is not entirely clear whether CMVR eyes without macular-involved necrotic lesions may have subtle macular damage. In this study, we conducted a cross-sectional study using optical coherence tomography angiography (OCTA) to evaluate macular microvasculature and structure in eyes with AIDS-related CMVR.

Methods: Acquired immune deficiency syndrome (AIDS)-related CMVR patients (active and inactive CMVR) and healthy controls treated in the Department of Ophthalmology, Beijing Youan Hospital, Capital Medical University between August 25, 2019, and October 18, 2019, were recruited. All OCTA parameters, including the foveal avascular zone (FAZ), retinal vessel density (VD), choroidal vascularity index (CVI), retinal thickness, and choroidal thickness, were compared between groups after the signal strength was corrected.

Results: Signal strength in the 3 × 3 and 6 × 6 mm scan patterns was significantly weaker in the inactive CMVR group than in the control group (both p < 0.001). After adjusting for signal strength, heterogeneity in the central fovea and parafoveal quadrants was present with a shift toward lower macular chorioretinal vasculature, decreased full choroidal thickness, and thicker retinal thickness in the active and inactive CMVR groups. The retinal nerve fiber layer (RNFL) and inner nuclear layer (INL) were significantly thicker in the active and inactive CMVR groups than in the control group (all p < 0.05). For photoreceptor-retinal pigment epithelium (PR-RPE) thickness, no significant differences were found in any quadrant between groups. Foveal avascular zone areas were not significantly different among the three groups (p = 0.053).

Conclusions: Subtle macular structure and microvasculature damage still existed in CMVR eyes without macular-involved necrotic lesions. The results of our study are helpful for a deep understanding of the damage caused by CMVR.

3D printed ocusert laden with ultra-fluidic glycerosomes of ganciclovir for the management of ocular cytomegalovirus retinitis

Cytomegalovirus (CMV) retinitisis a vision-threatening disease that principally afflicts immunosuppressed patients. For the management of the disease, Ganciclovir (GCV) is usually administered systemically, where patients may suffer severe untoward effects. The ocularly-applied alternatives are either the intravitreal injections, which are frequently administered due to GCV short half-life, or the sustained-release implants, which require surgical removal upon drug depletion. Both therapies are invasive and should be completed by a medical expert. The objective of this research was to formulate a non-invasive alternative represented in GCV loaded ultra-fluidic glycerosomes (UFGs), which are glycerosomes containing sodium taurocholate as an edge activator (EA), then incorporating the optimal UFGs in polylactic acid (PLA)-based 3D printed ocusert to prolong the release of GCV. The experimental design, the statistical analysis, and the optimization were performed via Design-Expert® software. The optimal formulation (UFGs 6; composed of 600 mg Phosphatidylcholine (PC), 20 mg cholesterol, 0.1:1 weight molar ratio of EA: PC and 1 gm glycerol) possessed nanovesicles (441.70 ± 1.13 nm) that entrapped 69.33 ± 0.28 % of GCV, with zeta potential value of -37.00 ± 0.42 mV and deformability index value of 74.68 ± 0.71. The confocal microscopy results showed the supreme penetration power of UFGs through the rabbit's cornea, compared to edge-activated vesicles and conventional glycerosomes from the laden ocusert. Moreover, the topical application of the ocusert laden with the optimal GCV loaded UFGs to the rabbits' eyes evidenced their safety as per the histopathological findings. Furthermore, a pharmacokinetic study in the rabbit's aqueous humor demonstrated the sustained release of GCV from the ocusert laden with the optimal GCV loaded UFGs over 5 days. Inclusively, the ocusert laden with UFGs could be considered as a non-invasive sustaining drug delivery system of GCV for the management of CMV retinitis.

Classification Criteria for Cytomegalovirus Retinitis

PURPOSE

The purpose of this study was to determine classification criteria for cytomegalovirus (CMV) retinitis.

DESIGN

Machine learning of cases with CMV retinitis and 4 other infectious posterior/ panuveitides.

METHODS

Cases of infectious posterior/panuveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on diagnosis using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used in the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the infectious posterior/panuveitides. The resulting criteria were evaluated in the validation set.

RESULTS

A total of 803 cases of infectious posterior/panuveitides, including 211 cases of CMV retinitis, were evaluated by machine learning. Key criteria for CMV retinitis included: 1) necrotizing retinitis with indistinct borders due to numerous small satellites; 2) evidence of immune compromise; and either 3) a characteristic clinical appearance, or 4) positive polymerase chain reaction assay results for CMV from an intraocular specimen. Characteristic appearances for CMV retinitis included: 1) wedge-shaped area of retinitis; 2) hemorrhagic retinitis; or 3) granular retinitis. Overall accuracy for infectious posterior/panuveitides was 92.1% in the training set and 93.3% (95% confidence interval: 88.2-96.3) in the validation set. The misclassification rates for CMV retinitis were 6.9% in the training set and 6.3% in the validation set.

CONCLUSIONS

The criteria for CMV retinitis had a low misclassification rate and appeared to perform sufficiently well for use in clinical and translational research.

The predictive value of interleukin-8 in the development of cytomegalovirus retinitis in HIV-negative patients

INTRODUCTION

To evaluate the value of interleukin (IL)-8 in the development and management of cytomegalovirus retinitis (CMVR) in HIV-negative patients.

INTRODUCTION

To evaluate the value of interleukin (IL)-8 in the development and management of cytomegalovirus retinitis (CMVR) in HIV-negative patients.

METHODS

A retrospective case series from January 2014 to May 2018 was conducted. Forty patients (40 eyes) received intravitreal injection of ganciclovir (IVG). The aqueous levels of the cytomegalovirus (CMV) DNA and IL-8 in each follow-up visit were tested. The initial and final best corrected visual acuity (BCVA), the course of treatment, the recurrence rate, and the occurrence of complications were recorded and analyzed.

RESULTS

The aqueous value of IL-8 was significantly correlated with the aqueous level of the CMV DNA during treatment but was not associated with the BCVA or the number of IVG. No recurrence occurred in the condition in which a low aqueous IL-8 level was set as the endpoint of the treatment.

CONCLUSION

In HIV-negative patients with CMVR, IL-8 was closely associated with CMV DNA concentration in the aqueous humor. The real-time aqueous level of IL-8 could be used as one of the evidences of disease recovery.

Clinical and Imaging Factors Associated With the Outcomes of Tubercular Serpiginous-like Choroiditis

PURPOSE

To analyze baseline clinical and imaging risk factors associated with poor outcome in patients with tubercular serpiginous-like choroiditis (TB SLC).

DESIGN

Retrospective clinical study.

METHODS

Charts and fundus photographs of consecutive patients with active TB SLC seen at a single tertiary referral center with 6 months follow-up after initiation of treatment were reviewed. Logistic mixed models were performed to determine the clinical and imaging factors associated with the response to therapy, including the opacity of choroiditis graded according to a 3-point scale.

RESULTS

This study included 203 eyes of 183 patients with active TB SLC. Poor initial best-corrected visual acuity (BCVA) and foveal and optic disc involvement were associated with poor response to therapy at 6 months (odds ratio [OR] 4.489, 95% confidence interval [CI]: 1.92-10.47; P = .001; OR 2.892, 95% CI: 1.23-6.81; P = .015; OR 11.633, 95% CI: 3.17-42.71; P < .001, respectively). The high opacity grades (2 and 3) were also associated with poor outcomes OR 9.541; 95% CI: 2.94-30.91; P = .001). Poor baseline BCVA and high grade of opacity of the lesions were the composite risk factors for paradoxical worsening of TB SLC (OR 7.555, 95% CI: 1.78-32.02; P = 0.006; OR 7.434, 95% CI: 1.34-41.18; P =0.021, respectively).

CONCLUSIONS

TB SLC with higher grades of lesion opacity at baseline may be associated with greater risk of poor therapeutic response and paradoxical worsening. Grading of baseline lesion opacity may be used in future prospective studies to predict the biological behavior of the lesions and may serve as a guide to therapeutic interventions.

Variability at the 3' untranslated region of the HLA-G gene: a study on patients with AIDS and cytomegalovirus retinochoroiditis

Cytomegalovirus retinochoroiditis (CMV-R) is the primary cause of blindness among AIDS patients. Since HLA-G is associated with the modulation of the immune response, we hypothesized that variability at the 3′ untraslated region (3′UTR) of the gene could be implicated on the predisposition to CMV-R. We evaluated whether HLA-G 3′UTR influences CMV-R development in Brazilian AIDS patients. Peripheral blood DNA was obtained from two groups of patients: (1) AIDS exhibiting CMV-R (n = 40) and (2) AIDS without CMV-R (n = 147). HLA-G 3′UTR typing was performed using sequencing analysis. Allele, genotype and haplotype frequencies were evaluated using Fisher’s exact test accompanied by the calculation of the odds ratio and its 95% confidence interval (95% CI). The etiologic (EF) and preventive fractions were also estimated. Compared to AIDS patients without CMV-R, AIDS patients with CMV-R showed increased frequencies of the: (1) + 3001T allele, (2) the + 3001C/T genotype and (3) the UTR-17 (InsTTCCGTGACG) haplotype (EFs = 0.02–0.04). The UTR-3 (DelTCCGCGACG) haplotype was associated with protection against CMV-R development. Although the risk for developing CMR-V at the population level was relatively low (EF), the identification of HLA-G 3′UTR variation sites may help to further evaluate the role of post-transcriptional factors that may contribute to the existent immunosuppresion caused by HIV per se.

Prognostic factors of cytomegalovirus retinitis after hematopoietic stem cell transplantation

PURPOSE

To identify the visual prognostic factors in patients with cytomegalovirus (CMV) retinitis after hematopoietic stem cell transplantation (HSCT).

METHODS

This retrospective cohort study included 4241 patients who underwent HSCT from April 1, 2010 to March 31, 2019 at Seoul St. Mary's Hospital. Of them, 1063 patients presented CMV viremia, and 67 patients (93 eyes) were diagnosed with CMV retinitis. We enrolled 66 patients (91 eyes). The main outcomes included the initial best-corrected visual acuity (BCVA), BCVA at the diagnosis of retinitis and last visit, involved retinal zone, peak CMV DNA levels in the peripheral blood and aqueous humor, time between HSCT and the diagnosis of retinitis, time between the diagnosis of viremia and retinitis, complications, recurrence, survival, and so on.

RESULTS

The mean BCVA (logarithm of the minimum angle of resolution) values before HSCT, at the time of retinitis diagnosis, and at the last visit were 0.041 ± 0.076, 0.262 ± 0.529, and 0.309 ± 0.547, respectively. Multiple regression analysis revealed that the involved zone (P = 0.001), time between HSCT and retinitis diagnosis (P = 0.019), and survival status (P = 0.001) were associated with the final visual acuity.

CONCLUSIONS

The final visual prognosis was worse in patients with greater invasion of the central retinal zone, those with a longer interval between HSCT and the diagnosis of retinitis, and those who died. Prompt diagnosis of CMV retinitis through periodic fundus examinations of patients with CMV viremia can prevent severe vision loss. Once CMV viremia is confirmed, we recommend fundus examinations to be immediately performed and repeated every 2 weeks for at least 2 months, even if the CMV DNA titer in the peripheral blood becomes negative.

Cytomegalovirus Retinitis in HIV and Non-HIV Individuals

Cytomegalovirus retinitis (CMVR) is a severe, vision-threatening disease that primarily affects immunosuppressed patients. CMVR is the most common ocular opportunistic infection in human immunodeficiency virus (HIV) infected patients and is the leading cause of blindness in this group; however, the incidence of CMVR in HIV patients has dramatically decreased with antiretroviral therapy. Other causes of immunosuppression, including organ transplantation, hematologic malignancies, and iatrogenic immunosuppression, can also lead to the development of CMVR. Herein, we describe the pathogenesis of CMVR and compare clinical features, epidemiology, and risk factors in HIV and non-HIV infected individuals with CMVR.