Pathogenesis, clinical manifestations, and diagnosis of AIDS-related cytomegalovirus retinitis
- Mark A Jacobson, MD
Mark A Jacobson, MD
- Clinical Health Sciences Professor of Medicine
- University of California San Francisco
Cytomegalovirus (CMV) retinitis is the most common serious ocular complication of AIDS. The majority of disease is related to reactivation of latent infection. However, the introduction of potent combination antiretroviral therapy (ART) regimens in 1996 has led to changes in the incidence, natural history, management, and sequelae of CMV retinitis .
The clinical manifestations, pathogenesis, risk factors, and diagnosis of CMV retinitis are discussed here. The treatment of CMV retinitis and the use of antiretroviral therapy for the treatment of HIV are reviewed separately. (See "Treatment of AIDS-related cytomegalovirus retinitis" and "Selecting antiretroviral regimens for the treatment-naïve HIV-infected patient" and "Selecting an antiretroviral regimen for treatment-experienced HIV-infected patients who are failing therapy".)
CMV IN THE ERA OF POTENT COMBINATION ART
Cytomegalovirus (CMV) retinitis was first reported as a complication of AIDS in 1982. Prior to the availability of potent combination antiretroviral therapy (ART) in 1996, CMV retinitis occurred in 21 to 44 percent of patients with AIDS, primarily in those with a CD4 T lymphocyte count below 50 cells/microL [2-4]. In early case series, patients who survived beyond six months without CMV-specific treatment became severely visually impaired or blind. The median time to progression of disease into previously uninvolved areas of the retina while on CMV-specific antiviral therapy was 47 to 104 days, mean survival after diagnosis was 6 to 10 months, and indefinite maintenance therapy was essential .
However, the introduction of potent combination ART has had a dramatic impact on CMV disease in the HIV-infected patient. CMV disease essentially occurs only in patients with advanced immunosuppression, such as those who are either not receiving or have failed to respond to ART .
Incidence — In the era prior to the availability of potent ART regimens, the incidence of CMV retinitis was high. As an example, in one observational study, approximately 25 percent of AIDS patients with a CD4 count <200 cells/microL developed CMV retinitis during four years of follow-up . In addition, in the placebo arm of a clinical trial of oral ganciclovir prophylaxis, which enrolled AIDS patients with a CD4 count of <50 cells/microL or patients with a history of an AIDS-defining opportunistic infection and a CD4 count <100 cells/microL, the incidence of CMV retinitis was 24 percent after only 12 months of follow-up .
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- CMV IN THE ERA OF POTENT COMBINATION ART
- Effect on clinical presentation
- Morbidity and mortality
- CMV specific immune responses
- RISK FACTORS
- CMV viremia
- Iatrogenic risk factors
- CLINICAL MANIFESTATIONS
- CMV IMMUNE RECOVERY UVEITIS
- SUMMARY AND RECOMMENDATIONS