View source for WBR1076

{{WBRQuestion
|QuestionAuthor=Chetan Lokhande
|ExamType=USMLE Step 3
|MainCategory=Primary Care Office
|SubCategory=Infectious Disease, Ophthalmology
|Prompt=A 47-year-old man with five years history of AIDS complains of blurry vision. On CD4 examination the count is 44. The patient doesn't have any other complaints.  A dilated eye exam shows necrotizing retinitis. What is the best treatment for this patient?
|Explanation=Cytomegalovirus (CMV) is the most common cause of HIV retinitis. CMV retinitis occurs when the CD4 count drops below 50.  The most common sign on a dilated ophthalmic examination is necrotizing retinitis. '''Cytomegalovirus retinitis''', also known as '''CMV retinitis''', is an inflammation of the [[eye]]'s [[retina]] that can lead to [[blindness]]. [[Cytomegalovirus]] (CMV)) is a [[DNA virus]] in the family [[Herpesviridae]] known for producing large cells with nuclear and cytoplasmic inclusions. Such inclusions are called an "owl's eye" effect.

While CMV is found in almost everyone, and is usually fought off by the [[immune system]], for people who are [[immunocompromised]], by diseases, transplants, or [[chemotherapy]] the virus is not adequately destroyed and can cause damage to the eye and the rest of the body.  [[HIV positive]] persons are most at risk, especially when the [[CD4]] cell count decreases.  CMV is a common virus that infects those who are HIV positive.  

It affects the eye in about 30% of the cases by causing damage to the  retina.  Symptoms can include blurred vision, eye pain, [[photophobia]], redness, and blindness. It may affect just one eye at first, but then may spread to the other. Because the virus is so threatening to vision, it is usually treated by a [[vitreo-retinal surgeon]], by [[antivirals]] such as [[ganciclovir]] or [[foscarnet]], which can be taken orally, intravenously, injected directly into the eye ([[intravitreal injection]]), or through an [[intravitreal implant]].

|EducationalObjectives=CMV retinitis can be treated with [[ganciclovir]] or [[foscarnet]]. Use of steroids have shown to elevate the risk of CMV retinitis in HIV patients.  Hence steroids are not indicated in patients of CMV retinitis.
LINK TO WBR 1077.
|References=
1.Hodge WG, Boivin JF, Shapiro SH, Shah KC, Dionne MA. Iatrogenic risk factors
for cytomegalovirus retinitis. Can J Ophthalmol. 2005 Dec;40(6):701-10. PubMed
PMID: 16518896.
2.Ahmadinejad Z, Ghetmiri Z, Rasoolinejad M. Cytomegalovirus retinitis after
initiation of antiretroviral therapy. Acta Med Iran. 2013 Oct;51(10):730-2.
PubMed PMID: 24338150.


|AnswerA=HAART


|AnswerAExp=HAART is not indicated in the treatment of CMV retinitis.  It is indicated for treatment of HIV . The patient has HIV since 5 years and doesn't have any other complaints. Hence HAART is not indicated now . It may be started in combination to treatment of CMV .  
|AnswerB=Efavirenz
|AnswerBExp=Efavirenz is not indicated in the treatment of CMV retinitis.  It is indicated for treatment of HIV . The patient has HIV since 5 years and doesn't have any other complaints. Hence Efavirenz is not indicated now . It may be started in combination to treatment of CMV .  
|AnswerC=Zidovudine
|AnswerCExp=Zidovudine is not indicated in the treatment of CMV retinitis.  It is indicated for treatment of HIV . The patient has HIV since 5 years and doesn't have any other complaints. Hence Zidovudine is not indicated now . It may be started in combination to treatment of CMV .  
|AnswerD=Foscarnet
|AnswerDExp=Foscarnet is the second drug of choice for treatment of CMV retinitis . Since steroids are not indicated in AIDS foscarnet is the correct answer.
|AnswerE=Ganciclovir with steroids
|AnswerEExp=Ganciclovir is the drug of choice for treatment of CMV retinitis . Since steroids increase the  risk of CMV retinitis they are not indicated here. As a result ganciclovir with steroids is not the correct answer.
|RightAnswer=D
|WBRKeyword=HIV, AIDS, CMV,Retinitis
|Linked=Yes
|Approved=Yes
}}