Sandbox jyostna

Retinitis HIV+ (AIDS) CD4 usually <100/mm3 Cytomegalovirus See Table 14, page 146 Occurs in 5–10% of AIDS patients Most common cause of blindness in AIDS patients with <50/mm3 CD4 counts. 19/30 pts (63%) with inactive CMV retinitis who responded to HAART (increase of ≥60 CD4 cells/mL) developed immune recovery vitreitis (vision decreases and floaters with posterior segment inflammation vitreitis, papillitis & macular changes) an average of 43 wks after teatment started. Corticosteroid treatment decreases inflammatory reaction of immune recovery vitreitis without reactivation of CMV retinitis, either periocular corticosteroids or short course of systemic steroid.

• Preferred regimen (1) for immediate sight-threatening lesions: Ganciclovir intraocular implant AND Valganciclovir 900 mg PO q24h.

• Preferred regimen (2) for peripheral lesions: Valganciclovir 900 mg PO q12h for 14–21 days, then 900 mg PO q24h for maintenance therapy
• Alternative regimen: Ganciclovir 5 mg/kg IV q12h for 14–21 days, then Valganciclovir 900 mg PO q24h OR Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h for 14–21d, then 90–120 mg/kg IV q24h OR Cidofovir 5 mg/kg IV x 2wks, then 5 mg/kg every other wk; each dose should be administered with IV saline hydration AND oral probenecid OR Repeated intravitreal injections with fomivirsen (for relapses only, not as initial therapy) Differential diagnosis: HIV retinopathy, herpes simplex retinitis, varicella-zoster retinitis (rare, hard to diagnose). Valganciclovir PO equal to Ganciclovir IV in induction of remission: Cannot use Ganciclovir ocular implant alone as approx. 50% risk of CMV retinitis other eye at 6 months.and 31% risk visceral disease. Risk decreases with systemic treatment but when contralateral retinitis does occur, Ganciclovir-resistant mutation often present. Concurrent systemic treatment recommended. Because of unique mode of action, fomivirsen may have a role if isolates become resistant to other therapies. Retinal detachments 50–60% within 1 year of diagnosis of retinitis. Equal efficacy of IV Ganciclovir AND Foscarnet. Ganciclovir avoids nephrotoxicity of Foscarnet; Foscarnet avoids bone marrow suppression of Ganciclovir. Although bone marrow toxicity may be similar to Ganciclovir. Oral Valganciclovir should replace both.

Patients who discontinue suppression therapy should undergo regular eye examination for early detection of relapses.Post treatment suppression (prophylactic) if CD4 count <100/mm3: Valganciclovir 900 mg PO q24h. Discontinue if CD4 >100/mm3 for 6 months on ART.

Herpesvirus Infections Cytomegalovirus (CMV)

Marked decrease in HIV associated CMV infections & death with Highly Active Antiretroviral Therapy. Initial treatment should optimize HAART.

Primary prophylaxis not generally recommended. Preemptive therapy in patients with increased in  CMV DNA titers in plasma & CD4 <100/mm3. Recommended by some: valganciclovir 900 mg po q24h. Authors rec. primary prophylaxis be dc if response to HAART with incerase in CD4 >100 for 6 months. 

Risk for developing CMV disease correlates with quantity of CMV DNA in plasma: each log10Ĺ associated with 3.1-fold increase in disease.