A 34‐year‐old woman presented with 2 days of headache, nausea, vomiting, and bilateral eye pain. The headache was describes as throbbing and radiated from the base of her skull down the back of her neck. Emesis was nonbilious and non‐bloody and precipitated by ingestion of solids and liquids. She had a fever of 38.3°F, a heart rate of 125 beats/minute, and a blood pressure of 100/60 mm Hg. Passive flexion of the neck elicited pain. She had a normal S1 and S2 without murmurs or rubs. Her lungs were clear to auscultation. She had slight epigastric tenderness and normal bowel sounds. A complete examination of the skin and nails revealed no rashes, A lumbar puncture revealed a normal opening pressure. Examination of the cerebrospinal fluid further revealed a glucose of 60, a protein of 40, 10 red blood cells, and 100 white blood cells composed of 80% lymphocytes. India ink stain was positive, and serum cryptococcal antigen was positive, at 1:1024. The patient's CD4 count was 5 cells/mm3. The patient was initiated on intravenous liposomal amphotericin B and flucytosine. The patient's headache and nausea steadily improved. On the third day of initiation, she complained of persistent ocular pain, scotoma, and decreased visual acuity. The retinal examination revealed evidence of active CMV. PCR analysis of a tissue biopsy was positive for cytomegalovirus. The patient was initiated on intravitreal foscarnet injections and intravenous ganciclovir, to which she responded. Serial retinal examinations revealed resolution of lesions, and she subsequently regained visual acuity.
Complications of HIV are commonly encountered by the general internist, with the majority being due to opportunistic infections such as CMV. Once a formal diagnosis of HIV has been made, it is important that the internist maintain fidelity to the specific guidelines for opportunistic infection prophylaxis depending on the level of immunosuppression. However, there is no guideline for the prophylaxis of cytomegalovirus infection. This necessitates vigilance on the part of the physician to monitor for the signs and symptoms suggesting infection. Even after the advent of HAART. CMV remains an important opportunistic infection in patients with CD4 counts below 100. Retinitis accounts for 85% of all CMV presentations, presenting with the typical symptoms of central vision blurring, vision loss, scotomata, floaters, or photopsia. Patients at risk for CMV retinitis should be thoroughly questioned regarding visual complaints; a complaint of floater or photopsia is highly indicative of active disease in AIDS patients. Patients should be promptly evaluated by dilated ophthalmoscopy. The propensity of HIV/AIDS patients to develop multiple concomitant opportunistic infections mandates a through history and physical exam with particular attention paid to cutaneous and ophthalmologic findings.
B. Gammon, none.