Case Presentation:
Ocular manifestations of opportunistic infection in HIV are rarely seen in the post HAART era, however, if left untreated it may result in permanent vision loss. Progressive outer retinal necrosis (PORN), acute retinal necrosis (ARN), and CMV retinitis constitute a spectrum of ocular manifestations in immunocompromised patients. Ms. B is a 45 year‐old female who presented to the emergency department (ED) with gradually worsening vision in both eyes over the past three weeks. She emigrated from Kenya 10 yrs ago, once in USA she was diagnosed with HIV. She was referred to an ID specialist who told her she did not need treatment at this time, she was then lost to follow‐up. Three weeks prior to presentation she noticed gradual loss of vision which started as shades of gray bilaterally. The vision eventually worsened, she also started experiencing odynophagia, and subsequently presented to the ED. At presentation she had complete loss of vision in her R eye and the lateral field of her L eye. Ophthalmology exam done in the ED did not reveal any gross abnormalities except for sluggish pupillary response to light both direct and consensual. Suspecting an opportunistic viral infection of her eyes, patient was started on oral valganciclovir pending further evaluation by an ophthalmologist. A dilated fundus examination performed by an ophthalmologist, revealed cotton wool spots with areas of outer retinal necrosis consistent with CMV retinitis with features of PORN. Lumbar puncture revealed a mildly elevated RBC count, low WBC count, CSF protein of 48, with positive CSF CMV PCR & CSF HSV‐2 PCR. These findings also supported the diagnosis of HSV encephalitis, and IV gancyclovir was started. HIV viral load was 288,735 with a CD4 count of 22. HAART therapy was initiated and patient’s vision gradually improved by day 3 of therapy. Patient subsequently received 14 days of anti viral therapy and antifungal therapy. Although her symptoms of esophagitis significantly improved, she continued to have poor vision upon discharge. Both CMV retinitis and PORN are treatable with IV ganciclovir, the patient was continued on viral treatment with the hope to prevent further vision loss.
Discussion:
PORN is a necrotizing chorioretinitis which is almost exclusively seen in HIV/AIDS patients with a CD4 count <100cells/mm. It starts as a necrotizing retinitis at the posterior pole and spreads towards the outer retina. Etiologic agent is primarily varicella zoster virus; however, case studies have shown that herpes simplex virus both type 1 & 2 have been associated with PORN. Patient’s with AIDS are known to have multiple concurrent retinopathies consisting of most commonly CMV retinitis with HIV retinopathy and PORN or ARN.
Conclusions:
Ocular manifestations of opportunistic infections in severely immunocompromised HIV patient’s demands early recognition and institution of antiviral therapy in order to avoid permanent vision loss and other morbidities.