Characteristics of patients with cytomegalovirus retinitis in the era of highly active antiretroviral therapy21For the Studies of Ocular Complications of AIDS Research Group.22Conflict of interest: Statements on file with the SOCA Coordinating Center, The Johns Hopkins University School of Hygien... (original) (raw)
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American Journal of Ophthalmology, 2008
PURPOSE: To describe host characteristics (use of highly active antiretroviral therapy [HAART]; CD4؉ T-lymphocyte count; HIV ribonucleic acid [RNA] blood level) of people who were diagnosed with AIDS-related cytomegalovirus (CMV) retinitis after HAART became available and to investigate effects of HAART on ophthalmic findings. • DESIGN: Retrospective, observational case series. • METHODS: We collected demographic, medical, laboratory, and ophthalmic data for all patients with AIDS and newly diagnosed, untreated CMV retinitis from January 1997 through December 2000 at 10 sites in Los Angeles and Orange Counties, California. • RESULTS: The proportions of Hispanic and African-American patients were equivalent to or greater than their prevalences in the AIDS and general populations of Los Angeles County. Most patients (n ؍ 80; 63.5%) were known to be receiving HAART at the time of CMV retinitis diagnosis; only 22 patients (17.5%) were HAART-naïve. Median CD4؉ T-lymphocyte count was 15 cells/l and median HIV RNA blood level was 103,000 copies/ml for all patients, but in 10 patients, CMV retinitis developed despite good immunologic and virologic responses to HAART. When compared with HAART-naïve patients, HAART-failure patients with CMV retinitis had more asymptomatic disease (P ؍ .073), better visual acuity in the better eye (P ؍ .003), more bilateral disease (P ؍ .007), less zone 1 involvement (P ؍ .042), and lower lesion border opacity scores (P ؍ .054). • CONCLUSIONS: Most patients with AIDS and newly diagnosed CMV retinitis in an urban setting are HAART-experienced. HAART may influence characteristics of new CMV retinitis lesions at presentation, despite laboratory evidence of treatment failure, possibly because of residual CMV-specific immunity. (Am J Ophthalmol 2008;145:12-22.
American Journal of Ophthalmology, 2003
PURPOSE: To determine the association between anticytomegalovirus (CMV) maintenance therapy after immune recovery and immune recovery uveitis in acquired immunodeficiency syndrome (AIDS) patients on highly active antiretroviral therapy (HAART). • DESIGN: Observational cohort study. • METHODS: Data were obtained on AIDS patients with CMV retinitis followed up at the AIDS Ocular Research Unit of University of California San Diego from November 1995 to October 1999. Immune recovery was defined as CD4 count greater than 50 cells/l for more than 3 months. Patients with immune recovery uveitis presented with vitritis, cystoid macular edema, or epiretinal membrane. Statistical analyses were conducted to determine the risk of continued use of anti-CMV therapy after immune recovery and the relationship of developing immune recovery uveitis with the type of anti-CMV therapy. • RESULTS: Forty-three patients (64 eyes) had healed CMV retinitis and had achieved immune recovery. Thirty-one patients (48 eyes) received anti-CMV therapy after immune recovery, and 20 patients (29 eyes) developed immune recovery uveitis. Per-eye analyses revealed a 3.8-fold increase in the odds of developing immune recovery uveitis with anti-CMV therapy compared with no treatment (P ؍ .02). If treated with cidofovir the odds were 3.3 greater than if treated with an alternative regimen (P ؍ .04), 4.1 greater if treated intravenously (P ؍ .01), and 5.2 greater than if not treated (P ؍ .004). If not treated with cidofovir, a nonsignificant increase in the risk (2.4) of immune recovery uveitis was found (P ؍ .15). Neither the potency nor the use of implants for noncidofovir treatment was related to the risk of recovery uveitis (P > .62). • CONCLUSIONS: The use of cidofovir is a primary risk factor in the subsequent development of immune recovery uveitis. Ongoing treatment of healed CMV retinitis after immune recovery does not appear to protect against the development of immune recovery uveitis. (Am J Ophthalmol 2003;136:696 -702.
Cytomegalovirus Retinitis in the Acquired Immunodeficiency Syndrome (Aids)
Acta Ophthalmologica, 2009
Background: Cytomegalovirus (CMV) retinitis remains the most common ocular opportunistic infection in patients with acquired immunodeficiency syndrome even in the era of highly active antiretroviral therapy (HAART). Increased survival of patients on HAART has increased incidence of blindness, which will further increase in the future. The objective of this study was to determine the incidence of CMV retinitis and the effect of HAART on the natural history of CMV retinitis in patients referred from ART center. Materials and Methods: Patients with baseline/current CD4 counts <150 cells/µl were evaluated for CMV retinitis. Complete ophthalmological evaluation was carried out and records of CD4 counts, HAART regime, presence of any form of CMV retinitis and response to HAART were noted. Results: Out of 800 patients registered with CD4 <150 cells/µl in ART center, 100 patients reached us. Among these, CMV retinitis was observed in 15% patients, with median CD4 count at the time of examination being 56 cells/µl (range: 24-306 cells/µl). 66.67% patients were HAART non-responders and 63.6% eyes were economically blind. Conclusion: CMV retinitis occurs even in patients with higher CD4 counts. Timely diagnosis and intervention of this treatable condition can reduce the number of blinding years in these young patients who otherwise live longer as a result of HAART.
HIV medicine: Cytomegalovirus retinitis in patients with acquired immune deficiency syndrome
Postgraduate Medical Journal, 1999
Cytomegalovirus (CMV) retinitis is the most common intra-ocular infection in patients with acquired immune deficiency syndrome (AIDS), and a leading cause of AIDS-related morbidity. Untreated CMV retinitis in AIDS patients is a progressive and potentially blinding disorder. The diagnosis of CMV retinitis is a clinical one and it is important for physicians to be familiar with the clinical features of the disease. Ophthalmic screening of AIDS suVerers should be undertaken at regular intervals, and this is dictated, in part, by the patient's CD4+ T-lymphocyte (CD4) counts. CMV retinitis may be treated with systemic ganciclovir, foscarnet or cidofovir, or with local (intravitreal) therapy. CMVrelated retinal detachment is treated surgically. In some patients with quiescent CMV retinitis receiving highly active antiretroviral therapy, anti-CMV maintenance therapy may be discontinued in favour of close ophthalmologic observation and CD4 count monitoring.
European Journal of Clinical Microbiology and Infections Diseases, 2001
In order to assess whether complete inactivation of retinitis at the end of induction therapy leads to delayed progression during maintenance therapy with weekly intravitreal ganciclovir, the time to the first progression to retinitis was evaluated in 27 AIDS patients (34 eyes) with stable cytomegalovirus retinitis. Data were censored before the introduction of protease inhibitors. Overall, retinitis progressed in 22 of 34 eyes in a median time of 12 weeks (meanBSD, 33B9 weeks). However, retinitis progressed in 15 of 19 eyes in which only partial inactivation was achieved following induction therapy (median time, 10 weeks; meanBSD, 17B4 weeks) but in only 7 of 15 eyes when complete inactivation was obtained (median time, 59 weeks; meanBSD, 56B19 weeks) (Pp0.02). There were no differences between the groups in CD4c cell counts, drugs, route of induction treatment, or length of induction therapy. Induction therapy should be prolonged until complete inactivation of retinitis is obtained, since achieving only a partial response appears to be a factor in earlier progression when patients are switched to maintenance therapy with intravitreal ganciclovir.
2007
Background: Before the introduction of highly active antiretroviral therapy (HAART), CMV retinitis was a common complication in patients with advanced HIV disease and the therapy was well established; it consisted of an induction phase to control the infection with ganciclovir, followed by a lifelong maintenance phase to avoid or delay relapses. Methods: To determine the safety of CMV maintenance therapy withdrawal in patients with immune recovery after HAART, 35 patients with treated CMV retinitis, on maintenance therapy, with CD4+ cell count greater than 100 cells/mm 3 for at least three months, but almost all patients presented these values for more than six months and viral load < 30000 copies/mL, were prospectively evaluated for the recurrence of CMV disease. Maintenance therapy was withdrawal at inclusion, and patients were monitored for at least 48 weeks by clinical and ophthalmologic evaluations, and by determination of CMV viremia markers (antigenemia-pp65), CD4+/CD8+ counts and plasma HIV RNA levels. Lymphoproliferative assays were performed on 26/35 patients. Results: From 35 patients included, only one had confirmed reactivation of CMV retinitis, at day 120 of follow-up. No patient returned positive antigenemia tests. No correlation between lymphoproliferative assays and CD4+ counts was observed. Conclusion: CMV retinitis maintenance therapy discontinuation is safe for those patients with quantitative immune recovery after HAART.
Journal of Infectious Diseases, 1998
Seven AIDS patients who were receiving suppressive therapy for previously diagnosed cytomegalovirus (CMV) retinitis were offered treatment with protease inhibitors (PIs). Secondary prophylaxis for CMV was discontinued after 3 months of therapy with PIs if patients had ú150 CD4 cells/mm 3 and a human immunodeficiency virus (HIV) load of õ200 copies/mL and if they were negative for CMV as determined by qualitative CMV polymerase chain reaction (PCR). Ophthalmologic exams were done periodically. After a median follow-up of 9 months (range, 9 -12), no new episodes of CMV retinitis were observed. CD4 cell counts were ú150 cells/mm 3 in all cases, HIV loads were õ200 copies/mL, and results for qualitative CMV PCRs remained negative. These observations suggest that for selected patients with healed CMV retinitis who have immunologic and virologic evidence of a clinical response to potent combination antiretroviral therapy, temporary discontinuation of a chronic anti-CMV suppressive therapy may not result in further retinal necrosis. However, the long-term immunologic benefit of PIs and hence the safety of prolonged withdrawal of anti-CMV therapy is unknown.