Correspondence

Cytomegalovirus Retinitis and Low CD4+ T-Lymphocyte Counts

N Engl J Med 1995; 333:670September 7, 1995

Article

To the Editor:

Cytomegalovirus retinitis is among the most common infections in patients with AIDS. With survival increasing in patients with AIDS as a result of successful primary prophylaxis against Pneumocystis carinii pneumonia, cytomegalovirus disease now develops in an estimated 45 percent of such patients in the United States.1 The risk of developing cytomegalovirus retinitis increases with progressive immunodeficiency. For patients with base-line CD4+ T-lymphocyte counts of 100 cells per cubic millimeter or 50 cells per cubic millimeter, Pertel et al.2 noted that the cumulative incidence at 27 months was 26.3 percent and 41.9 percent, respectively. In one series, the cross-sectional prevalence of cytomegalovirus retinitis in patients with CD4+ T-lymphocyte counts below 50 per cubic millimeter was reported to be 30 percent.3

We reviewed the ophthalmologic findings in 62 patients infected with the human immunodeficiency virus from one institution who had CD4+ T-lymphocyte counts below 100 per cubic millimeter and who were examined before entry into a study of the prevention of cytomegalovirus-induced end-organ disease (AIDS Clinical Trials Group protocol 204). These patients had no history of cytomegalovirus disease at any site, including the retina. Seven patients (11.3 percent) had cytomegalovirus retinitis, on the basis of the characteristic ophthalmologic features. Fifty-three patients had CD4+ T-lymphocyte counts below 50 per cubic millimeter, including the seven with cytomegalovirus retinitis (among patients with such low CD4+ T-lymphocyte counts, the prevalence of cytomegalovirus retinitis was thus 13.2 percent). Three of the seven patients had bilateral retinitis, and four had disease that was immediately sight-threatening, defined as active infection within two disk diameters of the fovea or one disk diameter of the optic nerve.

In a prospective cross-sectional study of patients in an AIDS clinic, Kuppermann et al.3 found cytomegalovirus retinitis in 26 of 87 patients with CD4+ T-lymphocyte counts below 50 per cubic millimeter. After the exclusion of 12 patients with previously diagnosed cytomegalovirus retinitis, the prevalence of previously undiagnosed cytomegalovirus retinitis was 18.7 percent (14 of 75), a value similar to our 13.2 percent figure.

Our findings suggest that undiagnosed cytomegalovirus retinitis, including cases that are immediately sight-threatening, is sufficiently common to warrant routine screening of patients with CD4+ T-cell counts below 50 per cubic millimeter. Screening should include a funduscopic examination of dilated eyes with indirect ophthalmoscopy by an experienced examiner to identify both posterior and peripheral retinitis. In addition to having regular ophthalmologic follow-up examinations, patients should be informed about the symptoms of cytomegalovirus retinitis, including floaters, photopsia, visual-field changes, and blurred vision, and instructed to seek attention promptly if such symptoms occur.

Vincent Baldassano, M.D.
James P. Dunn, M.D.
Judith Feinberg, M.D.
Douglas A. Jabs, M.D.
Johns Hopkins University, Baltimore, MD 21205

3 References

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   Hoover DR, Saah AJ, Bacellar H, et al. Clinical manifestations of AIDS in the era of pneumocystis prophylaxis. N Engl J Med 1993;329:1922-1926
   Full Text | Web of Science | Medline

2. 2

   Pertel P, Hirschtick JP, Phair J, Chmiel J, Poggensee L, Murphy R. Risk of developing cytomegalovirus retinitis in persons infected with the human immunodeficiency virus. J Acquir Immune Defic Syndr 1992;5:1069-1074
   Web of Science | Medline

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   Kuppermann BD, Petty JG, Richman DD, et al. Correlation between CD4+ counts and prevalence of cytomegalovirus retinitis and human immunodeficiency virus-related noninfectious retinal vasculopathy in patients with acquired immunodeficiency syndrome. Am J Ophthalmol 1993;115:575-582
   Web of Science | Medline

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   SM Mitchell, MMF Shiew, M Nelson. (2011) 5 Ocular infections. HIV Medicine 12, 55-60
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   Alay S Banker, Rohan Chauhan, Deepa A Banker. (2009) HIV and opportunistic eye diseases. Expert Review of Ophthalmology 4:2, 173-185
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   Jennifer E Thorne, Anat Galor. (2007) Cytomegalovirus retinitis. Expert Review of Ophthalmology 2:4, 583-595
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   Tamara R Vrabec. (2004) Posterior segment manifestations of HIV/AIDS. Survey of Ophthalmology 49:2, 131-157
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   LISA L. WEI, SUSANNA S. PARK, DANIEL J. SKIEST. (2002) PREVALENCE OF VISUAL SYMPTOMS AMONG PATIENTS WITH NEWLY DIAGNOSED CYTOMEGALOVIRUS RETINITIS. Retina 22:3, 278-282
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   Douglas Ormrod, Lesley J. Scott, Caroline M. Perry. (2000) Valaciclovir. Drugs 59:4, 839-863
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   Caroline R Baumal, Alex V Levin, Stanley E Read. (1999) Cytomegalovirus retinitis in immunosuppressed children. American Journal of Ophthalmology 127:5, 550-558
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   Daniel J. Skiest. (1999) Cytomegalovirus Retinitis in the Era of Highly Active Antiretroviral Therapy (HAART). The American Journal of the Medical Sciences 317:5, 318
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   David C Ritterband, Dorothy N. Friedberg. (1998) Virus infections of the eye. Reviews in Medical Virology 8:4, 187-201
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    Tamara R Vrabec, Vincent F Baldassano, Scott M Whitcup. (1998) Discontinuation of maintenance therapy in patients with quiescent cytomegalovirus retinitis and elevated CD4+ counts. Ophthalmology 105:7, 1259-1264
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    Sharon Safrin, Julie Cherrington, Howard S. Jaffe. (1997) Clinical uses of cidofovir. Reviews in Medical Virology 7:3, 145-156
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    Stephen A. Spector. (1997) Current Therapeutic Challenges in the Treatment of Cytomegalovirus Retinitis. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 14, S32-S36
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    Steven A. Teich, Brian R. Saltzman. (1996) Evaluation of a New Self-Screening Chart for Cytomegalovirus Retinitis in Patients with AIDS. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 13:4, 336-342
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