Abstract
Purpose
Cytomegalovirus (CMV) retinitis is one of the most common opportunistic infections in immunocompromised patients, including patients with acquired immunodeficiency syndrome (AIDS). CMV retinitis in non-human immunodeficiency virus (HIV)-infected patients has been reported with variable presentations. Significant intraocular inflammation is common, and visual prognosis is poor if not properly managed.
Observations
We present a case of presumed CMV retinitis in a non-immunocompromised breast cancer patient that occurred during cancer treatment. The ocular symptoms developed one day after partial mastectomy with intra-operative radiotherapy following five months of chemotherapy treatment. Ocular manifestations included panuveitis with mild peripheral retinitis.
Conclusions and Importance
Early diagnosis and prompt treatment with oral valganciclovir based on the clinical manifestation and serologic test findings helped to preserve vision.
1
Introduction
CMV retinitis is one of the most common opportunistic infection in immune compromised patients, like acquired immunodeficiency syndrome (AIDS). Although HAART has decreased the incidence of CMV retinitis, CMV retinitis remains the most common HIV-related ocular manifestation and lead to visual impairment. The ocular manifestation is usually typical, but may be variable in non-HIV-infected patients. Significant intraocular inflammation was not uncommon, and the visual prognosis is poor if not properly managed. We present a case of presumed CMV retinitis in a non-immune compromised woman with breast cancer during treatment. She presented with panuveitis with mild peripheral retinitis. Even though aqueous CMV polymerase chain reaction (PCR) was not done to confirm the diagnosis, we treated her successfully based on clinical manifestations and course after treatment with ganciclovir.
2
Case report
A 65-year-old female presented to our clinic with chief complaint of increased floaters in her right eye for five days. She had history of stage 2A left breast cancer, status post five months of chemotherapy, and had undergone left partial mastectomy with intra-operative radiotherapy one day prior to the onset of symptom. Her visual acuity (VA) was 1.0 in both eyes. Ocular examination of her right eye showed superficial punctuate keratitis (SPK), trace aqueous cells in the anterior chamber, mild nuclear opacity, vitreous haze grade of 0.5, and a small creamy patch at the 3-o’clock position of the peripheral retina ( Fig. 1 A). Examination of her left eye was unremarkable except for mild SPK and lens opacity ( Fig. 1 B). Optical coherence tomography revealed slightly thickened choroid and some vitreous cells in the right eye ( Fig. 2 ). Serological tests for possible infectious origins, including herpes simplex virus (HSV), and varicella zoster virus (VZV), were not specific except for high CMV IgG reactivity (>250.0 AU/mL). CMV, HSV, and VZV IgM titers were non-reactive. CD4 count was slightly below normal range at 440 cells/μl.
Five days after the initial visit, right eye VA dropped to 0.4 with increased vitreous opacity. CMV retinitis was presumed, and oral valganciclovir 900 mg twice daily was prescribed. Over the following two weeks, right eye VA improved to 0.8, although floaters persisted. Presence of inflammatory cells resolved gradually with more consolidation of the creamy patch in the peripheral retina ( Fig. 3 A). Valganciclovir was discontinued after three months of treatment. The patient’s VA recovered to 1.0 with only residual mottling scars at the retina periphery. She felt no more blurred vision, and she was satisfied with the treatment course. No recurrence was observed up to the six-month follow-up visit ( Fig. 3 B).
