Immune Recovery Uveitis Masked as an Endogenous Endophthalmitis in a Patient with Active CMV Retinitis

Abstract

Cytomegalovirus (CMV) retinitis may occur in profoundly immunocompromised patients and be the initial AIDS-defining infection. The incidence and prevalence of CMV retinitis has declined substantially in the era of highly active antiretroviral therapy (HAART); nevertheless, it remains a leading cause of ocular morbility. We report the case of a 40-year-old man with blurred vision and pain in the right eye, three weeks after the initiation of effective HAART treatment. Ocular examination revealed a panuveitis causing an anterior chamber reaction with hypopyon and a dense vitreous haze. An endogenous endophthalmitis was suspected and treatment was ensued, without improvement. A vitreous tap was performed, and a positive polymerase chain reaction for CMV was found. A diagnosis of immune recovery uveitis (IRU) was made, and the patient responded to treatment with valganciclovir and dexamethasone. IRU is an intraocular inflammation that develops in patients with HAART-induced immune recovery and inactive CMV retinitis, although cases of active CMV retinitis have been described. Presentation with panuveitis and hypopion is rare and may be misleading regarding diagnosis and management.

Immune Recovery Uveitis: Pathogenesis, Clinical Symptoms, and Treatment

“…IRU usually develops in patients with inactive CMV retinitis but it rarely can occur in eyes with active CMV retinitis, especially at the onset of inflammation [25]. IRU usually affects all eyes with CMV retinitis, but sometimes patients had IRU in only one of the two eyes with CMV retinitis (26.3% of those with bilateral retinitis in the study of Kempen et al) [26].…”

“…The severity of inflammation is related to various factors such as extent of CMV retinitis, amount of intraocular CMV antigen, degree of immune constitution, and previous treatment [ 19 ]. IRU usually develops in patients with inactive CMV retinitis but it rarely can occur in eyes with active CMV retinitis, especially at the onset of inflammation [ 25 ]. IRU usually affects all eyes with CMV retinitis, but sometimes patients had IRU in only one of the two eyes with CMV retinitis (26.3% of those with bilateral retinitis in the study of Kempen et al) [ 26 ].…”

Immune recovery uveitis in a patient with previously undiagnosed cytomegalovirus retinitis

“…Additionally, there was a positive serum and cerebrospinal fluid CMV load in his previous hospitalisation, and, most importantly, active CMV retinitis with IRU has been reported 18 19. We also thought that anti-CMV therapy should be started to prevent the reactivation of CMV retinitis when using systemic steroids in patients with IRU.…”

A rare case of cytomegalovirus papillitis in patient with immunodeficiency

“…8 Many studies reported the incidence of CMV papilitis found less than 10% in CMV retinitis cases. CMV retinitis accounts for 75-85% of CMV disease and over 90% 14 in an active CMV retinitis infection. In his report the patient had good visual outcome, from hand movement with good projection to 5/12 after induction doses of oral valganciclovir.…”