Oral Herpes

Cytomegalovirus Retinitis: The Neglected Disease of the AIDS Pandemic

The dawn of the 21st century brings with it the sobering realisation that the human immunodeficiency virus (HIV) epidemic continues to exact an enormous human, social, and economic toll on the world.1 2 As of December 1999, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organisation (WHO) estimated that nearly 34 million people are infected by HIV worldwide, and stated further that the prevalence of HIV infection continues to rise at an alarming rate, perhaps doubling early in this century. This may be because the virus becomes resistant to the drugs so that the drugs are no longer effective, or because the patient’s immune system has deteriorated further. No systemic disease associations have been identified. People with HIV whose CD4 counts are below 50 cells/mm3 are most at risk for developing this disease. Even with treatment, it can eventually cause blindness. HIV positive individuals are at the greatest risk for CMV, especially when their CD4 cell count decreases. For CMV retinitis, it has been estimated that between 5% and 25% of HIV-positive patients in developing countries can be expected to develop this blinding disorder at one point during their illness.

It is also increasingly common among organ transplant recipients, as the number of those procedures performed each year increases. Quantitative HIV-1 RNA is a more reliable surrogate marker for progression to AIDS and death than CD4 counts.1 However, HIV-1 RNA levels can vary up to fourfold during acute infections,2 and there is no defined relation between HIV-1 RNA levels and risk of opportunistic infections. Clinically evident disease is found almost exclusively in individuals who are immunocompromised. Complete resolution of inflammatory lesions was observed in 8 patients. Diagnosing cytomegalovirus retinitis begins with taking a thorough personal and family medical history, including symptoms, and completing a physical examination that includes a thorough eye examination. 2005 Dec;40(6):701-10. Kim HR, Kim SD, Kim SH, et al.

“Cytomegalovirus retinitis in a patient with dermatomyositis.” 2006 Mar 15; [Epub ahead of print]. Natural Standard: The Authority on Integrative Medicine. It allows for better visualization of any peripheral retinal disease. StLukesEye.com. Between three and six HIV/AIDS clinicians are enrolled for each workshop. Causes CMV is present in nearly everyone. However, individuals who have compromised immune systems may not be able to adequately destroy the virus, which can lead to potentially serious eye damage.

The differential diagnosis includes syphilis, tuberculosis, histoplasmosis, sarcoidosis, and idiopathic multifocal chorioretinitis.3 West Nile virus-associated chorioretinitis can be distinguished from these entities on the basis of history, systemic signs and symptoms, and particularly the unique pattern of chorioretinitis. The aerobic and aerobic cultures were sterile. After anterior chamber paracentesis, we were able using PCR to detect VZV DNA in the aqueous humor. MR studies were performed on July 19 with a 1.5-T system (Magnetom Vision, Siemens-Asahi Medical Technologies, Germany). Extraocular CMV infection in the CNS, gastrointestinal tract, and other organs contributed to AIDS-related mortality. Berbel RF, Casella AM, de Souza EC, Farah ME. [Medline].

During the procedure, the patient is given eye drops to dilate the pupils. Intravenous ganciclovir is cumbersome and costly, requiring twice daily infusions for two to three weeks, followed by once daily infusions for three months until immunity is sufficiently restored (usually with the CD4 count above 100). The second is intraocular injections of ganciclovir, which is currently considered the only viable option in resource-poor settings, despite the fact that as a local treatment it entirely fails to address systemic CMV morbidity and mortality, or protect the other eye. The need for repeated injections into a patient’s eye makes this option both technically complex to administer, and challenging to achieve good compliance, particularly when patients are asymptomatic. Other reported complications are subretinal fibrosis, cystoid macular edema, branch vein occlusion, serous retinal detachment, optic disk neovascularization and anterior uveitis. If you are diagnosed with CMV-related diseases and are not already taking ART, treatment guidelines recommend that you start ART right away. It addresses systemic disease.

Treatment CMV retinitis can potentially cause serious eye damage, often including vision loss. All these factors combine to make valganciclovir the only option simple enough to make integration of CMV treatment into HIV programs feasible. A vitreo-retinal surgeon usually treats the virus. In a series of 980 patients with AIDS studied by Nightingale et al., those with disseminated histoplasmosis had a median CD4 count of 33/mm 3.22 Aspergillosis is rare and occurs in patients with CD4 counts below 50/mm 3.23 Risk factors for aspergillosis include neutropenia, corticosteroid use, and underlying lung disease. These drugs can be administered orally, intravenously, injected directly into the eye or through an intravitreal implant (small capsules of medications surgically inserted into the eye). Similar findings were reported by Yan Guex-Crosier [3,11]. This remains extremely expensive.

There are few reports of adverse effects in humans associated with alizarin, including contact dermatitis, nausea, vomiting, transient weakness, loss of muscle control, sub-acute toxicity, progressive listlessness, hyperirritability, insomnia and abnormal breathing. However, alizarin may be toxic and should not be handled for long periods of time, rubbed in the eyes or eaten. Avoid if allergic to alizarin, Rubia tinctorum or other plants from the Rubiaceae family. Avoid if pregnant or breastfeeding. Roche is targeting a small but lucrative market, and protecting its position through patent monopolies. Effects of blessed thistle (or chemicals in blessed thistle called lignans) against HIV are not clear. Screening coverage extends over most of the country, including areas in conflict.

Blessed thistle is generally considered to be safe when taken by mouth in recommended doses for short periods of time, with few reported side effects such as birth defects, bleeding, breathing problems, bruising, cancer of the nose or throat, increased production of stomach acid, itching, kidney disease, liver toxicity, skin rash, stomach discomfort, stomach ulcers and vomiting. Allergic reactions to blessed thistle including rash may occur, as well as cross-sensitivity to mugwort and Echinacea. (a) Fundus photograph; (b) fluorescein angiogram; (c) and optical coherence tomogram of the right eye showing dengue maculopathy manifesting as severe retinal vasculitis with serous retinal detachment. Although good recovery is reported spontaneously, pulse steroids speed up the recovery. Patients are then referred to specialist centres for intra-ocular ganciclovir if indicated. MSF is currently collaborating with the Ministry of Public Health on disseminating this care model to other districts. Based on the rate of spread, the most common condition confused with CMV retinitis—HIV retinopathy with “cotton-wool” spots—can easily be distinguished by repeat examination after three to four weeks.