02/29/2024
I shared this photo in my stories yesterday, and was pleased to see many of you correctly guess this patient has cytomegalovirus (CMV) retinitis. This was confirmed with PCR testing of a vitreous sample, which was positive for CMV and negative for herpes simplex virus (HSV) and varicella zoster virus (VZV).
Cytology testing and flow cytometry of the vitreous sample did not show evidence of malignant cells. Typically, Vitreoretinal lymphoma would not present with retinal hemorrhages, which is a clue as to why that was lower on my differential diagnosis.
He was an elderly male with history of lymphoma treated with chemotherapy, which means he was immuncompromised. CMV retinitis pretty much only affects immunocompromised patients, whereas Acute retinal necrosis (caused by HSV and VZV) can affect both immunocompetent and immunocompromised patients. It can be tough to distinguish CMV retinitis and ARN since both can present with retinal whitening, vasculitis, retinal hemorrhages and vitritis. That’s why PCR testing is helpful to guide treatment.
This patient was treated with intravitreal ganciclovir and foscarnet, along with IV ganciclovir and oral valganciclovir. These drugs are useful because they treat CMV, HSV and VZV, whereas acyclovir and valacyclovir can treat HSV and VZV, but do not treat CMV effectively. Unfortunately his vision is limited to hand motions and I am not expecting much recovery even after the inflammation quiets down.