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Clinical Summary

Cytomegalovirus (CMV) can be a cause of considerable morbidity in severely immunocompromised HIV-infected individuals. The major problems encountered are, in order of frequency, retinitis, colitis, esophageal ulceration, encephalitis, and pneumonitis.

CMV retinitis is the most common cause of blindness and eye disease in patients with HIV/AIDS. Patients typically present with loss of vision, floaters, scotoma, or visual field loss. Fundoscopic examination reveals exudates and hemorrhages, which follow the vasculature of the retina, giving it the typical “pizza pie” or “cottage cheese and ketchup” appearance.

CMV colitis is an uncommon but serious complication of HIV. The usual presenting features include generalized abdominal pain, diarrhea (which may be bloody), and a low-grade fever. Loops of dilated large bowel may be seen on abdominal imaging, but definitive diagnosis is made with mucosal biopsy revealing characteristic “owl’s eye” inclusion bodies.

Management and Disposition

Treatment for CMV retinitis can be sight-saving and should be started as soon as the diagnosis is considered. Emergent ophthalmologic consultation is needed. Treatment can be initiated with intravenous, intravitreal, or oral ganciclovir formulations. Relapse is common with CMV retinitis, and if left untreated, it may progress to complete blindness.

Pearls

  1. Ocular complaints in HIV patients require a comprehensive eye examination along with ophthalmology involvement if lesions are observed or complaints are significant.

  2. Patients presenting with odynophagia or dysphagia may require esophagogastroduodenoscopy to evaluate for esophageal involvement of CMV (and to distinguish from other causes, like Candida). Those with severe immunosuppression, diarrhea, and CMV viremia may require colonoscopy.

FIGURE 20.25

Cytomegalovirus Retinitis. Funduscopic examination shows exudates and hemorrhages (“cottage cheese and ketchup” appearance) seen with CMV retinitis. (Photo contributor: Edward C. Oldfield III, MD.)

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