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Clinical Manifestations of Cytomegalovirus-Associated Posterior Uveitis and Panuveitis in Patients Without Human Immunodeficiency Virus Infection

Kessara Pathanapitoon, MD, PhD; Nattaporn Tesavibul, MD; Pitipol Choopong, MD; Sutasinee Boonsopon, MD; Natedao Kongyai, PhD; Somsanguan Ausayakhun, MD; Paradee Kunavisarut, MD; Aniki Rothova, MD, PhD
JAMA Ophthalmol. 2013;131(5):638-645. doi:10.1001/jamaophthalmol.2013.2860.
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Importance Little attention has been paid to clinical features of cytomegalovirus (CMV) infections in individuals without human immunodeficiency virus (HIV).

Objective To describe the clinical manifestations and comorbidities of patients without HIV infection who have CMV-associated posterior uveitis or panuveitis.

Design and Setting Retrospective observational case series in an academic research setting.

Participants The medical records were reviewed of 18 patients (22 affected eyes) diagnosed as having posterior uveitis or panuveitis who had aqueous positive for CMV by polymerase chain reaction techniques.

Main Outcome Measures Demographic data, clinical manifestations, and associated systemic diseases were recorded.

Results Ocular features included focal hemorrhagic retinitis (n = 13) and peripheral retinal necrosis (n = 7). Two eyes had no focal retinal lesions but manifested vasculitis and vitritis. All patients exhibited vitreous inflammation. Inflammatory reactions in anterior segments developed in 14 of 22 eyes (64%). Retinal vasculitis was observed in 16 of 22 eyes (73%) and included mostly arteries (in 13 of 16 eyes [81%]). Eleven of 18 patients were taking immunosuppressive medications (5 for hematologic malignant diseases, 4 for systemic autoimmune diseases, and 2 following organ transplants). One additional patient was diagnosed as having non-Hodgkin lymphoma 3 months after the onset of CMV-associated panuveitis, and another patient had primary immunodeficiency disorder. Of the remaining 5 patients, 2 had diabetes mellitus, and 3 had no associated systemic diseases and exhibited no evidence of immune deficiency.

Conclusions and Relevance Cytomegalovirus-associated infections of posterior eye segments can develop in patients without HIV infection who have compromised immune function of variable severity but may occur also in individuals who have no evidence of immune insufficiency. Cytomegalovirus infections located in posterior eye segments in patients without HIV infection caused intraocular inflammatory reaction in all cases and demonstrated more variable clinical presentation than classic CMV retinitis observed in patients with HIV infection.

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Figure 1. Clinical presentation of cytomegalovirus-associated posterior uveitis and panuveitis in patients 4, 10, and 13 in Table 1. A and B, Cytomegalovirus-associated panuveitis in a 49-year-old woman (patient 4) who was seen with decreased vision in the left eye for 3 months. During the screening for uveitis, B-cell non-Hodgkin lymphoma was diagnosed. The anterior segment exhibited stellate keratic precipitates and endotheliitis; necrotic retinitis with hemorrhaging and vitritis were also observed. C, Cytomegalovirus-associated focal hemorrhagic retinitis in a 59-year-old man (patient 13) who had been receiving cyclophosphamide therapy for nephritis developed cytomegalovirus-associated unilateral posterior retinitis and vitritis. D and E, Cytomegalovirus-associated peripheral retinal necrosis and arteritis in a 54-year-old man (patient in 10) who had been receiving tacrolimus therapy after undergoing renal transplantation 3 years previously.

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Figure 2. Clinical presentation of cytomegalovirus-associated posterior uveitis and panuveitis in patients 5, 8, and 18 in Table 1. A, A 41-year-old healthy man (patient 18) without evidence of previous immunosuppression was seen with severe unilateral vitritis complicated by epiretinal membrane formation and retinal traction. After pars plana vitrectomy, severe vasculitis and sheathing became visible, but retinal lesions were not observed. B and C, A 59-year-old woman (patient 8) with non-Hodgkin lymphoma had been successfully treated with chemotherapy. She developed cytomegalovirus-associated unilateral peripheral retinal necrosis, areas of granular retinitis, and retinal arteritis 16 months after the diagnosis of non-Hodgkin lymphoma. D and E, A 50-year-old man (patient 5) with underlying non-Hodgkin lymphoma had been receiving repeated cycles of chemotherapy. He developed cytomegalovirus-associated panuveitis with focal retinitis and peripheral retinal necrosis, as well as frosted branch angiitis.




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