HIV Retinopathy

11,233 views

Published on

HIV Retinopathy

1 Comment
5 Likes
Statistics
Notes
  • Really? Most of hiv personals didn't hear of this. One of my friend said it was the first time he know this after I posted this news on our blog page on stdpal.com.
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total views
11,233
On SlideShare
0
From Embeds
0
Number of Embeds
73
Actions
Shares
0
Downloads
711
Comments
1
Likes
5
Embeds 0
No embeds

No notes for slide

HIV Retinopathy

  1. 1. Grand Rounds Michael Rubin, MD Department of Ophthalmology and Visual Science The University of Chicago 2587840
  2. 2. November 25, 2003 <ul><li>40 y/o M presents for retinal evaluation. </li></ul><ul><li>Referred by Dr. Pitrak because pt newly diagnosed with HIV (CD4 168) </li></ul><ul><li>PMH: HIV x 1 month </li></ul><ul><li>Meds: Paxil, Bactrim </li></ul><ul><li>VA: 20/25 20/30 </li></ul><ul><li>Exam: Unremarkable </li></ul>
  3. 3. April 26, 2005 <ul><li>Pt presents to ER Service with pressure, pain, and clear discharge both eyes. </li></ul><ul><li>VA CC: 20/20 20/40 </li></ul><ul><li>VA RX: 20/20 20/25 </li></ul>
  4. 4. Exam <ul><li>IOP: 16 and 14 </li></ul><ul><li>Anterior Exam: </li></ul><ul><li>Right: 2+ injection / KPs / 4 + Cell and Flare </li></ul><ul><li>Left: 2 + injection / PEK / D&Q </li></ul><ul><li>Posterior Exam: </li></ul><ul><li>Unremarkable </li></ul>
  5. 5. Treatment <ul><li>Started on PF QID OU and HA BID OU </li></ul><ul><li>F/U 3 days </li></ul>
  6. 6. April 29, 2005 <ul><li>Pt seen by Dr. Yeh in ER Clinic </li></ul><ul><li>Pt “doing better.” </li></ul><ul><li>VA CC: 20/20 20/25 </li></ul>
  7. 7. Exam <ul><li>IOP: 15 and 15 </li></ul><ul><li>Anterior Exam: </li></ul><ul><li>Right: 2+ injection / KPs / 4 + Cell and Flare </li></ul><ul><li>Left: 2 + injection / PEK / tr Cell and Flare </li></ul><ul><li>Posterior Exam: </li></ul><ul><li>Unremarkable </li></ul>
  8. 8. Treatment <ul><li>Cont PF QID R, decrease PF to TID L, Cont HA Bid, f/u with ER Service on 5/3 </li></ul>
  9. 9. May 3, 2005 <ul><li>Patient states he is doing better </li></ul><ul><li>VA: 20/20 20/25 </li></ul><ul><li>Exam: </li></ul><ul><li>Trace cell right, quiet left </li></ul><ul><li>Taper PF to BID RE, QD LE </li></ul><ul><li>F/U 2 weeks </li></ul>
  10. 10. May 17 and 31, 2005 <ul><li>Eyes quieted down, VA remained the same, tapered off of PF. </li></ul>
  11. 11. June 14, 2005 <ul><li>Patient presents to Dr. Rezaei with “severe vision loss in the right eye.” </li></ul><ul><li>VA: CF at 2ft 20/25 </li></ul>
  12. 12. Thoughts? <ul><li>Differential Diagnosis… </li></ul>
  13. 13. History <ul><li>PMH: HIV with CD4 of 250 and HIV RNA less than 75 </li></ul><ul><li>Meds: Sustiva 600/1, AZT 300/2, Abacavir 300/2, Lamivudine 150/2, Paxil 20/1 </li></ul><ul><li>All: NKDA </li></ul><ul><li>FH: N/C </li></ul><ul><li>SH: Grad student, former heavy ETOH use, No tobacco or IVDA use </li></ul>
  14. 14. EXAM <ul><li>Anterior </li></ul><ul><li>Right: D4 C1 F1 </li></ul><ul><li>Left: Normal </li></ul><ul><li>Posterior: See Fundus Photo </li></ul>
  15. 15. Photo Montage
  16. 16. Right Eye
  17. 17. Right Eye Peripheral View
  18. 18. Left Eye
  19. 19. Next Step… <ul><li>What do you want to do now? </li></ul>
  20. 20. Right Eye
  21. 21. LE
  22. 22. FANG LE
  23. 23. Right
  24. 24. Right Eye
  25. 25. Treatment?
  26. 26. Treatment Rendered <ul><li>IV Acyclovir 600 mg IV q8 hours then PO for total of 10 days </li></ul><ul><li>Pred Forte 1% q6 hours </li></ul><ul><li>HA BID </li></ul>
  27. 27. Labs?
  28. 28. Labs <ul><li>WBC: 4.5 </li></ul><ul><li>H/H: 14.3/42.0 </li></ul><ul><li>PLT: 227 </li></ul>
  29. 29. RPR <ul><li>RPR 512 ( < 1) </li></ul><ul><li>Treponema IFA: Positive </li></ul>
  30. 30. Spinal Tap <ul><li>App: Clear </li></ul><ul><li>Cells: 20 </li></ul><ul><li>WBC: 13 </li></ul><ul><li>Glc 57 (50-70) </li></ul><ul><li>Protein 51 (15-45) </li></ul><ul><li>VDRL CSF NR </li></ul>
  31. 31. Spinal Tap Viral Load <ul><li>VDRL CSF 8 ( <1) </li></ul><ul><li>HSV and VZV PCR for CSF Negative </li></ul>
  32. 32. <ul><li>CD 4 306 </li></ul>
  33. 33. Further Treatment <ul><li>Penicillin G 4 million units IV q4 for 10 days </li></ul>
  34. 34. Right Eye After Treatment
  35. 35. Left Eye After Treatment
  36. 36. Demographics <ul><li>More than 900,000 individuals are infected with HIV in the US, and close to 30 million individuals carry the virus worldwide. Among the individuals infected with HIV, approximately 70-80% will be treated for an HIV-associated eye disorder during the course of the illness. </li></ul>
  37. 37. CD 4 Counts… <ul><li>What diseases do you see at CD4: </li></ul><ul><li>< 500: </li></ul><ul><li>< 250: </li></ul><ul><li><100: </li></ul>
  38. 38. CD 4 Counts <ul><li>In general, CD4+ T-lymphocyte count has been used to predict the onset of certain ocular infections in patients who are HIV positive. </li></ul><ul><li>CD4+ T-cell count less than 500 cells/mm3 is associated with Kaposi sarcoma, lymphoma, and tuberculosis </li></ul><ul><li>CD4+ T-cell count less than 250 cells/mm3 is associated with pneumocystosis and toxoplasmosis </li></ul><ul><li>CD4+ T-cell count less than 100 cells/mm3 is associated with retinal or conjunctival microvasculopathy, cytomegalovirus (CMV) retinitis, varicella-zoster virus (VZV) retinitis, mycobacterium avium complex infection, cryptococcosis, microsporidiosis, HIV encephalopathy, and progressive multifocal leukoencephalopathy. </li></ul>
  39. 39. HZO <ul><li>Background: HZO is a painful vesiculobullous dermatitis, which results mostly from the reactivation of previously established primary VZV infection. </li></ul><ul><li>20% of adults with primary infection eventually show clinical symptoms. </li></ul><ul><li>Clinical manifestation usually begins as pain over the involved dermatome, most commonly the first division of trigeminal nerve (V1), lasting for several days, followed by dermatitis in the form of vesicular rash. </li></ul><ul><li>Herpes zoster can involve any dermatome, particularly T3 to L3 and cranial V1 (most common), V2, and V3. When the ophthalmic division is affected with or without ocular involvement, it is referred to as HZO. </li></ul>
  40. 40. Pathopysiology of HZO <ul><li>Pathophysiology: HZO results from the reactivation of latent VZV from a previous primary infection that subsequently travels down the involved nerve; the most common nerve involved is the first division of cranial nerve V (trigeminal nerve). </li></ul>
  41. 41. Frequency <ul><li>HZO affects about 5-15% of patients who are infected with HIV. </li></ul>
  42. 42. Iridocyclitis <ul><li>Background: Iridocyclitis in patients who are HIV positive tends to be mild and often is associated with retinitis due to CMV or VZV. </li></ul><ul><li>When iridocyclitis is severe, it usually is seen in association with ocular toxoplasmosis, tuberculosis, syphilis, or bacterial or fungal retinitis (rare). Other causes of iridocyclitis in HIV-positive patients include medications (eg, rifabutin, cidofovir). </li></ul>
  43. 43. Posterior Findings <ul><li>Disorders of the posterior segment are seen in more than 50% of patients who are HIV positive. </li></ul><ul><li>Common presenting complaints include floaters, flashing lights, visual field defect, and decreased visual acuity. </li></ul>
  44. 44. Second Years… <ul><li>What is the most common retinal pathology in patients who are HIV positive? </li></ul><ul><li>How does it present? </li></ul><ul><li>What is the underlying pathophysiology? </li></ul>
  45. 45. HIV Retinopathy <ul><li>Background: This is the most common retinal pathology in patients who are HIV positive, often manifesting as cotton-wool spots. </li></ul><ul><li>Pathophysiology: The cause of retinal microvasculopathy in patients who are infected with HIV is similar to those suggested for conjunctival vascular changes; increased plasma viscosity, immune-complex deposition, and a direct cytopathic effect of the virus on the retinal vascular endothelium are believed to be involved. The arteriolar occlusion in HIV microvasculopathy leads to interruption of the axoplasmic flow, which manifests as cotton-wool spots. </li></ul><ul><li>Frequency: HIV retinal microvasculopathy occurs in as many as 50-70% of patients who are HIV positive. </li></ul>
  46. 46. HIV-Related Retinochoroiditis <ul><li>Background: Viral retinitis and/or choroiditis is the most common cause of infectious retinitis and/or choroiditis. The herpesvirus family is implicated most commonly in infections of the retina and/or choroid in patients who are HIV positive. </li></ul><ul><li>CMV is the most common cause of necrotizing retinitis in patients who are HIV positive. VZV and HSV may cause acute retinal necrosis (ARN), with VZV as a more common cause of such necrotizing retinitis. This necrotizing retinitis may be unilateral or bilateral. Another form of necrotizing retinitis, progressive outer retinal necrosis (PORN), may occur in advanced HIV disease. To date, VZV is the only organism associated with PORN. </li></ul>
  47. 47. Bacterial Causes <ul><li>Common bacterial causes of retinitis in patients who are HIV positive include Treponema pallidum (syphilis) and Mycobacterium tuberculosis . </li></ul><ul><li>Fungal causes of retinitis and/or choroiditis include Pseudallescheria boydii, Cryptococcus neoformans, Histoplasma capsulatum , as well as Candida, Sporothrix, and Aspergillus species. Parasitic causes include Toxoplasma gondii and Pneumocystis carinii. </li></ul>
  48. 48. Acute Retinal Necrosis <ul><li>Background: ARN is a fulminant retinal vaso-occlusive necrotizing retinitis that may complicate VZV, HSV, or, rarely, CMV infections. HIV-positive patients with ARN tend to have a CD4+ count greater than 60 cells/mL, usually with an associated history of VZV or HSV dermatitis. </li></ul><ul><li>Frequency: Incidence of VZV-associated retinitis after HZO in patients who are HIV positive is 4-17%. For retinitis following HSV or CMV infections, the frequencies are much lower compared to the VZV-associated retinitis. A 2:1 male-to-female predilection with the occurrence of ARN exists. </li></ul>
  49. 49. Progressive Outer Retinal Necrosis <ul><li>Background: PORN is a rapidly progressive, necrotizing retinitis that has been reported in patients with advanced AIDS. PORN is associated with a history of VZV infection in patients with AIDS. </li></ul><ul><li>Pathophysiology: While the exact pathophysiologic mechanism for PORN has not been elucidated completely, the general consensus is that severe immunocompromise along with a previous infection with at least VZV infection are necessary. PORN also has been described in patients with severe immunocompromise secondary to chemotherapy. </li></ul><ul><li>Frequency: Incidence of PORN is much lower than ARN. </li></ul>
  50. 50. ARN <ul><li>Acute retinal necrosis: Patients with ARN usually present with eye pain associated with decreased visual acuity, floaters, and history of recent HSV or HZV infection. In early disease, funduscopic examination often reveals small, necrotic yellowish lesions in the periphery, which rapidly spread into a larger confluent white area, most often involving the entire peripheral retina, and then progress toward the posterior pole. In about 36% of cases, the second eye is involved. Associated anterior uveitis, retinal vasculitis, episcleritis, scleritis, or retinal detachment may be present. </li></ul>
  51. 51. Complications of ARN <ul><li>Acute retinal necrosis: ARN frequently is complicated by anterior uveitis, retinal and choroidal vasculitis, vitritis, and papillitis. Episcleritis, scleritis, or optic neuropathy also may be present. </li></ul><ul><li>During the initial phase of the infection, the severity of the retinitis could lead to exudative retinal detachment. However, following the resolution of the retinitis, traction between the vitreous and the resulting gliotic scar of the necrotic retina may occur and can cause retinal breaks at the interface between the normal and necrotic retina. Subsequently, this may result in RRD. As many as 75% of eyes affected by ARN may be complicated by RRD after 2-3 months of onset. </li></ul>
  52. 52. PORN <ul><li>Progressive outer retinal necrosis: Patients with PORN usually present with minimal anterior chamber inflammation, with no vitritis or retinal vasculitis. In general, the lesions in PORN usually are multifocal, deep to the retina, opaque, and patchy, with a tendency to start from the posterior pole and spread with extreme rapidity to involve the entire retina. </li></ul>
  53. 53. Complications of PORN <ul><li>Complications of PORN may include macular retinitis, optic nerve disease, acute vitreous hemorrhage, and/or retinal detachment. Up to 66% of patients diagnosed with PORN eventually become blind within 6 weeks of diagnosis despite aggressive treatment. </li></ul>
  54. 54. Labs for PORN and ARN <ul><li>Acute retinal necrosis </li></ul><ul><ul><li>Perform a detailed history and a complete ophthalmologic examination with dilated funduscopic examination for diagnosis of ARN. </li></ul></ul><ul><ul><li>Check for HSV-1, HSV-2, and CMV IgG and IgM titers. </li></ul></ul><ul><li>Progressive outer retinal necrosis </li></ul><ul><ul><li>Workup of PORN is similar to ARN, except that the serology focuses on HZV IgG and IgM titers. </li></ul></ul><ul><ul><li>See ARN for details. </li></ul></ul>
  55. 55. Treatment for ARN / PORN <ul><li>Start acyclovir 5-10 mg/kg/d IV in 3 divided doses for 1 week, then change to oral acyclovir 800 mg 5 times daily for the following 1-2 months. Monitor blood urea nitrogen and creatine levels because of the nephrotoxic effect of acyclovir. </li></ul><ul><li>Start a slow tapering dosage of prednisone 60-100 mg PO daily 24 hours after starting acyclovir, continue for about 1-2 months. Be sure to obtain a chest x-ray and PPD before starting the oral steroid. </li></ul><ul><li>A topical steroid, such as prednisolone acetate 1%, instilled q2-6h, and a cycloplegic agent, such as homatropine 5% instilled 2-3 times daily. </li></ul><ul><li>Add Zantac 150 mg PO twice daily for steroid-induced gastritis. </li></ul><ul><li>In fulminate cases, particularly in HIV-positive patients, IV or intravitreal ganciclovir and/or foscarnet, or intravenous cidofovir may be considered (see CMV for dosage). </li></ul><ul><li>Use of retinal laser photocoagulation to surround the necrotic lesion is still controversial. </li></ul><ul><li>For retinal detachment, vitrectomy, membranectomy, endolaser, and silicone oil infusion usually is required. </li></ul>
  56. 56. Intravitreal Antivirals in the Management of Patients With Acquired Immunodeficiency Syndrome With Progressive Outer Retinal Necrosis
  57. 57. Syphilis <ul><li>Pathophysiology: Syphilis is believed to result from the proliferation and subsequent infiltration of T pallidum spirochetes into ocular structures. Histologic evaluation demonstrates mononuclear and polymorphonuclear cell infiltration of the involved ocular tissue, particularly cornea, iris, retina, and choroid. </li></ul><ul><li>Frequency: Incidence of syphilis has been on the rise since 1985, with 25% of the new cases reported from 1986-1987. This rise in the number of new cases of syphilis was correlated to a shift from heterosexual to homosexual and bisexual males who constitute approximately 30-40% of all the new cases. Usually a 5% rate of ocular involvement in untreated cases occurs with rare ocular involvement within 6 months of primary infection. </li></ul>
  58. 58. Syphilis <ul><li>Syphilis: The presentation of the patient depends on the stage of the disease. The ocular findings in syphilis can mimic any ocular inflammatory disorder, including conjunctivitis, interstitial keratitis, episcleritis, scleritis, choroiditis, vascular occlusion, Argyll-Robertson pupil, Raeder syndrome, cranial nerve palsies, optic neuritis, and optic atrophy. Most of the ocular findings are seen in stage 2 (secondary) and stage 3 (tertiary). Initial presentation of ocular syphilis is unilateral with subsequent contralateral eye involvement in 50% of cases. </li></ul>
  59. 59. Stages <ul><li>Primary - Eyelid or conjunctival chancre </li></ul><ul><li>Secondary or tertiary - Iridocyclitis or more diffuse intraocular inflammation is present. Other manifestations of secondary and/or tertiary syphilis include optic neuritis, active chorioretinitis, retinitis, retinal vasculitis, conjunctivitis, episcleritis dacryoadenitis, dacryocystitis, scleritis, and monocular interstitial keratitis. Dissemination of the disease in secondary syphilis may be accompanied by arthralgia, headache, low-grade fever, and maculopapular rash. Three distinct patterns of iris findings may be seen prior or during the active stage of the disease, as follows: (1) iris roseata in which reddish spots or engorged vascular tufts that resolve with treatment are present, (2) iris papulosa in which the roseata spots increase in size to resemble a papule, and (3) iris nodosa in which the area of iris lesion forms a large yellow-red nodule. </li></ul>
  60. 60. Tertiary <ul><li>Tertiary - Inadequately treated syphilis or untreated disease sets the stage for tertiary syphilis, which includes the development of an obliterative endarteritis in about one third of the patients. Optic atrophy, chorioretinitis, chronic iritis, Argyll-Robertson pupil also are seen in this stage. </li></ul>
  61. 61. Labs for Syphilis <ul><li>Syphilis </li></ul><ul><ul><li>The VDRL becomes positive 1-3 weeks after the appearance of the chancre. </li></ul></ul><ul><ul><li>Fluorescent treponemal antibody absorption (FTA-ABS) test or microhemagglutination Treponema pallidum (MHA-TP) is highly sensitive and specific in all stages of syphilis. Once reactive, these tests do not reverse to normal, and they are not helpful in assessing the patient's response to treatment. </li></ul></ul><ul><ul><li>Lumbar puncture (LP) may be performed if the FTA-ABS test is positive combined with neurologic or neuro-ophthalmologic signs, papillitis, active chorioretinitis, or uveitis. </li></ul></ul><ul><ul><li>Diagnoses of ocular syphilis should include obtaining a specific treponemal-antibody assay (FTA-ABS or MHA-TP) and nonspecific treponemal-antibody assay (Venereal Disease Research Laboratory [VDRL] test or rapid plasma reagin [RPR]). VDRL or RPR correlates with disease activity, and it is useful in monitoring response to treatment. It also is used for screening, but it may show a false-negative result in early primary, latent, or late syphilis. It is not as specific as FTA-ABS or MHA-TP. </li></ul></ul>
  62. 62. Treatment for Syphilis <ul><li>All HIV-positive patients with syphilitic eye findings are considered to have tertiary syphilis and are treated accordingly. </li></ul><ul><li>Treatment of syphilis is with intravenous penicillin G (24 million U/d for 7-10 d). Relapse may occur in spite of adequate treatment. For penicillin-allergic patients, tetracycline 500 mg 4 times per day or doxycycline 200 mg twice a day by mouth for 30 days or a third-generation cephalosporin (ceftriaxone). </li></ul><ul><li>Cycloplegia with either cyclopentolate 2% or homatropine 5% 3 tid and prednisolone acetate 1% qid is recommended if anterior segment inflammation is present. </li></ul>
  63. 63. Financial Considerations <ul><li>Initial visit: $160 </li></ul><ul><li>Follow up visit x 3: $103 x 3 = $309 </li></ul><ul><li>Yet to collect </li></ul>
  64. 64. Cost of Lumbar Puncture <ul><li>Lumbar Puncture Dx (CPT 62270): $ 600 </li></ul><ul><li>Labs Associated with LP: $740 </li></ul><ul><li>Yet to collect </li></ul>
  65. 65. Inpatient billing <ul><li>Inpatient Billed: $2389.00 x 3 = $7267 </li></ul><ul><li>Insurance Pays: $1433.40 x 3 = $4300.20 </li></ul>
  66. 66. Practice Based Learning <ul><li>1. Ocular inflammation in a patient with HIV merits consideration of a broader differential diagnosis. </li></ul><ul><li>2. Multiple diseases processes could be implicated in HIV related chorioretinopathy. </li></ul><ul><li>3. Laboratory evaluation early in the course of the ophthalmic disease process may minimize morbidity. </li></ul>
  67. 67. ARN

×