Patient Case: Cytomegalovirus (CMV) Infection
Chief Complaint: “I’ve been feeling extremely tired and have had blurry vision for the past few weeks.”
History of Present Illness:
A 45-year-old man presents with complaints of persistent fatigue, low-grade fever, and progressively worsening blurry vision in his left eye over the past three weeks. He also reports occasional headaches and mild muscle aches. He denies any recent travel or sick contacts but mentions that he has been experiencing frequent infections in the past year.
The patient has a history of HIV infection but has not been adherent to his antiretroviral therapy (ART) due to financial difficulties. He was diagnosed five years ago but has not had his CD4 count checked recently. He denies any nausea, vomiting, or significant weight loss but expresses concern about his declining energy levels and vision changes.
Physical Examination:
- Appears fatigued but is alert and oriented
- Low-grade fever (37.8°C)
- Mild cervical lymphadenopathy
- No skin rashes or oral lesions
- Ophthalmologic exam: White, fluffy retinal lesions with hemorrhages in the left eye (suggestive of CMV retinitis)
Diagnosis:
Given the patient's history of untreated HIV, progressive vision loss, and characteristic retinal findings, cytomegalovirus (CMV) infection is highly suspected, particularly CMV retinitis, which is a serious opportunistic infection seen in immunocompromised patients with advanced HIV/AIDS.
Management Plan:
- Confirmatory Testing: CMV PCR and fundoscopic exam to confirm CMV retinitis
- Antiviral Therapy: Initiation of intravenous ganciclovir or oral valganciclovir to control CMV infection
- HIV Management: Urgent re-initiation of antiretroviral therapy (ART) after managing the acute CMV infection
- Ophthalmology Consultation: Close monitoring to prevent retinal detachment and further vision loss
- Patient Education: Importance of ART adherence, CMV monitoring, and follow-up care
The patient is admitted for IV antiviral treatment and monitoring, with plans for a long-term ART regimen once the CMV infection is stabilized.
- What is the most likely risk factor for this patient’s CMV infection?
a) Recent travel to an endemic area
b) Long-term steroid use
c) Advanced HIV/AIDS with low CD4 count
d) Poor dietary habits - Which of the following is the most common ocular manifestation of CMV in HIV/AIDS patients?
a) Retinal detachment
b) CMV retinitis
c) Optic neuritis
d) Corneal ulceration - What is the best initial treatment for CMV retinitis in this patient?
a) Intravenous ganciclovir or oral valganciclovir
b) High-dose corticosteroids
c) Topical antibiotics
d) Immediate initiation of ART without antivirals - Why should ART be initiated cautiously after treating CMV retinitis?
a) To avoid viral resistance to ART
b) To prevent CMV transmission to others
c) To reduce the risk of immune reconstitution inflammatory syndrome (IRIS)
d) To prevent acute kidney injury from ART drugs
