Challenging cases discussed by experts retinal va

Authors: Thomas Albini Janet L Davis Claudio D Tuda

Publish Date: 2011/04/22

Volume: 1, Issue: 3, Pages: 89-93

PDF Link

Abstract

A 42yearold human immunodeficiency virus HIVinfected male on highly active antiretroviral therapy HAART was referred for new floaters in the left eye He was diagnosed with HIV 6 years prior when he presented with disseminated Kaposi’s sarcoma with lymph node involvement A year later he was diagnosed with human herpes virus 8 HHV8associated primary effusion lymphoma and successfully treated with 6 months of oral valganciclovir He had not sustained any opportunistic infections The most recent CD4 Tcell count was 720 cells/mm3 and the HIV viral load was undetectablePast medical history included a nonpruritic rash of the trunk 18 months prior to presentation associated with an RPR of 1128 Positron emission tomography–computed tomography showed diffuse lymphadenopathy Subsequent lymph node biopsy revealed reactive lymphadenitis thought to be secondary to syphilis He was treated twice with three weekly intramuscular injections of 24 million units of benzathine penicillin PCN over the subsequent yearA 42yearold HIVpositive male with recent onset floaters Segmental sheathing and beading of arterioles and venules extend most prominently along the superotemporal arcades in the right eye a In the left eye sheathing of the arteries and veins is most prominent along the inferotemporal arcade with peripapillary and intraretinal hemorrhage b Fluorescein angiography demonstrates normal arterial filling The venous filling is segmental and shows areas of perivenous hypofluorescence in the right eye c and left eye dAn evaluation for causes of retinal vasculitis revealed an RPR of 18 and a positive FTAABS Cytomegalovirus CMV IgG antibody varicella zoster virus VZV IgG herpes simplex virus HSV1 IgG HSV2 IgG and Epstein–Barr virus IgG antibodies were all present Quantitative PCR for Epstein Barr virus and CMV measured 12456 copies per milliliter and less than 200 copies per milliliter respectively Cardiolipin antibody was not present ANCA screen was negative ANA was positive with a titer of 180 in a speckled pattern and a titer of 140 in a nucleolar pattern Protein C and S activity were both normal The HLA B51 haplotype was present A brain MRI and MRA were both unremarkableIntravenous PCN sodium 24 million units daily was administered for 14 days Over the subsequent 6 months the RPR titer decreased to 14 One month following presentation he developed a vitreous hemorrhage in his left eye associated with retinal neovascularization and vasculitis Due to the progression of the eye disease a lumbar puncture was obtained which showed a clear cerebrospinal fluid CSF without pleocytosis CSF analysis including VDRL cytology flow cytometry and PCR for VZV and HSV was negativeSix weeks after presentation a diagnostic vitrectomy was performed in the left eye PCR for Mycobacterium tuberculosis HSV HHV8 toxoplasmosis VZV Epstein–Barr virus cytomegalovirus and Treponema pallidum were all negative Flow cytometry disclosed only 43 viable cells without any definable pattern

Keywords: