Bilateral Cytomegalovirus Retinitis in a Patient with Systemic Lupus Erythematosus

Abstract

Purpose: The purpose of this study was to report the case of a patient who underwent vitrectomy for bilateral rhegmatogenous retinal detachment caused by cytomegalovirus (CMV) retinitis while undergoing steroid and immunosuppressant therapy for systemic lupus erythematosus (SLE). Case Report: We report on a 29-year-old female who was undergoing steroids and immunosuppressants treatment for SLE at Osaka Medical College Hospital, Takatsuki City, Japan. Examination of the patient due to prolonged and worsening diarrhea revealed positive test results for C7-HRP, and she was diagnosed with CMV colitis. She was subsequently admitted to the hospital and started on intravenous ganciclovir for treatment. Approximately 1.5 months later, her primary complaint was deterioration of the upper visual field in her left eye, and she was then referred to the Department of Ophthalmology. Numerous granular exudative spots were found around the lower retinal area of her left eye with retinal breaks that had developed in an area of retinal necrosis that resulted in retinal detachment. After time was allowed for the patient’s general condition to improve, a vitrectomy was performed on that eye. The patient subsequently developed a similar retinal detachment in her right eye, for which she underwent a vitrectomy. Although the patient required multiple surgeries on both eyes, her retinas currently remain reattached and the inflammation has subsided. Conclusion: The findings of this study show that strict attention must be paid to SLE patients on immunosuppressive therapy due to the possible association of CMV retinitis.

Cytomegalovirus Retinal Necrosis With Occlusive Vasculopathy Secondary to Steroid Immunosuppression for Giant Cell Arteritis

“…form of CMV retinitis may also develop in patients with connective tissue diseases, including systemic lupus erythematosus and chronic rheumatoid arthritis in conjunction with steroid and immunosuppressant therapy. 9 Downes and colleagues reported that CMV retinitis occurred in 65.7% of patients on corticosteriods, which has been reported as the most common immunosuppressive medication associated with infection with this virus. 11 Within this disease spectrum, our current patient has similarities to the 5 patients whom Schneider and colleagues discussed, with relative limited immune dysfunction, who developed severe CMV necrotizing retinitis with panretinal obliterative vasculitis similar to the findings in ARN from HSV or VZV infections.…”

“…It establishes latency in mononuclear cells in the bone marrow and peripheral blood being controlled by the host's immune system, principally cellmediated immunity. 9 However, once the immune system of the host is either relatively or completely suppressed, the virus is able to spread, infect, and replicate in other tissues in the body, including the retina. In healthy individuals, cell-mediated immunity (CMI) suppresses the disease, whereas in severely immunocompromised patients, the lack of CMI leads to direct viral organ damage and uncontrolled viral replication.…”

“…In healthy individuals, cell-mediated immunity (CMI) suppresses the disease, whereas in severely immunocompromised patients, the lack of CMI leads to direct viral organ damage and uncontrolled viral replication. 9 In these cases of necrotizing retinitis with ischemic vasculitis, one hypothesis is that partially immunocompromised patients may have some CMV-specific CMI that limits viral spread but also causes direct specific T lymphocyte-induced tissue damage as seen in patients with HSV-or VZV-related ARN. 8 We report the first case of CMV retinitis in a patient with GCA on prednisone monotherapy.…”

“…8 Although seroprevalence of CMV antibodies is found in the majority of the adult population, CMV infections are uncommon in immunocompetent individuals. 9 As such, CMV retinitis is most commonly seen in patients with either secondary immunodeficiencies such as HIV/AIDS, primary immunodeficiencies, malignant tumors, or in patients who are immunocompromised because of immunosuppressant-based therapies used to prevent organ transplant rejection. 9 Recently, reports have identified atypical CMV acute retinal necrosis (ARN) infections in non-HIV patients with lesser degrees of immune dysfunction manifesting with severe occlusive arteritis.…”

“…9 As such, CMV retinitis is most commonly seen in patients with either secondary immunodeficiencies such as HIV/AIDS, primary immunodeficiencies, malignant tumors, or in patients who are immunocompromised because of immunosuppressant-based therapies used to prevent organ transplant rejection. 9 Recently, reports have identified atypical CMV acute retinal necrosis (ARN) infections in non-HIV patients with lesser degrees of immune dysfunction manifesting with severe occlusive arteritis. 8,10 Such a presentation may occasionally be seen in patients who have a relatively decreased cell-mediated immunity, including those with diabetes mellitus, advanced age, and noncytotoxic immunosuppressive medications.…”