A 47-year-old Hispanic female with untreated human immunodeficiency virus (HIV) presented with decreased vision and floaters in her left eye for 1-week duration. She was diagnosed with both HIV and type II diabetes mellitus 4 months prior. On ophthalmic examination, best-corrected visual acuity was 20/25 in the right eye and 20/60 in the left eye. The anterior chambers were deep and quiet, and the intraocular pressures were 18 mm Hg in both eyes. A few inflammatory cells were present in the vitreous of the left eye. Funduscopic examination revealed moderate non-proliferative diabetic retinopathy in both eyes and an advancing border of white granular retinitis surrounding the inferior and temporal macula of the left eye. Kyrieleis plaques were present on the retinal arteries without any significant sheathing or involvement of the retinal veins (Fig. 1a). Fluorescein angiography had normal retinal arterial filling with multiple hyperfluorescent microaneurysms and retinal pigment epithelial window defects peripheral to the leading edge of retinitis. Kyrieleis plaques seen on funduscopic examination did not leak or have significant late staining of fluorescein dye (Fig. 1b).
Laboratory evaluation revealed an elevated serum CMV IgG antibody with a negative systemic work up for T. gondii, VZV, herpes simplex virus (HSV), T. pallidum, and tuberculosis. CD4 T cell count was 55 cells/μL, and HIV viral load was 193,065 copies/ml. Polymerase chain reaction of the aqueous was positive for CMV DNA (420,000 copies/ml) and negative for HSV and T. gondii DNA.
The CMV retinitis was treated with intravitreal injections of foscarnet sodium and oral valganciclovir. The patient was also started on HAART, antiglycemic therapy, azithromycin for Mycobacterium avium complex prophylaxis, and atovaquone for Pneumocystis jiroveci pneumonia prophylaxis. Over the first 6 weeks as the retinitis resolved, the Kyrieleis plaques increased in number and become confluent along parts of the retinal arteries (Fig. 2). The Kyrieleis plaques subsequently faded over the next few months with a few persisting adjacent to the optic nerve at 5 months (Fig. 3). On follow-up, the CD4 T cell count increased to 305 cells/μL, and the HIV viral load became undetectable. Despite resolution of the retinitis, vision in the left eye decreased to 20/100, complicated by immune recovery uveitis and macular edema.