Torriani F J, Freeman W R, Macdonald J C, Karavellas M P, Durand D M, Jeffrey D D, Meylan P R, Schrier R D
Department of Medicine, University of California, San Diego, USA.
AIDS. 2000 Jan 28;14(2):173-80. doi: 10.1097/00002030-200001280-00013.
To determine predictors of clinical relapse of cytomegalovirus (CMV) end-organ disease in a cohort of 17 HIV-infected patients with healed and treated CMV retinitis (CMVR) who responded to HAART with an increase in CD4 cell counts to above 70 cells/mm3 and discontinued CMV maintenance therapy (MT).
Seventeen patients were monitored for reactivation of retinitis. The CD4 cell counts, HIV RNA and peripheral blood mononuclear cell (PBMC) lymphoproliferative assays to CMV at 3 month intervals were compared between patients with and without reactivation of CMVR. Positive lymphoproliferative responses were defined as a stimulation index of 3 or greater.
Five out of 17 (29%) patients experienced a recurrence of CMVR a mean of 14.5 months after stopping CMV MT and between 8 days and 10 months after CD4 cell counts fell below 50 cells/mm3. Median CD4 cell counts and plasma HIV RNA at reactivation were 37 cells/mm3 and 5.3 log10 copies/ml. Three patients recurred at a previously active site of the retina, one had contralateral CMVR, and one a recurrence of retinitis and pancreatitis simultaneously. Mean lymphoproliferative responses to CMV were 2.4 in patients with reactivation versus 21.0 stimulation index (SI) in patients without reactivation (P= 0.01). A model incorporating four variables (CD4 cell counts and HIV RNA at maintenance discontinuation, highest CD4 cell count, nadir HIV RNA and median lymphoproliferative responses) identified correctly 88% of patients with and without reactivation.
CMV disease recurs after virological and immunological failure of HAART if CD4 cell counts drop below 50. In this situation, anti-CMV agents should be resumed before clinical reactivation ensues, because of the risk of contralateral retinal involvement and systemic disease.
在一组17例感染HIV且巨细胞病毒（CMV）视网膜炎（CMVR）已治愈并接受治疗的患者中，确定CMV终末器官疾病临床复发的预测因素。这些患者对高效抗逆转录病毒治疗（HAART）有反应，CD4细胞计数增加至70个细胞/mm³以上，并停止了CMV维持治疗（MT）。
对17例患者进行视网膜炎再激活监测。比较有和没有CMVR再激活的患者每隔3个月的CD4细胞计数、HIV RNA以及外周血单个核细胞（PBMC）对CMV的淋巴细胞增殖试验结果。阳性淋巴细胞增殖反应定义为刺激指数为3或更高。
17例患者中有5例（29%）在停止CMV MT后平均14.5个月，且在CD4细胞计数降至50个细胞/mm³以下的8天至10个月后出现CMVR复发。复发时CD4细胞计数中位数和血浆HIV RNA分别为37个细胞/mm³和5.3 log10拷贝/ml。3例患者在视网膜先前的活动部位复发，1例出现对侧CMVR，1例同时出现视网膜炎和胰腺炎复发。复发患者对CMV的平均淋巴细胞增殖反应为2.4，而未复发患者的刺激指数（SI）为21.0（P = 0.01）。一个包含四个变量（停止维持治疗时的CD4细胞计数和HIV RNA、最高CD4细胞计数、HIV RNA最低点以及淋巴细胞增殖反应中位数）的模型正确识别了88%有或没有复发的患者。
如果CD4细胞计数降至50以下，HAART出现病毒学和免疫学失败后CMV疾病会复发。在这种情况下，由于存在对侧视网膜受累和全身性疾病的风险，应在临床再激活发生之前恢复抗CMV药物治疗。
