Gabarin Nadia, Dadak Rohan, Roy Mili, Kaplan Alexander J, Haider Shariq, Khalaf Dina
Department of Medicine, Michael G. DeGroote School of Medicine McMaster University Hamilton Canada.
Department of Ophthalmology and Visual Sciences University of Toronto Toronto Canada.
Clin Case Rep. 2023 Mar 15;11(3):e7095. doi: 10.1002/ccr3.7095. eCollection 2023 Mar.
Cytomegalovirus (CMV) retinitis is an uncommon presentation post allogeneic transplant and can be vision-threatening. Our case demonstrates the occurrence of polymerase chain reaction (PCR) proven mixed viral retinitis (cytomegalovirus and varicella zoster virus) post allogeneic stem cell transplant despite multiple prophylactic antiviral therapies, including letermovir, and in the documented absence of CMV DNAemia. A 21-year-old female with acute myeloid leukemia presented with mixed viral retinitis (cytomegalovirus and varicella zoster virus) post allogenic transplant. This presentation occurred despite ongoing standard prophylaxis for both of these viruses, as well as following two courses of treatment for CMV viremia, with a documented negative CMV PCR in the blood prior to the presentation with retinitis. The patient was treated with intravenous ganciclovir and subsequently transitioned to oral valganciclovir with durable resolution of the retinitis. We report a rare case of mixed viral retinitis occurring despite multiple antiviral prophylaxes including letermovir and with PCR-documented absence of preceding CMV viremia, in a post-allogeneic stem cell transplant patient, with PCR of the aqueous fluid demonstrating two viral populations. With very little existing literature on either mixed viral retinitis or CMV retinitis during letermovir prophylaxis, this case expands the literature on both topics. CMV retinitis is an uncommon potentially vision threatening presentation post hematopoietic stem cell transplant, and can occur due to early CMV reactivation, low CD4 count, and delayed CD4 lymphocyte recovery. Letermovir has poor CNS and retinal penetration. This case highlights the need for more research on secondary prophylaxis with letermovir.
巨细胞病毒（CMV）视网膜炎是同种异体移植后一种不常见的表现，可能会威胁视力。我们的病例显示，在同种异体干细胞移植后，尽管采取了多种预防性抗病毒治疗，包括使用来特莫韦，且记录显示不存在CMV血症，但仍发生了聚合酶链反应（PCR）证实的混合病毒性视网膜炎（巨细胞病毒和水痘带状疱疹病毒）。一名21岁的急性髓系白血病女性在同种异体移植后出现了混合病毒性视网膜炎（巨细胞病毒和水痘带状疱疹病毒）。尽管对这两种病毒都进行了持续的标准预防，并且在出现视网膜炎之前针对CMV病毒血症进行了两个疗程的治疗，且血液中的CMV PCR记录为阴性，但仍出现了这种情况。患者接受了静脉注射更昔洛韦治疗，随后转为口服缬更昔洛韦，视网膜炎得到了持久缓解。我们报告了一例罕见的混合病毒性视网膜炎病例，该病例发生在一名同种异体干细胞移植患者身上，尽管采取了包括来特莫韦在内的多种抗病毒预防措施，且PCR记录显示之前不存在CMV病毒血症，房水PCR显示有两种病毒群体。由于关于来特莫韦预防期间混合病毒性视网膜炎或CMV视网膜炎的现有文献非常少，这个病例扩展了这两个主题的文献。CMV视网膜炎是造血干细胞移植后一种不常见的、可能威胁视力的表现，可能由于CMV早期重新激活、CD4计数低以及CD4淋巴细胞恢复延迟而发生。来特莫韦对中枢神经系统和视网膜的穿透力较差。这个病例凸显了对来特莫韦二级预防进行更多研究的必要性。
