Xia Julia, Kantipudi Sanjana, Striebich Christopher C, Henao-Martinez Andrés F, Manoharan Niranjan, Palestine Alan G, Reddy Amit K
Department of Ophthalmology, University of Colorado School of Medicine, 1675 Aurora Court, F731, Aurora, CO, 80045, USA.
Division of Rheumatology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
J Ophthalmic Inflamm Infect. 2024 Oct 8;14(1):50. doi: 10.1186/s12348-024-00434-w.
Cytomegalovirus (CMV) chronic retinal necrosis (CRN) is a rare viral retinal infection that occurs in mildly immunocompromised people. It shares some features with both acute retinal necrosis and CMV retinitis. It is typically treated with combination intravitreal and systemic ganciclovir. We discuss the management of a case of CMV CRN with ganciclovir resistance.
An 80-year-old female presented with one month of blurry vision in the left eye. She was being treated with abatacept, methotrexate, and prednisone for rheumatoid arthritis. Examination revealed anterior chamber and vitreous cell along with peripheral retinal whitening. Fluorescein angiogram showed diffuse retinal non-perfusion. Aqueous fluid PCR testing returned positive for CMV. The retinitis was initially controlled with oral and intravitreal ganciclovir, but then recurred and progressed despite these therapies. Ganciclovir resistance was suspected and the patient was switched to intravitreal foscarnet injections, along with oral letermovir and leflunomide, which lead to resolution of the retinitis. The patient has now continued with letermovir and leflunomide for approximately 2.5 years without reactivation of the retinitis or need for further intravitreal anti-viral injections and with adequate control of her rheumatoid arthritis.
The incidence of CMV CRN may increase in the future as the use of non-cytotoxic immunosuppressive therapies that result in relatively mild immunosuppression also increases. Treatment with ganciclovir is effective but frequently leads to resistance, as in our case. In this situation, combination therapy with letermovir and leflunomide, particularly in the setting of rheumatoid arthritis where leflunomide can also have an anti-inflammatory effect, can be considered.
巨细胞病毒（CMV）慢性视网膜坏死（CRN）是一种罕见的病毒性视网膜感染，发生于轻度免疫功能低下的人群。它兼具急性视网膜坏死和CMV视网膜炎的一些特征。通常采用玻璃体内注射和全身使用更昔洛韦联合治疗。我们讨论一例对更昔洛韦耐药的CMV CRN病例的治疗。
一名80岁女性因左眼视力模糊1个月就诊。她正在接受阿巴西普、甲氨蝶呤和泼尼松治疗类风湿关节炎。检查发现前房和玻璃体有细胞浸润，周边视网膜变白。荧光素血管造影显示视网膜弥漫性无灌注。房水PCR检测CMV呈阳性。视网膜炎最初通过口服和玻璃体内注射更昔洛韦得到控制，但尽管进行了这些治疗，仍复发并进展。怀疑更昔洛韦耐药，患者改为玻璃体内注射膦甲酸钠，同时口服来特莫韦和来氟米特，视网膜炎得到缓解。患者现已持续使用来特莫韦和来氟米特约2.5年，视网膜炎未复发，无需进一步玻璃体内抗病毒注射，类风湿关节炎也得到充分控制。
随着导致相对轻度免疫抑制的非细胞毒性免疫抑制疗法的使用增加，CMV CRN的发病率未来可能会上升。如我们的病例所示，更昔洛韦治疗有效，但常导致耐药。在这种情况下，可以考虑来特莫韦和来氟米特联合治疗，特别是在类风湿关节炎的背景下，来氟米特还具有抗炎作用。
