Cytomegalovirus Retinitis after Intravitreal Bevacizumab Injection in an Immunocompetent Patient
A 61-year-old woman with well controlled diabetes visited our clinic in March 2009 for ocular pain and visual impairment of the left eye persisting for 2 weeks. In another clinic, she had been diagnosed with proliferative diabetic retinopathy of both eyes and cystoid macular edema of the left eye. She had received an inravitreal injection of bevacizumab (Genetech, San Francisco, CA, USA) in the left eye 3 weeks prior and panretinal photocoagulation in both eyes 2 weeks before her visit to our clinic. After treatment, she had used an anti-glaucoma agent because of increased intraocular pressure of the left eye.\nAt presentation, vision of the left eye was hand motion only. Slit lamp examination demonstrated 4+ cells and hyphema in the anterior chamber and iris neovascularization. Funduscopy revealed dense vitritis and retinal vascular obliteration. Ocular ischemia was suspected through fluorescein angiography which revealed arterial filling delay. No abnormal findings were observed in carotid Doppler sonography which was performed to rule out ocular ischemic syndrome. Examination of the right eye was unremarkable except diabetic retinopathy and scarring from panretinal photocoagulation. Further detailed examination was needed to draw the diagnosis and treatment plan but dense vitritis disturbed further evaluation. As a result, a pars plana vitrectomy was performed. During the vitrectomy, necrotizing retinitis with dense retinal whitening and hemorrhage along the inferotemporal vascular arcade was observed, suggestive of infectious retinitis (). The undiluted vitreous sample acquired by vitrectomy was analyzed by polymerase chain reaction (PCR; Q-CMV real time complete kit, Nanogen Advanced Diagnostics, Turin, Italy) and cultured for herpes simplex virus (HSV), varicellar zoster virus (VZV), and CMV. To rule out other etiologies of infectious retinitis, vitreous was also analyzed by staining and culture for bacteria and fungus.\nBlood tests did not show any immune dysfunction and complete blood count was normal. CD4 and CD8 cells counts were also within the normal range, 522 and 275 cells/µL. Human immunodeficiency virus (HIV) antigen and antibodies were negative. Her serum CMV IgG level was 244.5 units (range of nonreactive <6.0 AU/mL) and IgM was negative. Although the CMV antigenemia test showed positive results (9/20,000 cells) using the Biotest CMV Brite kit (Biotest Diagnostics, Denville, NJ, USA), there were no other clinical manifestations of CMV infection except retinitis.\nWhile the culture for CMV was negative, PCR for CMV DNA was positive in the vitreous and negative in peripheral blood, confirming the diagnosis as CMV retinitis. The others including HSV and VZV were negative in the vitreous and blood. Neither bacteria nor fungus were observed by staining and culture.\nThe patient underwent intravenous administration of ganciclovir (2.5 mg/kg/12 hr), a half dose reduction because of renal insufficiency. Necrotizing retinitis with retinal whitening and iris neovascularization had markedly decreased, but obliterated vessels were sustained without recovery of nonperfusion. After 17 days of administration, intravenous treatment was discontinued. During the follow-up period of 12 months, there has been no recurrence of retinitis, but her left eye could not perceive light because of optic nerve atrophy and retinal ischemia due to obliteration of retinal vessels.