CMV Retinitis After Initiation of Antiretroviral Therapy in Patients With AIDS
American Journal of Ophthalmology, February 2017
Cytomegalovirus (CMV) retinitis is a common ocular opportunistic infection in patients with AIDS. Jabs et al. sought to determine the rates of new-onset and worsening CMV after patients with AIDS start combination antiretroviral therapy (cART). The likelihood of an immune reconstitution inflammatory syndrome (IRIS) also was explored. The authors found no increase in new-onset or worsening CMV in the initial months of therapy and noted that “immune recovery retinitis” (IRR), a previously proposed phenomenon, appears to be rare.
This observational study included participants in the Longitudinal Study of Ocular Complications of AIDS (LSOCA) who initiated cART after enrollment in LSOCA and whose CD4+ T-cell count was <100 cells/μL when cART was initiated (106 without CMV retinitis, 52 with CMV retinitis). Of the 106 patients without CMV retinitis, 75 experienced immune recovery (defined as an increase in CD4+ T-cell count to ≥100 cells/μL). Within 6 months of starting cART, CMV retinitis occurred in 1 of these patients and in 1 of the 31 patients who did not have immune recovery. Among patients with CMV retinitis at enrollment, the rates of retinitis progression and increasing border activity in the first 6 months of cART were 0.11 per person-year (PY) and 0.11 per PY, respectively, for those with immune recovery. For those without immune recovery, the respective rates were 0.67 per PY and 0.40 per PY.
Clinical assessments corroborated the expected overall reduction in retinitis and mortality associated with immune recovery. Event rates were consistently higher for patients who did not have immune recovery. Animal models of infectious retinitis suggest that vitritis and retinal vascular sheathing may be inflammatory responses to an antigen but that retinitis per se requires replicating organisms. Therefore, IRR would be unlikely to occur as an IRIS phenomenon.
In conclusion, the rate of new or worsening CMV retinitis in the first 3 to 6 months of cART is no higher for persons with AIDS who experience immune recovery than for those who do not. These findings are consistent with the known benefits of immune recovery and the 3- to 6-month lag in recovery of specific immunity to CMV after initiation of cART.
The original article can be found here.