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Progression of varicella-zoster virus necrotizing retinopathy in an HIV-negative patient with transient immune deviation

  • Wee-Kiak Lim
  • Soon-Phaik Chee
  • Robert Burton Nussenblatt
Short Communication

Abstract

Purpose

To report a case of unilateral varicella-zoster virus (VZV) necrotizing retinopathy that progressed from outer retinitis with features of progressive outer retinal necrosis (PORN) to typical acute retinal necrosis (ARN) in an HIV-negative patient with a transient decrease in CD4 lymphocyte counts and CD4/CD8 ratio.

Method

Case report.

Results

A 41-year-old Chinese man presenting with blurred vision in the right eye was diagnosed with herpetic necrotizing retinitis without vitritis. Fundus examination revealed retinal arteritis and extensive deep whitish retinal lesions in the mid-periphery with minimal vitritis. Aqueous humor and vitreous PCR were positive for VZV. His CD4 count on presentation was depressed (239 cells/ul) and the CD4/CD8 ratio was low (0.8). The referring ophthalmologist had treated him with prednisolone 60 mg/day. At our institution, when intravenous acyclovir was started and the steroid therapy discontinued, he developed severe vitritis and the deep retinal lesions progressed to full-thickness retinitis typical of ARN. Repeat CD4 count was 512 cells/ul at day 14. In total, he was treated with 14 days of IV acyclovir (12 mg/kg 8-hourly) followed by oral valaciclovir 500 mg three times a day for 3 months. Prednisolone 30 mg once daily was restarted and tapered over 3 months. Despite prophylactic argon retinal photocoagulation to the edge of the retinitis, the patient developed a total retinal detachment at 3 months.

Conclusions

VZV retinal infection in an HIV-negative patient with transient immune deviation can manifest initially as outer retinitis with features similar to PORN and progress to typical ARN when CD4 counts return to normal.

Keywords

Human Immunodeficiency Virus Retinal Detachment Retinitis Human Immunodeficiency Virus Patient Valaciclovir 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Abendroth A, Arvin A (2001) Immune evasion mechanisms of varicella-zoster virus. Arch Virol Suppl 17:99–107Google Scholar
  2. 2.
    Engstrom RE Jr, Holland GN, Margolis TP, Muccioli C, Lindley JI, Belfort R Jr, Holland SP, Johnston WH, Wolitz RA, Kreiger AE (1994) The progressive outer retinal necrosis syndrome. A variant of necrotizing herpetic retinopathy in patients with AIDS. Ophthalmology 101(9):1488–1502Google Scholar
  3. 3.
    Ganatra JB, Chandler D, Santos C, Kuppermann B, Margolis TP (2000) Viral causes of the acute retinal necrosis syndrome. Am J Ophthalmol 129(2):166–172CrossRefPubMedGoogle Scholar
  4. 4.
    Guex-Crosier Y, Rochat C, Herbort CP (1997) Necrotizing herpetic retinopathies. A spectrum of herpes virus-induced diseases determined by the immune state of the host. Ocul Immunol Inflamm 5(4):259–265Google Scholar
  5. 5.
    Holland GN (1994) Standard diagnostic criteria for the acute retinal necrosis syndrome. Am J Ophthalmol 117:663–667PubMedGoogle Scholar
  6. 6.
    Kezuka T, Sakai J, Usui N, Streilein JW, Usui M (2001) Evidence for antigen-specific immune deviation in patients with acute retinal necrosis. Arch Ophthalmol 119:1044–1049Google Scholar
  7. 7.
    Morrow G, Slobedman B, Cunningham AL, Abendroth A (2003) Varicella-zoster virus productively infects mature dendritic cells and alters their immune function. J Virol 77(8):4950–4959CrossRefGoogle Scholar
  8. 8.
    Nussenblatt RB, Lane HC (1998) Human immunodeficiency virus disease: changing patterns of intraocular inflammation. Am J Ophthalmol 125:374–382CrossRefGoogle Scholar
  9. 9.
    Palay DA, Sternberg P Jr, Davis J et al (1991) Decrease in the risk of bilateral acute retinal necrosis by acyclovir therapy. Am J Ophthalmol 112:250–255Google Scholar
  10. 10.
    Saibara T, Maeda T, Onishi S, Yamamoto Y (1993) Depressed immune functions in the early phase of Varicella-Zoster reactivation. J Med Virol 39(3):242–245Google Scholar
  11. 11.
    Schulyer MR, Gerblich A, Urda G (1984) Prednisolone and T-cell subpopulations. Arch Intern Med 144(5):973–975CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2005

Authors and Affiliations

  • Wee-Kiak Lim
    • 1
    • 2
  • Soon-Phaik Chee
    • 1
    • 3
  • Robert Burton Nussenblatt
    • 2
  1. 1.Singapore National Eye CenterSingaporeSingapore
  2. 2.National Eye InstituteNational Institute of HealthBethesdaUSA
  3. 3.National University of SingaporeSingaporeSingapore

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