First Author: A.Karatay Arsan TURKEY
Co Author(s): A. Oflaz C. Agalar M. Şimsek 0 0 0 0 0 0 0 0 0
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To describe a case of unilateral CMV retinitis in a 15-year-old immuno-competent patient who had no medical history of any systemic disease or immunsupressive therapy and to evaluate the success of oral valganciclovir as monotherapy.
A case presentation,who referred to our clinic in June 2012 with reducing vision in the right eye over a 2-3 week period.
Her visual acuity decreased to 20/125 in the right eye whereas her visual acuity was 20/20 in the left eye. Fundoscopic examination of the right eye revealed arcuate, whitish, necrotizing retinitis along the upper temporal arcuade of the retina. In fundus fluorescein angiography, there was leakage from upper temporal arcuade vessels and optic disc. Slit-lamp examination, intraocular pressure and light reflexes were normal.There was no abnormality on the left eye. She was otherwise medically healthy with no relevant ophthalmic history. Laboratuary tests were performed , including complete blood count, peripheral blood smear, liver and kidney function tests,coagulation tests, rheumatoid factor, Factor V level, protein C and S activity, ELISA (Anti Toxo Ig G and Ig M , anti CMV Ig G and Ig M ) and CMV Ig G avidity. Also, tests for HIV, hepatitis B and C were performed. All laboratuary tests were normal except CMV antibodies. Serum CMV Ig G level was 16.7 IU/ml, serum CMV Ig M level was 32.7 IU/ml. According to this clinical and laboratuary results, an Ig G avidity test was planned. Test result showed high avidity ( 0.91). Patient was consulted with clinic of infectious diseases and internal medicine.
Evaluating the clinical and laboratuary findings, the diagnosis was active CMV infection-retinitis. Depending on the results of systemic evaluation and avidity test, we decided that vitreous biopsy was not mandatory for a PCR examination .Then, oral anti-viral treatment was started immediately as valganciclovir 450 mg twice a day. Her visual acuity progressively increased and in September 2012, visual acuity was 20/20 in the right eye. As a result of improvement in vision and clinical findings, maintenance therapy was planned as oral valganciclovir 450 mg once a day and then it continued for the next 4 months. Serum anti CMV Ig G and Ig M level measurements were repeated and results were 96.7 IU/ml and 17.4 IU/ml respectively. These results also confirmed our diagnosis of CMV retinitis. In October 2012 , success rate in visual acuity were same as before. At following visits, the patient showed no recurrence. On the last visit, visual acuity did not change in the both eye.There were no adverse effects associated with oral valganciclovir.
CMV retinitis in immunocompetent patients is a rare condition.With clinical findings and serological results including avidity parameters, CMV retinitis can be diagnosed without vitreous biopsy and the need of generel anesthesia. Oral valganciclovir is a new and highly efficacious alternative to the chronic administration of ganciclovir in the treatment of cytomegalovirus (CMV) retinitis . Valganciclovir can be taken orally for both initial and maintenance treatment of CMVretinitis. In our case ,we used valganciclovir for both initial and maintenance therapy. Hence, we avoided the risks and complications of the intravitreal and intravenous therapy . Also, it achieves prophylaxis against CMV retinitis in the other eye when we compared with intravitreal ganciclovir implant. Visual acuity was improved and patient recovered with oral valganciclovir treatment in our case. She showed no recurrence for 2 years. Oral valganciclovir was convenient and effective for the management of CMV retinitis.