Differential Diagnosis I: HIV Retinopathy or CMV retinitis? (CWS or CMV ?)

CWS CWS CMV retinitis

AIDS-related Eye pathology overview HIV/AIDS clinics / Wards / Workshops, 2004-2012 approx 450 patients with eye disease (Myanmar, China, Russia, Cambodia, Laos, Thailand, Uganda, South Africa) “other” = the disease was very unusual, or not related to HIV (such as retinitis pigmentosa), or that no diagnosis was established CMV CWS TB crypto syph toxo ARN “other” 50% 25% 10% 3-5% 1% 5-7%

HIV Retinopathy A microvasculopathy that occurs in about 1/3 of patients with a CD4<50cells/µl. Correlates to high HIV viral load. Is a marker for those who are at high-risk for opportunistic infection, and may be present in addition to CMV or other OI’s Rapidly resolves with ART No symptoms No treatment

HIV Retinopathy The most common eye complication of HIV/AIDS. Characterized by cotton wool spots (CWS) Sometimes with hemorrhages. The primary entity that must be distinguished from CMV retinitis

Pattern Recognition cotton wool spots (CWS) are generally small, less than ½ DD, with regular borders. (also occur in DM and HTN) They are typically bright white, with no hint of yellow They are commonly round or oval, or may look like a “twisted piece of cotton” The “long axis” may sometimes be perpendicular to the NFL They are superficial, may appear slightly “3 dimensional” and lie on top of the retinal blood vessels, often obscuring a portion of the vessel As they fade they may exhibit a “granular” appearance They occur in the “posterior pole” – usually within 4-5 “disc diameters” from the optic nerve

HIV Retinopathy

Retinal whitening in the peripheral retina is not a CWS Retinal whitening in the peripheral retina is not a CWS. If the CD4 count is low suspect CMV retinitis Vortex vein

Clinical Course CWS condense and fade, usually over 3-6 weeks CMV retinitis advances

Cotton-Wool Spots condense and fade

CWS 2/6/09 and 2/27/09 Note granular appearance as CWS fades

CMV retinitis advances

Clinical Course Following the clinical course is the key “test” to distinguish HIV Retinopathy (lesions condense and fade) from CMV retinitis (lesions advance)

Progression of small non-specific white spot into characteristic pattern of CMV retinitis

Pattern Recognition Dense opaque retinal whitening Irregular border with small white satellite lesions Centrifugal spread with Central clearing Tends to follow vessels Hemorrhage, but this is highly variable

Describe what you see & Give your diagnosis

Describe & dx please What is this?