Title

CYTOMEGALOVIRUS RETINITIS IN AN IMMUNOSUPPRESSED PATIENT WITH AZATIOPRIN WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Introduction

Cytomegalovirus (CMV) is a virus of the β-herpes family, wich is often diagnosed in patients with acquired immunodeficiency syndrome and in patients using immunosupressive therapy.

Methods

Retrospective analysis of medical records and examinations associated with a literature review of the case of a patient with systemic lupus erythematosus undergoing treatment with azathioprine and diagnosis of cytomegalovirus retinitis. The evaluated patient underwent treatment with sulfamethoxazole-trimethroprim (SMX/TMP), prednisone and intravenous ganciclovir with daily eye exams and wide-angle retinography.

Results

At the beginning of the treatment, the patient presented visual acuity (VA) in the right eye of finger counting at 1 meter and intraocular pressure (IOP) of 25mmHg. In standard “cheese and ketchup”fundus, in addition to vitreitis, exudations and perivasculitis. There was worsening 48 hours after the institution of treatment with VA of hand motion, retinal lesions compatible with necrosis. The laboratory results showed positive CMV IgG and IgM, in addition to positive toxoplasmosis IgG, HIV negative. SMX/TMP was maintained and after rheumatology was released, azatrioprine was removed. Within 5 days of treatment, there was no vitreitis, and after 21 days there was an improvement in IOP, exudation and VA - finger counting at 1meter.

Discussion

CMV eye lesions are characterized by retinal necrosis and hemorrhage, the pattern in “cheese and ketchup”. In this case, the overlap with toxoplasmosis cannot be discarded. We believe that the combination of medications played a part in the development and worsening of the patient's retinitis, with corticotherapy as an aggravating factor. Although ganciclovir therapy is the standard used, it has not yet been established whether the use of systemic corticosteroids is beneficial, especially in the patient in question, in which the withdrawal of azathioprine can precipitate uveitis by immune reconstitution, which is why oral corticosteroids was maintained.

Keywords

Cytomegalovirus; Retinitis; Immunosupressives

Area

CLINICAL CASE

Authors

CAROLINE CORDEL RINGVELSKI, CAIO CÉZAR GAZIM, ANGELO ANTONIO DE BORBA, ANA PAULA BORTOLOTTO, LARISSA BOWENS, REBECA GRANGEIRO DE CARVALHO CABRAL, THIAGO ISSAMU SWIECH