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4–34 | Clinical Manual for Management of the HIV-Infected Adult/2006
Cytomegalovirus
CMV retinitis
CMV retinitis may occur in patients with a history of
CMV retinitis or in patients with no previous evidence
of retinitis. In those with a previous diagnosis of
CMV retinitis, a new opacified retinal lesion develops,
frequently at the site of an earlier lesion. CMV
retinitis IRS is identical to active CMV retinitis on
ophthalmologic examination. Clinical information,
therefore, will inform the diagnosis, and patients should
be monitored closely. As with other IRS reactions,
symptoms will be associated temporally with initiation
of ART and a recent increase in CD4 count. In
patients who were adequately treated for CMV and
who experience IRS, serial ophthalmologic exams will
reveal that the lesions clear without a new or different
therapy for CMV. This clinical picture differs from
that of retinal lesions caused by active CMV infection
and uncontrolled CMV replication, in which lesions
will increase in size or new lesions will appear, if CMV
therapy has not been introduced or changed.
CMV vitreitis and CMV uveitis
CMV vitreitis and CMV uveitis are seen exclusively
in people with previous CMV retinitis infection who
responded to ART:
CMV vitreitis: IRS is an alarming syndrome but a
benign one. Patients who are receiving anti-CMV
therapy typically present with acute onset of blurred
vision and “floaters” caused by posterior segment
inflammation. Ophthalmologic exam reveals numerous
inflammatory cells in the vitreous humor. Symptoms
usually resolve in 1 month without specific treatment
and without any lasting visual effects.
CMV uveitis: In patients with a history of CMV
retinitis, CMV uveitis IRS may occur within months
of ART initiation, but typically is a late complication,
occurring about 3 years after patients begin ART.
Uveitis is painless and primarily involves inflammation
in the iris, the ciliary body, and the choroid layers.
However, CMV uveitis may have serious sequelae. It
often results in macular edema, epiretinal membrane
formation, or cataracts, which can lead to permanent
vision loss. Because of the risk of vision loss, clinicians
should have a high index of suspicion for CMV uveitis.
Cryptococcal Meningitis
In patients with or without previously diagnosed
cryptococcal meningitis, presentation of cryptococcal
IRS typically includes fever, headache, and meningeal
signs and symptoms. Onset has been reported
between 1 week and 11 months after initiating ART.
Lymphadenitis also has been reported. (See chapter
Cryptococcal Disease.)
Pneumocystis jiroveci Pneumonia
Pneumocystis jiroveci pneumonia (PCP) IRS may
occur in patients with current or recent PCP who are
starting ART in the early weeks after initiation of PCP
treatment. IRS may present as worsening pulmonary
symptoms and high fever in patients who had been
improving on PCP therapy or in patients with recent
successful treatment of PCP. Chest x-rays may show
worsening lung involvement, and oxygen saturation or
arterial blood gas measurements may show worsening
hypoxia or alveolar-arterial oxygen gradient. PCP IRS
may sometimes cause severe acute respiratory failure.
(See chapter Pneumocystis Pneumonia.)
S: Subjective
Symptoms of IRS will vary according to the specific
illness.
Include the following in the history:
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Specific symptoms and time course of symptoms
History of OIs including recently diagnosed OIs
Treatment of OIs, including date of initiation,
medication adherence, duration of therapy, and
clinical response
ART initiation: date, specific antiretroviral
regimen, medication adherence, prior history of
ART
CD4 count and HIV viral load before ART
initiation
Current CD4 count and HIV viral load, if known
Other medications, especially new medications,
including over-the-counter and herbal preparations
O: Objective
Obtain vital signs, including temperature, heart rate,
blood pressure, respiratory rate, and oxygen saturation.
Perform a thorough physical examination based on
symptoms and suspicion of systems involved.