title: CMV retinitis recurs after stopping treatment in virological and immunological failures of potent antiretroviral therapy.
abstract: OBJECTIVE
  To determine predictors of clinical relapse of cytomegalovirus (CMV) end-organ disease in a cohort of 17 HIV-infected patients with healed and treated CMV retinitis (CMVR) who responded to HAART with an increase in CD4 cell counts to above 70 cells/mm3 and discontinued CMV maintenance therapy (MT).
  
  
  METHODS
  Seventeen patients were monitored for reactivation of retinitis. The CD4 cell counts, HIV RNA and peripheral blood mononuclear cell (PBMC) lymphoproliferative assays to CMV at 3 month intervals were compared between patients with and without reactivation of CMVR. Positive lymphoproliferative responses were defined as a stimulation index of 3 or greater.
  
  
  RESULTS
  Five out of 17 (29%) patients experienced a recurrence of CMVR a mean of 14.5 months after stopping CMV MT and between 8 days and 10 months after CD4 cell counts fell below 50 cells/mm3. Median CD4 cell counts and plasma HIV RNA at reactivation were 37 cells/mm3 and 5.3 log10 copies/ml. Three patients recurred at a previously active site of the retina, one had contralateral CMVR, and one a recurrence of retinitis and pancreatitis simultaneously. Mean lymphoproliferative responses to CMV were 2.4 in patients with reactivation versus 21.0 stimulation index (SI) in patients without reactivation (P= 0.01). A model incorporating four variables (CD4 cell counts and HIV RNA at maintenance discontinuation, highest CD4 cell count, nadir HIV RNA and median lymphoproliferative responses) identified correctly 88% of patients with and without reactivation.
  
  
  CONCLUSIONS
  CMV disease recurs after virological and immunological failure of HAART if CD4 cell counts drop below 50. In this situation, anti-CMV agents should be resumed before clinical reactivation ensues, because of the risk of contralateral retinal involvement and systemic disease.
authors.affiliation: Department of Medicine, University of California, San Diego, USA.
authors.forename: F J
authors.initials: FJ
authors.lastname: Torriani
authors.forename: W R
authors.initials: WR
authors.lastname: Freeman
authors.forename: J C
authors.initials: JC
authors.lastname: Macdonald
authors.forename: M P
authors.initials: MP
authors.lastname: Karavellas
authors.forename: D M
authors.initials: DM
authors.lastname: Durand
authors.forename: D D
authors.initials: DD
authors.lastname: Jeffrey
authors.forename: P R
authors.initials: PR
authors.lastname: Meylan
authors.forename: R D
authors.initials: RD
authors.lastname: Schrier
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy* / Q000276:immunology / Q000821:virology; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count / Q000187:drug effects; D015331:Cohort Studies; D003587:Cytomegalovirus / Q000187:drug effects; D017726:Cytomegalovirus Retinitis / Q000188:drug therapy* / Q000517:prevention & control; D005260:Female; D006678:HIV / Q000187:drug effects / Q000235:genetics; D006801:Humans; D008213:Lymphocyte Activation; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012367:RNA, Viral / Q000097:blood; D012008:Recurrence; D012307:Risk Factors; D013601:T-Lymphocytes / Q000276:immunology; D017211:Treatment Failure; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents; D012367:RNA, Viral