Progression of varicella-zoster virus necrotizing retinopathy in an HIV-negative patient with transient immune deviation.
OBJECTIVE
To report a case of unilateral varicella-zoster virus (VZV) necrotizing retinopathy that progressed from outer retinitis with features of progressive outer retinal necrosis (PORN) to typical acute retinal necrosis (ARN) in an HIV-negative patient with a transient decrease in CD4 lymphocyte counts and CD4/CD8 ratio.


METHODS
Case report.


RESULTS
A 41-year-old Chinese man presenting with blurred vision in the right eye was diagnosed with herpetic necrotizing retinitis without vitritis. Fundus examination revealed retinal arteritis and extensive deep whitish retinal lesions in the mid-periphery with minimal vitritis. Aqueous humor and vitreous PCR were positive for VZV. His CD4 count on presentation was depressed (239 cells/ul) and the CD4/CD8 ratio was low (0.8). The referring ophthalmologist had treated him with prednisolone 60 mg/day. At our institution, when intravenous acyclovir was started and the steroid therapy discontinued, he developed severe vitritis and the deep retinal lesions progressed to full-thickness retinitis typical of ARN. Repeat CD4 count was 512 cells/ul at day 14. In total, he was treated with 14 days of i.v. acyclovir (12 mg/kg 8-hourly) followed by oral valaciclovir 500 mg three times a day for 3 months. Prednisolone 30 mg once daily was restarted and tapered over 3 months. Despite prophylactic argon retinal photocoagulation to the edge of the retinitis, the patient developed a total retinal detachment at 3 months.


CONCLUSIONS
VZV retinal infection in an HIV-negative patient with transient immune deviation can manifest initially as outer retinitis with features similar to PORN and progress to typical ARN when CD4 counts return to normal.
Lim
Wee-Kiak
WK
Singapore National Eye Center, 11, Third Hospital Avenue, Singapore, Singapore, 168751.
Chee
Soon-Phaik
SP
Nussenblatt
Robert Burton
RB
D000328:Adult; D000998:Antiviral Agents / Q000008:administration & dosage / Q000627:therapeutic use; D001082:Aqueous Humor / Q000821:virology; D018791:CD4 Lymphocyte Count; D016516:CD4-CD8 Ratio; D015496:CD4-Positive T-Lymphocytes / Q000276:immunology; D018450:Disease Progression; D004333:Drug Administration Routes; D004359:Drug Therapy, Combination; D005500:Follow-Up Studies; D018023:HIV Seronegativity / Q000276:immunology*; D006563:Herpes Zoster Ophthalmicus / Q000188:drug therapy / Q000503:physiopathology* / Q000821:virology; D014645:Herpesvirus 3, Human / Q000302:isolation & purification*; D006801:Humans; D008297:Male; D015882:Retinal Necrosis Syndrome, Acute / Q000188:drug therapy / Q000503:physiopathology* / Q000821:virology; D014822:Vitreous Body / Q000821:virology
D000998:Antiviral Agents