CMV

Zone I - 1 dd around nerve and 2 dd around fovea (right around arcades)

 

double stranded herpes virus

high prevalence of antibody against CMV

when CD4 drops below 50, sometimes 100 or 200, have active viral replication

if PCR+, means active replication

CMV IgM not useful

 

CD4 and HAART history

likelihood of immune recover

 

CMV's favorite organs:

eye

colitis, esophagitis, gastritis

pneumonitis

encephalitis

adrenalitis

 

whiteness comes from edema of retina

any white spot at periphery of central lesion is from active replication

edema follows subclinical infection, lags by couple of weeks

 

moves at 250um/week

 

incidence of CMV retinitis

pre-haart

-30% of patients CD4<50

post-haart

-75% decline in CMV

 

IMMUNE RECOVERY LIKELY:

zone 2/3 - start with valcyte and follow CD4, if dz relapse, add an implant

zone 1 - valcyte alone vs. implant and valcyte

 

IMMUNE RECOVERY UNLIKELY

zone 2/3 - implant + valcyte vs. valcyte alone

zone 1 - implant + valcyte

 

when have implant, should always keep with valcyte

 

2-3 weeks to tell if intravit ganciclovir injection working

 

can take off valcyte when CD4 is back to 100 or doubled, for 3 months (6 months total)

 

if have myelosupression, can add nupogen

 

sudofavir is toxic, can get uveitis

 

15-30% detach