CMV Retinitis in HIV MCQ — NEET PG Practice Question | NEETPGAI
CMV Retinitis in HIV
medium
eye Ophthalmology
A 34-year-old man with newly diagnosed HIV presents to the ophthalmology clinic with a 2-week history of floaters and blurred vision in the right eye. His CD4+ count is 28 cells/μL. Dilated fundoscopy reveals the pattern marked **B** in the diagram—areas of yellow-white granular retinal opacification interspersed with patchy intraretinal hemorrhages distributed along the major vascular arcades, advancing at the leading edge. Which of the following is the most appropriate INITIAL management strategy for this sight-threatening lesion?
A. Initiate oral valganciclovir 900 mg twice daily for 21 days induction, followed by daily maintenance therapy and urgent optimization of combination antiretroviral therapy
B. Perform immediate intravitreal ganciclovir injection for rapid local control, particularly if the lesion is within 1500 microns of the fovea
C. Administer intravenous cidofovir weekly for 2 weeks, then switch to oral valganciclovir maintenance without initiating antiretroviral therapy
D. Prescribe topical acyclovir drops and oral famciclovir, as this is most consistent with acute retinal necrosis
Explanation
Why option 1 is correct
The pattern marked B is CMV retinitis with the classic "pizza pie" or "brushfire" appearance—full-thickness retinal necrosis with patchy hemorrhages along vascular arcades. This is the most common opportunistic ocular infection in advanced HIV (CD4 < 50 cells/μL) and the leading cause of blindness in this population. The standard-of-care INDUCTION regimen is oral valganciclovir 900 mg twice daily for 21 days, followed by 900 mg daily maintenance (AAO BCSC Section 9, CDC OI Guidelines 2024). Critically, the MOST IMPORTANT long-term intervention is urgent initiation or optimization of combination antiretroviral therapy (cART) to reconstitute immunity; once CD4 sustains above 100 cells/μL for 3–6 months, anti-CMV maintenance can be discontinued. This dual approach addresses both the immediate viral replication and the underlying immunosuppression.
Why each distractor is wrong
Option 2: While intravitreal ganciclovir or foscarnet injections ARE indicated for ZONE 1 sight-threatening lesions (within 1500 microns of the fovea or 3000 microns of the optic disc), they are typically used as adjunctive therapy alongside systemic valganciclovir induction, not as monotherapy. The question stem does not specify that the lesion is in ZONE 1, and the standard first-line approach remains oral valganciclovir with cART optimization.
Option 3: Topical acyclovir and oral famciclovir are appropriate for acute retinal necrosis (ARN), which is caused by HSV or VZV, occurs in more immunocompetent patients, presents with peripheral rapidly progressive lesions, and features prominent vitritis and arteritis. The clinical presentation and CD4 count here are pathognomonic for CMV retinitis, not ARN.
Option 4: Intravenous cidofovir is reserved for ganciclovir-resistant CMV strains (mediated by UL97 kinase mutations) and is not first-line therapy. More critically, initiating anti-CMV therapy WITHOUT concurrent cART optimization is a fundamental error—immune reconstitution is the cornerstone of long-term control and prevents relapse and immune recovery uveitis.
High-YieldNEET PG
CMV retinitis in advanced HIV is a CD4 < 50 diagnosis with a "pizza pie" fundus pattern; treat with valganciclovir induction PLUS urgent cART to reconstitute immunity—this dual approach is curative.
