## Clinical Diagnosis: CMV Retinitis **Key Point:** The clinical presentation—immunocompromised host (CD4 <50), hemorrhagic retinal infiltrate with minimal anterior inflammation, floaters, and blurred vision—is classic for **CMV retinitis** ("pizza pie" or granular hemorrhagic pattern). ## CMV Retinitis Management Algorithm ```mermaid flowchart TD A[Immunocompromised patient<br/>CD4 < 50 cells/μL]:::outcome --> B[Hemorrhagic retinal infiltrate<br/>Minimal anterior inflammation]:::outcome B --> C{CMV retinitis<br/>suspected?}:::decision C -->|Yes| D[Urgent ophthalmology<br/>referral]:::action D --> E[IV ganciclovir<br/>induction]:::action E --> F[Intravitreal ganciclovir<br/>injection if needed]:::action F --> G[Immune reconstitution<br/>with ART]:::action G --> H[Remission of retinitis]:::outcome ``` ## Treatment Regimen | Phase | Agent | Route | Dose | Duration | |-------|-------|-------|------|----------| | **Induction** | Ganciclovir | IV | 5 mg/kg BID | 2–3 weeks | | **Maintenance** | Ganciclovir | IV or intravitreal | 5 mg/kg daily or injection | Until CD4 >100 | | **Immune reconstitution** | ART | Oral | Standard regimen | Lifelong | **High-Yield:** CMV retinitis in CD4 <50 is a medical emergency. IV ganciclovir induction + intravitreal injection (if available) + urgent ART is the standard approach. Do NOT delay treatment waiting for vitreous culture results. **Clinical Pearl:** The "pizza pie" retinopathy (hemorrhagic, granular infiltrate) with minimal anterior chamber reaction is the hallmark of CMV retinitis in AIDS. It differs from acute retinal necrosis (ARN), which presents with more inflammation and peripheral involvement. **Warning:** Vitreous tap is not required to diagnose CMV retinitis in this clinical context. The diagnosis is clinical (CD4 <50 + characteristic fundoscopic findings). Delaying treatment for PCR results risks irreversible vision loss.
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