HIV Microvasculopathy with Cotton-Wool Spots MCQ — NEET PG Practice Question | NEETPGAI
HIV Microvasculopathy with Cotton-Wool Spots
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stethoscope Medicine
A 34-year-old man living with HIV presents for routine fundus screening after re-engagement in care. His CD4 count is 142 cells/μL and viral load is 86,000 copies/mL. He is asymptomatic with visual acuity of 6/6 bilaterally. Dilated fundus examination reveals the findings marked **A** in the diagram — white, fluffy lesions scattered in the posterior pole. There is no granular necrotising retinitis, no haemorrhages, and no chorioretinal scars. OCT is unremarkable. Which of the following best describes the clinical significance of the lesions marked **A**?
A. Benign HIV-associated retinal microvasculopathy that typically resolves with sustained virological suppression
B. Early-stage CMV retinitis requiring immediate ganciclovir therapy to prevent vision loss
C. Progressive outer retinal necrosis requiring long-term intravitreal foscarnet injections
D. Acute retinal necrosis syndrome indicating need for intravenous acyclovir and urgent vitrectomy
Explanation
Why "Benign HIV-associated retinal microvasculopathy that typically resolves with sustained virological suppression" is right
The lesions marked A — multiple cotton-wool spots in the posterior pole of an asymptomatic patient with low CD4 count — are classic for HIV-associated retinal microvasculopathy. According to Harrison's Principles of Internal Medicine (21st Edition, Chapter on HIV/AIDS Ophthalmic Manifestations), cotton-wool spots represent nerve fibre layer infarcts caused by HIV-related microvasculopathy and are benign, asymptomatic, and do not require specific treatment. They typically resolve spontaneously with immune reconstitution following sustained antiretroviral therapy, as demonstrated in this patient who was restarted on tenofovir-lamivudine-dolutegravir 2 weeks prior.
Why each distractor is wrong
Early-stage CMV retinitis requiring immediate ganciclovir therapy: CMV retinitis presents with granular white necrotising lesions, often with haemorrhages and a "cottage cheese and ketchup" appearance. The clinical vignette explicitly states there is "no white granular necrotising retinitis" and "no haemorrhages along the vascular arcades to suggest CMV retinitis." Cotton-wool spots lack these features and do not progress to vision-threatening disease.
Acute retinal necrosis syndrome indicating need for intravenous acyclovir and urgent vitrectomy: Acute retinal necrosis is caused by herpes simplex or varicella-zoster virus, presents with severe vitritis, scalloped borders of retinal necrosis, and rapid progression with floaters and visual symptoms. This patient is asymptomatic with no vitritis on examination, ruling out this diagnosis.
Progressive outer retinal necrosis requiring long-term intravitreal foscarnet injections: Progressive outer retinal necrosis (PORN) is a rare, aggressive form of CMV retinitis occurring at very low CD4 counts, characterized by multifocal outer retinal whitening and rapid progression. The absence of granular necrosis, haemorrhages, and the benign clinical course described make this diagnosis untenable.
High-YieldNEET PG
Cotton-wool spots in HIV are benign microvasculopathy lesions that resolve with immune reconstitution—do not confuse with CMV retinitis (granular, haemorrhagic, progressive) or ARN (vitritis, rapid vision loss).
Harrison's Principles of Internal Medicine, 21st Edition, Chapter on HIV/AIDS Ophthalmic Manifestations
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