A 35-year-old man with HIV (CD4 count 45 cells/μL, viral load 120,000 copies/mL) presents with painless progressive vision loss in the right eye. Fundoscopy shows white granular retinal lesions with hemorrhages in a 'pizza pie' or 'cottage cheese and ketchup' pattern along the vascular arcades. What is the most likely diagnosis and first-line treatment?
- A Toxoplasma retinochoroiditis — pyrimethamine + sulfadiazine
- B Progressive outer retinal necrosis (VZV) — IV acyclovir
- C CMV retinitis — intravitreal ganciclovir + systemic valganciclovir ✓
- D Pneumocystis choroiditis — trimethoprim-sulfamethoxazole
Explanation
CMV retinitis is the most common serious ocular opportunistic infection in AIDS, typically occurring when CD4 <50 cells/μL. The fundoscopic appearance of fluffy white retinal infiltrates with hemorrhages in a 'pizza pie' or 'cottage cheese and ketchup' pattern along vascular arcades is pathognomonic. First-line treatment for CMV retinitis is oral valganciclovir 900 mg BD (or IV ganciclovir for severe posterior pole disease) combined with intravitreal ganciclovir injection for immediate threat to vision. ART initiation is essential to restore CD4 counts and prevent recurrence. Without treatment, blindness occurs within weeks.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.