A 32-year-old HIV-positive man (CD4 count 38 cells/µL, not on ART) presents with bilateral visual impairment. Fundoscopy shows perivascular yellow-white infiltrates with haemorrhage ('pizza-pie' appearance) along the vascular arcades. What is the most likely diagnosis and treatment?
- A Toxoplasma chorioretinitis; pyrimethamine + sulfadiazine
- B Cryptococcal choroiditis; IV amphotericin B
- C Ocular tuberculosis; standard 4-drug ATT
- D CMV retinitis; IV ganciclovir induction or intravitreal ganciclovir implant, plus ART initiation ✓
Explanation
CMV retinitis is the most common ocular opportunistic infection in AIDS (CD4 < 50 cells/µL), presenting with the classic 'pizza-pie' or 'brushfire' fundoscopic appearance. IV ganciclovir (induction 5 mg/kg twice daily for 14–21 days followed by maintenance) or intravitreal ganciclovir implant are treatments of choice; oral valganciclovir is an equally effective alternative with better compliance. Prompt ART initiation is critical. Toxoplasma retinochoroiditis in HIV typically has less haemorrhage. Cryptococcal disease usually affects the choroid. Ocular TB shows choroidal granulomas.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.