A 32-year-old man with HIV (CD4 count 45 cells/µL, viral load 85,000 copies/mL, not on ART) presents with painless progressive bilateral visual loss and fundoscopy reveals 'pizza pie' or 'cheese and ketchup' retinopathy with haemorrhages and exudates along vessels. CSF is normal. The MOST likely diagnosis and initial treatment is:
- A CMV retinitis; IV ganciclovir or oral valganciclovir plus ART ✓
- B Toxoplasma chorioretinitis; IV co-trimoxazole
- C Cryptococcal chorioretinitis; IV liposomal amphotericin B
- D Progressive outer retinal necrosis (PORN); IV aciclovir
Explanation
CMV retinitis is the most common serious ocular opportunistic infection in advanced HIV (CD4 <50 cells/µL). The characteristic fundoscopic appearance is 'pizza pie retinopathy' — haemorrhagic and exudative lesions with irregular borders along the retinal vasculature ('cheese and ketchup'/'brushfire' appearance). Treatment is IV ganciclovir (or oral valganciclovir for non-sight-threatening lesions) combined with urgent initiation of ART (within 2 weeks for eye and non-CNS OIs). Intravitreal ganciclovir implants are an option. Toxoplasma retinitis typically shows vitritis with focal lesions. PORN shows widespread outer retinal necrosis in a VZV-immunocompromised pattern. Cryptococcal retinitis is rare.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.