A 40-year-old man with AIDS (CD4 count 28 cells/µL) presents with a painless progressive scotoma and sees a white opaque area encroaching on his visual field. Fundus shows a granular, white retinal opacity with haemorrhages along vessels ('pizza pie' or 'crumbled cheese and ketchup' appearance). The most likely diagnosis and treatment are:
- A Toxoplasma retinochoroiditis; pyrimethamine + sulfadiazine
- B Cytomegalovirus (CMV) retinitis; systemic ganciclovir or valganciclovir plus intravitreal ganciclovir implant ✓
- C Progressive outer retinal necrosis (PORN) from VZV; acyclovir
- D Candida endophthalmitis; intravenous fluconazole
Explanation
CMV retinitis is the most common ocular opportunistic infection in AIDS patients, typically occurring when CD4 < 50 cells/µL. The characteristic fundus appearance is a full-thickness necrotising retinitis with granular yellow-white retinal opacity (leading edge of virus) and haemorrhages in a 'pizza pie' or 'crumbled cheese and ketchup' pattern along the vascular arcades. It is painless and slowly progressive. Systemic valganciclovir (oral) is now the preferred initial treatment; intravitreal ganciclovir implants provide local control for sight-threatening disease. Immune restoration with ART is essential to prevent relapse.
Reference: Khurana Comprehensive Ophthalmology, 7th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.