A 48-year-old man comes to the emergency department due to a week of progressive blurred vision and floaters in the right eye. He has not had ocular pain, fever, or headache. The patient has a history of AIDS and has been noncompliant with therapy. He was recently hospitalized for Pneumocystis pneumonia. Temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, and pulse is 78/min. BMI is 17 kg/m². Vision is decreased in the right eye, and funduscopic examination shows several yellow-white exudates immediately adjacent to the fovea and retinal vessels. Several white patches are present on the oropharyngeal mucosa. Neurologic examination shows no focal weakness or sensory loss. Which of the following is the most likely diagnosis?

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This patient with advanced AIDS has progressive blurred vision, floaters, and yellow-white exudates adjacent to the fovea/retinal vessels, raising strong suspicion for cytomegalovirus (CMV) retinitis. CMV is a widely prevalent herpetic virus that typically causes an asymptomatic initial infection followed by lifelong latent infection. Although healthy patients rarely develop sequelae of dormant infection, those with severe deficits in cell-mediated immunity due to the use of immunosuppressive medications (eg, following organ transplantation) or advanced AIDS are at high risk for reactivation and subsequent end-organ disease. Retinitis is the most common end-organ manifestation of CMV in patients with advanced AIDS. It primarily occurs in those with CD4 counts <100/mm³ and generally presents with blurred vision, floaters, and photopsia (sensation of flashing lights). Funduscopic examination is diagnostic and typically reveals yellow-white, fluffy, hemorrhagic lesions adjacent to the fovea and retinal vessels. yellow-white Patients with CMV retinitis are usually treated with oral antivirals (eg, valganciclovir). Lesions near the fovea or optic nerve typically require concomitant intravitreal injections to reduce the risk of blindness and retinal detachment due to retinal scarring. Antiretroviral therapy should also be initiated (usually 2 weeks after beginning CMV treatment) to prevent CMV recurrence and progression. (Choice B) Herpes simplex keratitis causes corneal (not retinal) lesions and results in ocular pain, tearing, and discharge. It is generally diagnosed using a slit lamp. (Choice C) Herpes zoster ophthalmicus presents with eye pain and a vesicular eruption usually involving the cornea or iris. This patient does not have pain, a rash, or an anterior lesion. (Choice D) HIV retinopathy is marked by cotton-wool retinal lesions that are rarely hemorrhagic and tend to resolve over weeks to months. HIV retinopathy does not commonly cause floaters or blurred vision. (Choice E) Toxoplasmic chorioretinitis usually causes eye pain and decreased vision. Retinal lesions appear in a nonvascular (not perivascular) distribution. (Choice F) Syphilitic chorioretinitis usually presents with uveitis and diminished visual acuity and almost always occurs with symptoms of syphilitic meningitis (eg, nuchal rigidity, confusion, fever). Educational objective: Cytomegalovirus (CMV) retinitis is the most common end-organ complication of CMV in those with advanced AIDS. It typically presents with blurred vision, floaters, and photopsia (sensation of flashing lights). The major complications are vision loss (including blindness) and retinal detachment. Treatment necessitates antiviral medication (eg, valganciclovir) and, in severe cases, intravitreal injections. All patients should also be started on antiretroviral treatment to prevent recurrence and progression.

A 48-Year-Old Man Comes to the Emergency Department Due to a Week