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Blurred Vision and Gastrointestinal Bleeding in a Patient With HIV

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 57-year-old man presented to the emergency department with 5 months of epigastric pain and a 6.8-kg (15-lb) weight loss. He had no fevers or night sweats. Physical examination was notable for oral thrush and mild epigastric tenderness. Results of a fourth-generation HIV Ab/Ag combination assay were positive, and subsequent testing showed a CD4 cell count of 16/mm3 and an HIV viral load greater than 10 million copies/mL. Computed tomography of the abdomen and pelvis showed thickening of the walls of the stomach, duodenum, and colon as well as multiple masses in the right hepatic lobe measuring up to 6.9 cm in diameter. A core biopsy of one of the liver masses demonstrated diffuse large B-cell lymphoma. He started antiretroviral therapy with bictegravir/emtricitabine/tenofovir/alafenamide and chemotherapy with rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (R-EPOCH).

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Cytomegalovirus (CMV) retinitis and hemorrhagic enteritis

C. Begin intravenous ganciclovir

The keys to the correct diagnosis in this case are the patient’s blurred vision and gastrointestinal hemorrhage in the setting of a profound immunocompromised state. This should prompt consideration of opportunistic infectious pathogens with tropisms for the eye and gastrointestinal tract, such as Toxoplasma, CMV, and Candida. The histopathologic finding of acute inflammation of the lamina propria with cytoplasmic and nuclear inclusions surrounded by a clear halo (“owl eye” sign) (Figure, left panel) confirms the diagnosis of CMV enteritis (choice C). While herpes simplex virus (choice A) is a common opportunistic infection with both ocular and gastrointestinal manifestations, it typically causes a painful keratitis and rarely involves the small or large intestines.1 Vitreous fluid sampling (choice B) is occasionally indicated to evaluate for ocular involvement of lymphoma, but this procedure has associated risks and should be preceded by a thorough dilated eye examination. While Crohn disease (choice D) might present with both ocular and gastrointestinal manifestations, the patient’s age, immunocompromised state, and acute presentation make opportunistic infections more likely.

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Article Information

Corresponding Author: Bradley W. Christensen, MD, Division of Hematology and Oncology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75235 (bradley.christensen@utsouthwestern.edu).

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for providing permission to share his information.

References
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Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-infected Adults and Adolescents: Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Published 2021. Accessed November 19, 2021. https://clinicalinfo.hiv.gov/sites/default/files/inline-files/adult_oi.pdf
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