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.