Paradoxical activity of CMV retinitis in patients receiving highly active antiretroviral therapy.

Purpose: To report two types of atypical behaviors of cytomegalovirus (CMV) retinitis in the highly active antiretroviral therapy (HAART) era, including active CMV retinitis in the presence of persistently high CD4 cell counts during HAART and CMV retinitis that has not reactivated despite persistently low CD4 cell counts.

Methods: Prospective, longitudinal, observational study of a cohort of 116 patients with acquired immunodeficiency syndrome who had a history of CMV retinitis during the HAART era.

Results: Sixty (52%) of the 116 patients with acquired immunodeficiency syndrome and CMV retinitis were HAART responders. Subsequently, HAART failed for 9 of the 60 patients with low CD4 cell counts. Of these 9 patients, 5 developed reactivation of CMV retinitis, and 4 remained free of CMV retinitis despite CD4 cell counts of <50/microL and lack of anti-CMV therapy. Paradoxically, there was a patient with a documented median CD4 cell count of 204/microL for 19 months who had newly diagnosed active CMV retinitis.

Conclusion: In the HAART era, CMV retinitis may remain quiescent despite extremely low CD4 cell counts, and rarely, CMV retinitis may become active in the setting of persistently high CD4 cell counts in a subset of HAART responders.