获得性免疫缺陷综合征患者视网膜微血管病变与巨细胞病毒视网膜炎对比研究
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摘要
目的分析获得性免疫缺陷综合征(acquired immunodeficiency syndrome,AIDS)患者视网膜微血管病变与巨细胞病毒视网膜炎(cytomegalovirus retinitis,CMVR)的疾病特征。方法回顾性病例分析。选取就诊于首都医科大学附属北京佑安医院眼科并经感染科专科医师确诊的AIDS患者145例,其中合并视网膜微血管病变者75例为微血管病变组,合并CMVR者70例为CMVR组。所有患者均进行AIDS相关病史询问,同时行血人类免疫缺陷病毒(HIV)载量和CD4+T细胞检测,并行最佳矫正视力、眼压、裂隙灯检查、散瞳眼底检查及彩色眼底照相等眼科检查。对全身情况允许的微血管病变组25例、CMVR组70例进行血液和房水CMV-DNA检测。结果视网膜微血管病变组最佳矫正视力为0.91±0.16,13例(17.33%)患者已开始高效联合抗反转录病毒治疗(HAART),CD4+T细胞数为22(0～506)个·μL~(-1),8例(10.67%)患者有眼前节反应;CMVR组患者最佳矫正视力为0.63±0.37,34例(48.57%)患者已开始HAART,CD4+T细胞数为13(1～48)个·μL~(-1),23例(32.85%)患者有眼前节反应,上述指标两组相比差异均有统计学意义(均为P=0.000)。微血管病变组25例中房水CMV-DNA阳性0例,血液CMV-DNA阳性8例(32.00%);CMVR组70例中房水CMV-DNA阳性60例(85.71%),血液CMV-DNA阳性33例(47.14%);两组血液中CMV-DNA阳性率相比差异无统计学意义(P=0.227),但房水中阳性率两组相比差异有统计学意义(P=0.000)。结论 AIDS合并CMVR患者比AIDS合并视网膜微血管病变患者视力更差,CD4+T细胞计数更低,眼前节反应及房水CMV-DNA阳性率更高,且视网膜微血管病变患者未接受HAART的人数明显高于CMVR患者。
Objective To analyze the characteristics of microvascular retinopathy and cytomegalovirus retinitis(CMVR) in patients with acquired immunodeficiency syndrome(AIDS).Methods Retrospective case analysis was conducted on 145 patients with AIDS who were treated in the ophthalmology department of Beijing Youan Hospital affiliated to Capital Medical University and confirmed by infectious specialists.Among them,75 were microvascular retinopathy and 70 were CMVR.All patients were inquired about AIDS-related medical history.At the same time,the blood human immunodeficiency virus(HIV) load and CD4 + T cells were detected,and the best corrected visual acuity,intraocular pressure,slit lamp examination,dilated fundus examination and color fundus photography were performed.CMV-DNA in blood and aqueous humor was detected in 25 patients with microvascular disease and 70 patients with CMVR.Results The best corrected visual acuity of microvascular retinopathy group was 0.91±0.16,13(17.33%) patients had begun highly active antiretroviral therapy(HAART),the median of CD4+T cells was 22(0-506)cells·μL~(-1),8(10.67%) patients had positive anterior segment examination;the best corrected visual acuity of CMVR group was 0.63±0.37,34(48.57%) patients had begun HAART treatment,and the median of CD4+T cells was 13(1-48) cells·μL~(-1),23(32.85%) patients had anterior segment reactions,and the differences between the two groups were statistically significant(all P=0.000).Among 25 patients with microvascular retinopathy,No patient was CMV-DNA positive in aqueous humor and 8 patients(32.00%) were CMV-DNA positive in blood.Among 70 patients in CMVR group,60 patients(85.71%) were CMV-DNA positive in aqueous humor and 33 patients(47.14%) were CMV-DNA positive in blood.There was no significant difference in the positive rate of CMV-DNA in blood between the two groups(P=0.227),but there was significant difference in the positive rate of aqueous humor between the two groups(P=0.000).Conclusion AIDS patients with CMVR has worse visual acuity and lower CD4+ T cell counts than patients with microvascular retinopathy,the anterior segment response and aqueous humor CMV-DNA positive rate are higher than patients with microvascular retinopathy.The number of patients without HAARTtreatment in microvascular retinopathy group is significantly higher than that in CMVR group.
Objective To analyze the characteristics of microvascular retinopathy and cytomegalovirus retinitis(CMVR) in patients with acquired immunodeficiency syndrome(AIDS).Methods Retrospective case analysis was conducted on 145 patients with AIDS who were treated in the ophthalmology department of Beijing Youan Hospital affiliated to Capital Medical University and confirmed by infectious specialists.Among them,75 were microvascular retinopathy and 70 were CMVR.All patients were inquired about AIDS-related medical history.At the same time,the blood human immunodeficiency virus(HIV) load and CD4 + T cells were detected,and the best corrected visual acuity,intraocular pressure,slit lamp examination,dilated fundus examination and color fundus photography were performed.CMV-DNA in blood and aqueous humor was detected in 25 patients with microvascular disease and 70 patients with CMVR.Results The best corrected visual acuity of microvascular retinopathy group was 0.91±0.16,13(17.33%) patients had begun highly active antiretroviral therapy(HAART),the median of CD4+T cells was 22(0-506)cells·μL~(-1),8(10.67%) patients had positive anterior segment examination;the best corrected visual acuity of CMVR group was 0.63±0.37,34(48.57%) patients had begun HAART treatment,and the median of CD4+T cells was 13(1-48) cells·μL~(-1),23(32.85%) patients had anterior segment reactions,and the differences between the two groups were statistically significant(all P=0.000).Among 25 patients with microvascular retinopathy,No patient was CMV-DNA positive in aqueous humor and 8 patients(32.00%) were CMV-DNA positive in blood.Among 70 patients in CMVR group,60 patients(85.71%) were CMV-DNA positive in aqueous humor and 33 patients(47.14%) were CMV-DNA positive in blood.There was no significant difference in the positive rate of CMV-DNA in blood between the two groups(P=0.227),but there was significant difference in the positive rate of aqueous humor between the two groups(P=0.000).Conclusion AIDS patients with CMVR has worse visual acuity and lower CD4+ T cell counts than patients with microvascular retinopathy,the anterior segment response and aqueous humor CMV-DNA positive rate are higher than patients with microvascular retinopathy.The number of patients without HAARTtreatment in microvascular retinopathy group is significantly higher than that in CMVR group.
引文
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[3] HODGE W G,BOIVIN J F,SHAPIRO S H,LALONDE R G,SHAH K C,MURPHY B D,et al.Clinical risk factors for cytomegalovirus retinitis in patients with AIDS[J].Ophthalmology,2004,111(7):1326-1333.
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[7] LUO J,JING D,KOZAK I,HUIMING Z,SIYING C,YEZHEN Y,et al.Prevalence of ocular manifestations of HIV/AIDS in the highly active antiretroviral therapy (HAART) era:a different spectrum in Central South China[J].Ophthalmic Epidemiol,2013,20(3):170-175.
[8] GLASGOW B J.Evidence for breaches of the retinal vasculature in acquired immune deficiency syndrome angiopathy.A flourescent microsphere study[J].Ophthalmology,1997,104(7):753-760.
[9] MANSOUR A M,RODENKO G,DUTT R.Half-life of cotton wool spots in the acquired immunodeficiency syndrome[J].Int J STD AIDS,1990,1(2):132-133.
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[12] JABS D A.Cytomegalovirus retinitis and the acquired immunodeficiency syndrome—Bench to Bedside:LXVII edward jackson memorial lecture[J].Am J Ophthalmol,2011,151(2):198-216.
[13] JACOBSON M A,SCHRIER R,MCCUNE J M,TORRIANI F J,HOLLAND G N,O’DONNELL J J,et al.Cytomegalovirus (CMV)specific CD4+T lymphocyte immune function in long-term survivors of AIDS-related CMV end-organ disease who are receiving potent antiretroviral therapy[J].J Infect Dis,2001,183(9):1399-1404.
[14] TORRIANI F J,FREEMAN W R,MACDONALD J C,KARAVELLAS M P,DURAND D M,JEFFREY D D,et al.CMV retinitis recurs after stopping treatment in virological and immunological failures of potent antiretroviral therapy[J].AIDS,2000,14(2):173-180.
[15] SUN H Y,PENG X Y,LI D,MAO F F,YOU Q S,JONAS J B.Cytomegalovirus retinitis in patients with AIDS before and after introduction of HAART in China[J].Eur J Ophthalmol,2014,24(2):209-215.
[16] JABS D A,MARTIN B K,FORMAN M S,RICKS M O.Cytomegalovirus (CMV) blood DNA load,CMV retinitis progression,and occurrence of resistant CMV in patients with CMV retinitis[J].J Infect Dis,2005,192(4):640-649.
[17] MIZUSHIMA D,NISHIJIMA T,YASHIRO S,TERUYA K,KIKUCHI Y,KATAI N,et al.Diagnostic utility of quantitative plasma cytomegalovirus DNA PCR for cytomegalovirus end-organ diseases in patients with HIV-1 infection[J].J Acquir Immune Defic Syndr,2015,68(2):140-146.
[18] CHEN C,GUO C G,MENG L,YU J,XIE L Y,DONG H W,et al.Comparative analysis of cytomegalovirus retinitis and microvascular retinopathy in patients with acquired immunodeficiency syndrome[J].Int J Ophthalmol,2017,10(9):1396-1401.
[19] SMITH I L,MACDONALD J C,FREEMAN W R,SHAPIRO A M,SPECTOR S A.Cytomegalovirus (CMV) retinitis activity is accurately reflected by the presence and level of CMV DNA in aqueous humor and vitreous[J].J Infect Dis,1999,179(5):1249-1253.
[2] GONZáLEZ C R,WILEY C A,AREVALO J F,GARCIá R F,KUPPERMANN B D,BERRY C,et al.Polymerase chain reaction detection of cytomegalovirus and human immunodeficiency virus-l in the retina of patients with acquired immune deficiency syndrome with and without cotton-wool spots[J].Retina,1996,16(4):305-311.
[3] HODGE W G,BOIVIN J F,SHAPIRO S H,LALONDE R G,SHAH K C,MURPHY B D,et al.Clinical risk factors for cytomegalovirus retinitis in patients with AIDS[J].Ophthalmology,2004,111(7):1326-1333.
[4] JABS D A.Ocular manifestations of HIV infection[J].Trans Am Ophthalmol Soc,1998,339(4):236-244.
[5] BENSON C A,KAPLAN J E,MASUR H,PAU A,HOLMES K K.Treating opportunistic infections among HIV-infected adults and adolescents:recommendations from CDC,the national institutes of health,and the HIV medicine association/infectious diseases society of America[J].Mmwr Recomm Rep,2004,53(RR-15):1-112.
[6] BECKER K N,BECKER N M.Ocular manifestations seen in HIV[J].Dis Mon,2014,60(6):268-275.
[7] LUO J,JING D,KOZAK I,HUIMING Z,SIYING C,YEZHEN Y,et al.Prevalence of ocular manifestations of HIV/AIDS in the highly active antiretroviral therapy (HAART) era:a different spectrum in Central South China[J].Ophthalmic Epidemiol,2013,20(3):170-175.
[8] GLASGOW B J.Evidence for breaches of the retinal vasculature in acquired immune deficiency syndrome angiopathy.A flourescent microsphere study[J].Ophthalmology,1997,104(7):753-760.
[9] MANSOUR A M,RODENKO G,DUTT R.Half-life of cotton wool spots in the acquired immunodeficiency syndrome[J].Int J STD AIDS,1990,1(2):132-133.
[10] HOLLAND G N,PEPOSE J S,PETTIT T H,GOTTLIEB M S,YEE R D,FOOS R Y.Acquired immune deficiency syndrome.Ocular manifestations[J].Ophthalmology,1983,90(8):859-873.
[11] FREEMAN W R,CHEN A,HENDERLY D E,LEVINE A M,LUTTRULL J K,URREA P T,et al.Prevalence and significance of acquired immunodeficiency syndrome-related retinal microvasculopathy[J].Am J Ophthalmol,1989,107(3):229-235.
[12] JABS D A.Cytomegalovirus retinitis and the acquired immunodeficiency syndrome—Bench to Bedside:LXVII edward jackson memorial lecture[J].Am J Ophthalmol,2011,151(2):198-216.
[13] JACOBSON M A,SCHRIER R,MCCUNE J M,TORRIANI F J,HOLLAND G N,O’DONNELL J J,et al.Cytomegalovirus (CMV)specific CD4+T lymphocyte immune function in long-term survivors of AIDS-related CMV end-organ disease who are receiving potent antiretroviral therapy[J].J Infect Dis,2001,183(9):1399-1404.
[14] TORRIANI F J,FREEMAN W R,MACDONALD J C,KARAVELLAS M P,DURAND D M,JEFFREY D D,et al.CMV retinitis recurs after stopping treatment in virological and immunological failures of potent antiretroviral therapy[J].AIDS,2000,14(2):173-180.
[15] SUN H Y,PENG X Y,LI D,MAO F F,YOU Q S,JONAS J B.Cytomegalovirus retinitis in patients with AIDS before and after introduction of HAART in China[J].Eur J Ophthalmol,2014,24(2):209-215.
[16] JABS D A,MARTIN B K,FORMAN M S,RICKS M O.Cytomegalovirus (CMV) blood DNA load,CMV retinitis progression,and occurrence of resistant CMV in patients with CMV retinitis[J].J Infect Dis,2005,192(4):640-649.
[17] MIZUSHIMA D,NISHIJIMA T,YASHIRO S,TERUYA K,KIKUCHI Y,KATAI N,et al.Diagnostic utility of quantitative plasma cytomegalovirus DNA PCR for cytomegalovirus end-organ diseases in patients with HIV-1 infection[J].J Acquir Immune Defic Syndr,2015,68(2):140-146.
[18] CHEN C,GUO C G,MENG L,YU J,XIE L Y,DONG H W,et al.Comparative analysis of cytomegalovirus retinitis and microvascular retinopathy in patients with acquired immunodeficiency syndrome[J].Int J Ophthalmol,2017,10(9):1396-1401.
[19] SMITH I L,MACDONALD J C,FREEMAN W R,SHAPIRO A M,SPECTOR S A.Cytomegalovirus (CMV) retinitis activity is accurately reflected by the presence and level of CMV DNA in aqueous humor and vitreous[J].J Infect Dis,1999,179(5):1249-1253.