Cytomegalovirus epithelitis in an immunocompromised patient of T-cell acute lymphoblastic leukemia.

A 10-year-old girl, known case of T- cell acute lymphoblastic leukaemia (ALL), into maintenance therapy which included dexamethasone was referred for raised intraocular pressures (IOPs) since 2 months. She was on maximal topical anti-glaucoma therapy and low potency topical steroid. Visual acuity in right eye was 20/200; left eye was 20/100. IOP was 44 mm Hg in both eyes (BE). Biomicroscopy revealed bilateral corneal epithelial edema with circum–ciliary congestion. No flare, cells, keratic precipitates, or iris atrophy were seen. Steroid- induced glaucoma was suspected; dexamethasone and topical steroid were withdrawn and oral Acetazolamide added which marginally reduced IOP. After a week, elevated, fluorescent stain-negative dendritic pigmented epithelial and anterior stromal infiltrates mimicking herpetic lesions [Fig. 1] were seen in lower cornea bilaterally. Anterior chamber revealed 2+ flare and cells. Also, she turned febrile with productive cough and cytomegalovirus (CMV) pneumonitis was diagnosed based on positive serum CMV DNA Polymerase chain reaction (PCR) (1500 copies/ml). Ocular diagnosis was revised to CMV epithelitis with hypertensive uveitis. She received intravenous ganciclovir for 21 days followed by oral valganciclovir for 45 days, topical ganciclovir gel 0.15% w/w six times a day, topical anti-glaucoma and homatropine eye drops. In 2 weeks, IOP was 12 mm Hg in BE. Visual acuity was BE 20/20 by 6 weeks. Corneal lesions disappeared completely after 8 months [Figs. 2 and 3] with no relapse of leukaemia.

Figure 1

Shows pigmented dendritic epithelial lesions in the inferior half of the cornea in right eye (a) and left eye (b) marked by white arrow head

Figure 2

Shows response to treatment with thinner pigmented epithelial pattern with mild surrounding haze in right eye (a) and left eye (b) marked by white arrow head

Figure 3

Shows complete resolution of lesions with clear cornea 8 months post treatment in right eye (a) and left eye (b)

Discussion

In Indian pediatiric ALL patients, 90% of CMV disease reactivates in the maintenance phase mainly as CMV retinitis.[1] Bilateral CMV epithelitis without iritis and unilateral CMV epithelitis have been previously reported in acquired immunodeficiency disease and post-cardiac transplant patients respectively.[23] However, unlike our case, in both these cases epithelial lesions were devoid of pigmentation. Ophthalmologists should be aware of this uncommon manifestation of CMV reactivation in immunocompromised patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.