Christine I Clavell, James P Dossett, Kevin T Eid, Ghassan R Ghorayeb
A 60-year-old woman with no ocular history and a past medical history of stage 3 non-Hodgkin follicular lymphoma treated with bendamustine and rituximab presented with vision loss and floaters in her right eye. Funduscopic exam revealed dense vitritis with areas of retinal whitening and hemorrhaging involving the macula and superior mid-periphery. An anterior chamber paracentesis of the right eye returned positive for CMV. Her laboratory work-up revealed pancytopenia including CD4 lymphopenia which was likely secondary to bendamustine. Systemic therapy with valganciclovir was initiated, yet active retinitis developed in the left eye as well. A treat-and-extend regimen of intravitreal ganciclovir and foscarnet to both eyes was initiated with a visual acuity of 20/400 in the right eye and 20/20 in the left eye at the final follow-up.
PURPOSE: The aim of the study was to describe a case of bilateral cytomegalovirus (CMV) retinitis in a patient with non-Hodgkin lymphoma who developed prolonged immunosuppression after chemotherapy with bendamustine.
METHODS: This was a retrospective chart review.
RESULTS: A 60-year-old woman with no ocular history and a past medical history of stage 3 non-Hodgkin follicular lymphoma treated with bendamustine and rituximab presented with vision loss and floaters in her right eye. Funduscopic exam revealed dense vitritis with areas of retinal whitening and hemorrhaging involving the macula and superior mid-periphery. An anterior chamber paracentesis of the right eye returned positive for CMV. Her laboratory work-up revealed pancytopenia including CD4 lymphopenia which was likely secondary to bendamustine. Systemic therapy with valganciclovir was initiated, yet active retinitis developed in the left eye as well. A treat-and-extend regimen of intravitreal ganciclovir and foscarnet to both eyes was initiated with a visual acuity of 20/400 in the right eye and 20/20 in the left eye at the final follow-up.
DISCUSSION: Bendamustine can cause profound lymphopenia with reduced CD4 T-cell levels; risk of herpes virus retinitis is elevated in the setting of such immunosuppression. In HIV-negative patients, there is no specific treatment to raise the CD4 count. Prompt initiation and continued administration of systemic and local antiviral treatment can lead to disease control and preservation of vision while awaiting immune reconstitution.