Retrospective analysis of misdiagnosis of cytomegalovirus retinitis

Initial misdiagnosis of cytomegalovirus retinitis (CMVR) may lead to irreversible loss of vision and systemic deterioration. We retrospectively reported some misdiagnosis related to CMVR. The medical records of 92 consecutive patients diagnosed or misdiagnosed as CMVR were reviewed retrospectively at the ophthalmology department of Beijing youan hospital from July 2017 to October 2019. The primary outcome measure was to evaluate cases with CMVR who were initially misdiagnosed or who were misdiagnosed as CMVR.

3 pay more attention to CMVR and systemic symptoms insulting to avoid deterioration of vision and delaying in the management of systemic conditions. Background Cytomegalovirus retinitis (CMVR) is an opportunistic infectious retinal disease. CMVR is most commonly seen in AIDS (Acquired Immune Deficiency Syndrome) patients and is the most common cause of vision loss in these patients [1]. It can also occur in other patients receiving immunosuppression after solid organ or stem cell transplantation, individuals with potential immune dysfunction, such as advanced age, diabetes, hypertension, or renal insufficiency [2]and patients after intravitreal injection (hormonal or non-hormonal) [3][4][5]. For patients with definite AIDS, CMVR can be confirmed by a fundus examination. It is easy to disregard CMVR for non-HIV patients or patients who are not clear about their human immunodeficiency virus (HIV) infection, so leading to unnecessary examinations, incorrect treatment, deterioration of vision and systemic condition. In this study, we retrospectively reviewed the medical records of seven patients with CMVR and one patient misdiagnosed as CMVR. We aim to appeal to the ophthalmologists to attach more attention to CMVR.

Methods
The medical records of 92 consecutive patients diagnosed/misdiagnosed with CMVR were reviewed retrospectively at Beijing infectious ophthalmopathy center, Beijing Youan Hospital, Capital Medical University, from July 2017 to October 2019. Patient clinical history and demographic data were recorded. Each patient underwent a complete medical evaluation for systemic illness, and laboratory investigations where indicated. The clinical diagnosis of CMVR primarily based on the presence of characteristic fundus findings in susceptible individuals [6]. We retrospectively analyzed eight cases that were initially misdiagnosed, seven were initially misdiagnosed as other diseases elsewhere and presented to our center at later stages of the disease, one patient presented to our center initially and misdiagnosed AS CMVR. Six patients consulted the ophthalmology department first for the ocular symptom before the diagnosis of AIDS. Six patients had received inappropriate treatments before the confirmed diagnosis. This study was approved by the Beijing Youan Hospital, Capital Medical University Institutional Review Board (LL2018150K), and adhered to the tenets of the Declaration of Helsinki.

Results
Eight (8.7%) out of the 92 patients were incorrectly diagnosed at the initial presentation.
The median age of the eight patients was 37.5 years (range 20-46 yeas). All ( symptoms. Seven patients were diagnosed with AIDS and other opportunistic infections with an extremely low level of CD4 + T lymphocyte: 5 cells/ul (range 1-9 cells/ul). All patients presented binocular involvement (sixteen eyes), and two patients (four eyes) presented pan-retinal involvement. Optic disc or macular area was involved in fourteen eyes. One patient (case 1) is blind, and two patients (cases 3 and 7) had a low vision when the diagnosis is clear. Six patients misdiagnosed as CMVR were received incorrect treatment before the final diagnosis. Among seven patients ( fourteen eyes) with CMVR in this study: five eyes presented typical form with yellowish-white retinal lesions and retinal hemorrhages; four eyes presented optic neuropathy; four eyes presented opaque white granular retinal lesions with no hemorrhages; one eye presented both optic neuropathy and perivascular form. The characteristic ophthalmologic findings of these patients were presented in Table 2.   propagation of the epidemic in the country [9].
Besides, the CMVR lesions in this study had deteriorated when final diagnosis was clear. All eyes presented binocular involvement. One patient is blind, and two patients had a low vision when the diagnosis is precise. Four eyes presented pan-retinal involvement. Fourteen eyes had optic disc or macular area involved, which is associated with poor visual prognosis [10]. These yellowish-white lesion and retinal hemorrhages were characteristic manifestations but could be easily confused with diabetic retinopathy, retinal vein occlusion, renal retinopathy, intraocular lymphoma [16], Coats' disease [17] or ocular toxoplasmosis [18]. The seventh patient showed quadrantally distributed white granular lesions without retinal hemorrhages and was misdiagnosed as PORN, which is also a kind of necrotizing herpetic retinopathies detected in immune-compromised patients [19]. CMVR and PORN might present confusing fundus changes, which could be difficult for inexperienced doctors, but they are different in the aetiological agent, treatment, and prognosis [20].

Availability of data and materials
The datasets used during the current study are available from the corresponding author on reasonable request.