Cytomegalovirus Retinitis as a Sole Manifestation of HIV Infection.

Retinitis is the most frequent manifestation of Cytomegalovirus (CMV) disease in patients with HIV infection. The virus reaches the retina by hematogenous spread, therefore patients with serum CMV load are at increased risk of developing CMV retinitis. The evolution of retinitis without specific treatment causes irreversible visual loss. Proper treatment is essential for controlling the disease progression, prevention of relapses, and contralateral eye involvement. This report describes a 56-year-old white male who started a progressive decrease in visual acuity (VA) of the right eye, without pain or inflammatory signs. Initial fundoscopy identified a dispersed preretinal hemorrhage and yellowish exudates. For the hypothesis of CMV retinitis, serology for HIV was requested and the subsequent result was positive. Other opportunistic infections, as well as manifestations of CMV infection in other organs, were ruled out. The patient was discharged on valganciclovir and highly active antiretroviral therapy (HAART) with progressive improvement in retinal changes, but without full recovery from VA due to chronic vitritis and tractional retinal detachment. Slow recovery of lymphocyte populations and sustained decrease in viral load were observed. CMV retinitis as an initial and sole manifestation of HIV infection is rare and requires screening. The importance of this case lies in its rarity, since CMV retinitis was the only manifestation of CMV infection and the only opportunistic infection in this patient. Early diagnosis and initiation of targeted therapy decrease the morbidity associated with this infection.

Epidural Abscess: A Cause of Back Pain That Must Not Be Missed.

Low back and cervical pain are common emergency department complaints. Most cases represent low-risk pathologies but in rare cases, it can be a symptom of a serious underlying disease and the distinction can be challenging. A case is reported of a 58-year-old male with recurrent cervical pain requiring several emergency department visits. He eventually presented with intense cervical and low back pain, tetraparesis, and dyspnea. His condition deteriorated in less than 24 hours, evolving with fever, shock, and respiratory insufficiency and was admitted to the Intensive Care Unit for aminergic support, invasive mechanical ventilation and started on empiric antibiotics. Investigations revealed raised inflammatory markers and a cervical pre-vertebral purulent collection associated with an epidural collection at the level of C2 to C5 with spinal cord compression. The patient underwent transoral drainage and removal of the posterior C1 arch along with C2-C3-C4-C5 laminectomy. Staphylococcus aureus was isolated in the blood, pus, and bone. Re-intervention was required due to persistent pre-vertebral abscesses with clinical improvement thereafter. Eight weeks of antibiotic treatment were completed in total. The patient was discharged after 72 days of hospitalization with significant improvement in force and autonomy. Epidural abscess is a rare finding that can cause rapid irreversible neurological deterioration. Clinical suspicion must be high for an early diagnosis and treatment, essential for a better prognosis.

Leptospirosis, a Re-emerging Threat.

Leptospirosis is a zoonosis transmitted by an animal vector and caused by the spirochete bacteria Leptospira. Human infection is rare and acquired by exposure to environmental sources (animal urine, contaminated water, soil, or infected animal tissue). It can have an extremely broad presentation, ranging from asymptomatic to serious illness. We report the case of a 59-year-old man admitted to the hospital with myalgia, fever, and abdominal discomfort. Routine laboratory tests revealed raised inflammatory markers, thrombocytopenia, kidney dysfunction, and hepatic cytolysis and cholestasis. The hypothesis of zoonosis was raised based on symptoms and analytical changes despite the weak epidemiological history to support it. Although leptospira serology tests were negative on admission, a polymerase chain reaction test was requested due to a high degree of suspicion which came back positive. The patient completed eight days of doxycycline with favorable clinical and analytical progression. This case highlights the changing epidemiology of leptospirosis and the importance of having a high degree of suspicion even outside endemic zones. It also highlights the importance of a wise choice of diagnostic tests according to the disease stage.