# Bilateral Cytomegalovirus Retinitis With Co-infection of Epstein-Barr Virus and Varicella-Zoster Virus: A Rare Case

## TL;DR

A rare case of eye inflammation caused by multiple viruses in an immunosuppressed patient is reported, highlighting the importance of accurate diagnosis.

## Contribution

This case report documents a rare co-infection of CMV, EBV, and VZV in bilateral retinitis.

## Key findings

- PCR testing identified CMV and EBV in the right eye and CMV and VZV in the left eye.
- The left eye showed rapid progression and required surgery, resulting in poor visual outcome.
- Coinfection with VZV may be associated with a worse prognosis in viral retinitis.

## Abstract

Cytomegalovirus retinitis (CMVR) is a form of infectious uveitis, a disease characterized by inflammation of the uvea, the middle layer of the eye. It is caused by the cytomegalovirus (CMV). Although CMVR generally involves a single virus, rare cases have been reported in which multiple viral DNAs have been detected in intraocular fluid using polymerase chain reaction (PCR) testing. The present case report documents a rare case of bilateral infectious uveitis with simultaneous detection of CMV and Epstein-Barr virus (EBV) in the right eye and CMV and varicella-zoster virus (VZV) in the left eye. A 75-year-old female patient with a history of long-term immunosuppressive therapy for rheumatoid arthritis presented with bilateral mild iritis and worsening retinal inflammation in the left eye. Fundus examination revealed granular exudates and retinal vascular occlusion in both eyes, with circumferential retinal lesions in the left eye. Qualitative PCR testing of the aqueous humor identified CMV and EBV in the right eye and CMV and VZV in the left eye. The patient was treated with intravenous acyclovir and ganciclovir, followed by intravitreal ganciclovir injections. Despite stabilization of the right eye, the left eye showed rapid lesion progression and developed a rhegmatogenous retinal detachment requiring surgical intervention. At the final follow-up, the corrected decimal visual acuity was 0.7 in the right eye and 0.02 in the left eye.Co-infection with multiple herpes viruses in viral retinitis is extremely rare. Immunosuppression may predispose individuals to such infections. PCR testing of intraocular fluid has been instrumental in diagnosis and guiding treatment. However, comprehensive evaluation is required to determine the pathogenicity of the viruses detected. This case highlights the importance of PCR testing for accurate diagnosis of atypical infectious uveitis. Although rare, concurrent infections with multiple herpesviruses may occur, and coinfection with VZV in particular could be associated with a poorer prognosis.