Adenovirus Vasculitis with Necrotising Retinitis and Schisis-Associated Macular Edema (SAME): A Rare Primary Manifestation of HIV-Related Immunodeficiency.

Purpose: Acute retinal necrosis (ARN) is a sight-threatening condition primarily caused by herpesviruses, with adenoviral retinitis being exceedingly rare. We report a case of bilateral adenoviral vasculitis progressing to peripheral necrotizing retinitis in an immunocompromised patient with newly diagnosed HIV, emphasizing the role of polymerase chain reaction (PCR)-based diagnosis and multimodal antiviral therapy.

Methods: A 33-year-old male, recently diagnosed with HIV (CD4 count: 158/µL), presented with floaters and blurred vision. Fundus examination revealed bilateral peripheral occlusive vasculitis with blot hemorrhages and macular edema. Anterior chamber fluid analysis via PCR revealed a high viral load of human adenovirus (HAdV) and tested negative for other common viral causes of retinal necrosis. Initial treatment involved topical corticosteroids, intravitreal ganciclovir, and systemic valganciclovir. Due to disease progression, therapy was subsequently escalated to high-dose valacyclovir (2 g TID) with intravitreal ganciclovir and later intravenous cidofovir was introduced.

Results: Despite initial worsening, the addition of cidofovir resulted in gradual lesion resolution over 4 weeks, leaving peripheral retinal necrosis. The final best-corrected visual acuity improved to 6/6 (right eye) and 6/8 (left eye), with residual macular ischemia. Concurrent antiretroviral therapy led to immune reconstitution with an increase in CD4 counts to 580/µL. Notably, a distinctive pattern of schisis-associated macular edema (SAME) was observed.

Conclusion: Adenoviral necrotizing retinitis remains an underrecognized entity, particularly in immunocompromised patients. This case underscores the importance of PCR testing for HAdV in atypical necrotizing retinitis and highlights the need for a combined treatment approach, including systemic and intravitreal antiviral therapy.