Cytomegalovirus Retinitis in an ALL Child on Exclusive Chemotherapy Treated Successfully With Intravitreal Ganciclovir Alone Ramandeep Singh, MS,* Rishiraj Singh, MS,* Amita Trehan, MD,w Richa Jain, MD,w and Swapnil Bhalekar, MS* Summary: A child suffering from acute lymphoblastic leukemia on treatment with exclusive chemotherapy presented with vision- threatening cytomegalovirus (CMV) retinitis in 1 eye. Prompt diagnosis and treatment with 3 weekly doses of 2 mg/0.1 mL intravitreal ganciclovir resulted in successful healing of CMV ret- initis with restoration of visual acuity. In children with acute lymphoblastic leukemia on exclusive chemotherapy without hem- atopoietic stem cell transplantation, CMV retinitis has been reported in only 1 case in literature. This child was treated suc- cessfully with intravenous ganciclovir. This report highlights the use of successful intravitreal ganciclovir in pediatric age group to avoid side effects of systemic ganciclovir. Key Words: ALL, CMV retinitis, intravitreal ganciclovir (J Pediatr Hematol Oncol 2013;35:e118–e119) C ytomegalovirus (CMV) retinitis is a major sight- threatening condition in neonatal CMV infection and immunocompromised children. Among the immunosup- pressed states, it has been reported frequently in children with acquired immunodeficiency syndrome but has been rarely reported in other immunosuppressive conditions. 1 In pediatric age group, acute lymphoblastic leukemia (ALL) is the most common hematologic malignancy and second most common malignancy overall in children forming the second most common cause of immunosuppression after acquired immunodeficiency syndrome. 2 In children with ALL on exclusive chemotherapy without hematopoietic stem cell transplantation, CMV retinitis has been reported in only 1 case in the literature. 3 The child was treated successfully with intravenous ganciclovir. We report a case of CMV retinitis in an ALL child on treatment with exclu- sive chemotherapeutic regimen in which prompt diagnosis and treatment with intravitreal ganciclovir resulted in successful healing of CMV retinitis with restoration of visual acuity. He is on complete remission with chemotherapy till date. CASE REPORT An 11-year-old male child was referred to our tertiary eye care center for diminution of vision in the left eye (OS) since 3 weeks. At presentation, his best corrected visual acuity was 20/20 in the right eye (OD) and 20/80 in OS. Slit-lamp biomicroscopic examination of the anterior chamber of the right eye was within normal limits, whereas we observed 1 + anterior chamber cellular reaction in the left eye. On indirect ophthalmoscopy, we found healed retinitis lesions in inferior fundus in both eyes along with active retinitis lesions (cream-colored lesions associated with hem- orrhages on posterior pole) in the left eye with no vitreous reaction (Fig. 1). On the basis of clinical picture, we made the diagnosis of healed CMV retinitis in the right eye and active CMV retinitis in the left eye. Systemically, he was suffering from ALL (diagnosed >2 y ago), treated according to UK MRC ALL 2003 protocol 4 in maintenance phase, week 131 of therapy. His systemic therapy comprised intra- venous vincristine (1.5 mg/m 2 /d), oral dexamethasone pulse (6 mg/ m 2 /d for 5 d/mo), oral 6-mercaptopurine (75 mg/m 2 /d), and oral methotrexate (20 mg/m 2 /wk). His systemic workup to rule out CMV involvement of the other organs was negative. Hematologic workup revealed white blood cell count of 2.6  10 3 with absolute neu- tropenia, platelets (47  10 3 millions/L), hemoglobin (8.2 g/dL), and peripheral blood smear showing microcytic hypochromic anemia. We planned to keep right eye under observation. As the lesions in the left eye seemed to threaten the fovea, we did a vit- reous aspiration with intravitreal injection of ganciclovir (2 mg/ 0.1 mL) in OS. Polymerase chain reaction analysis done on vitreous aspirate was positive for CMV. The child showed good response to therapy with healing of all fundus lesions (Fig. 2) after 3 FIGURE 1. Left eye fundus photograph at presentation showing active cytomegalovirus retinitis lesions with associated hemor- rhages on posterior pole and healed lesion in the inferior periphery. Received for publication March 1, 2012; accepted August 22, 2012. From the *Advanced Eye Centre; and wAdvanced Pediatric Centre, Postgraduate Institute for Medical Education and Research, Chandigarh, India. The authors declare no conflict of interest. Reprints: Ramandeep Singh, MS, Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Educa- tion and Research (PGIMER), Sector 12, Chandigarh 160012, India (e-mail: mankoo95@yahoo.com). Copyright r 2012 by Lippincott Williams & Wilkins CLINICAL AND LABORATORY OBSERVATIONS e118 | www.jpho-online.com J Pediatr Hematol Oncol  Volume 35, Number 3, April 2013