Intended for healthcare professionals

Endgames Case Review

A brushfire in the eye

BMJ 2016; 353 doi: (Published 30 June 2016) Cite this as: BMJ 2016;353:i3075
  1. Mehnaz Khan, vitreoretinal fellow1,
  2. P Kumar Rao, professor2,
  3. Rajesh C Rao, assistant professor3 4
  1. 1Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, USA
  2. 2Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St Louis, MO, USA
  3. 3Department of Ophthalmology and Visual Sciences, WK Kellogg Eye Center, University of Michigan, Ann Arbor, MI 48105, USA
  4. 4Department of Pathology, University of Michigan
  1. Correspondence to: R C Rao rajeshr{at}

A 44 year old man with untreated HIV infection was referred to the department of ophthalmology for routine screening of ocular disease. He reported non-compliance with highly active antiretroviral therapy (HAART) consisting of efavirenz, tenofovir, and emtricitabine, and his CD4 count was below 50×106 cells/L. He had no ocular problems at the time of presentation to his general practitioner.

His visual acuity was normal. Examination of the anterior structures of both eyes was unremarkable. Examination of the right eye identified a white annular edge of haemorrhagic retinitis in a brushfire pattern (fig 1). The fundus of the left eye looked normal.

Fig 1 Fundus photograph of the right eye on presentation showing a white, annular leading edge of retinitis (white arrows) associated with haemorrhage (blue arrow) in a brushfire pattern.


  1. What are the differential diagnoses for retinitis?

  2. What is the diagnosis?

  3. What is the most common cause of blindness in this condition?

  4. What are the available treatments and follow-up recommendations?


1. What are the differential diagnoses for retinitis?

Short answer

Retinitis can be secondary to viral, bacterial, fungal, and parasitic infections; autoimmune conditions; and cancer.


The differential diagnoses include infections—viral (eg, herpes simplex virus (HSV), herpes zoster virus (VZV), cytomegalovirus (CMV)), bacterial (eg, syphilis and tuberculosis), parasitic (eg, toxoplasmosis and Toxocara canis), and fungal (eg, candida) entities. Autoimmune diseases such as Behçet’s syndrome and cancers such as vitreoretinal lymphoma should also be considered. A complete medical history, as well as serological or intraocular fluid analysis (eg, polymerase chain reaction, fungal smear) can help narrow the diagnosis.

2. What is the diagnosis?

Short answer

Cytomegalovirus retinitis.


Our case is a striking example of CMV retinitis with a “brushfire” pattern in an immunocompromised host. Although the diagnosis was largely based on clinical examination, polymerase chain reaction of biopsied intraocular fluid confirmed the presence of CMV.

Occasionally described as a “pizza pie,” “cheese and ketchup,” or “brushfire” retinitis, …

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