I recently looked at the JAMA clinical challenge, written by Drs Bradley Christensen, Hsiao Li, and Sergio Huerta, entitled “Blurred Vision and Gastrointestinal Bleeding in a Patient with HIV.”
The case described the situation of a 57-year-old man with five months of epigastric pain and 15 pound weight loss, HIV/AIDS with a CD4 of 16, and liver masses which had a biopsy demonstrating B-cell lymphoma, for which he was treated with antiretrovirals and chemotherapy.
Four weeks later, he developed sudden bright red blood per rectum, tachycardia, and extravasation in the jejunum from a branch of the superior mesenteric artery. He underwent surgery on his small intestine, and pathology demonstrated acute inflammation of the lamina propria with cytoplasmic and nuclear inclusions surrounded by a clear halo (“owl eye”). Then, he developed blurred vision, and was diagnosed with CMV retinitis and hemorrhagic enteritis. He was treated with oral valganciclovir, IV ganciclovir, and maintenance gancyclovir, as well as chemotherapy, and has gotten much better, with a CD4 count of 337.
I don’t have much of a comment regarding the medical management of the case. My concern is that in 2022 we continue to have patients presenting with advanced HIV/AIDS and CD4 counts of 16. They should be diagnosed much earlier in their course. And ideally, with a variety of preventive methods including PrEP, these HIV infectious should never happen in the first place. But we need a single payer / Medicare-for-all system to fix this “leaky cascade.” We need to rebuild our community health centers and public health infrastructure nationwide – this must be an urgent priority.
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Philip A. Lederer 
If the ART had been given earlier at a higher CD4 count, would the end-organ CMV disease have been prevented?
Possibly.
preventable suffering