ALL-243 Cytomegalovirus Reactivation in Adult Acute Lymphoblastic Leukemia Patients during POMP Maintenance Chemotherapy: Do We Underestimate the Dormant Virus?

Abstract

Cytomegalovirus (CMV) is a common herpes virus that infects around 60-100% of adults and is one of the most common pathogens involved in infectious complications post-hematopoietic stem cell transplantation (HSCT). Infections with the CMV can cause complications such as pneumonia, retinitis, and enterocolitis. Studies have shown that HSCT patients are at higher risk for CMV reactivation leading to disease and have high morbidity and mortality rates. Nevertheless, CMV infections have been reported in non-transplant patients, especially in the pediatric population. There are several case reports that highlight the complications of CMV in non-transplant acute lymphoblastic leukemia (ALL) pediatric patients. Very few cases of CMV infections have been reported in non-transplanted adult ALL patients during maintenance chemotherapy. To report a case series on adult ALL, non-transplant patients with CMV disease. We report four adult patients who were diagnosed with ALL, achieved complete remission after induction chemotherapy without HSCT, and then developed CMV disease during their maintenance chemotherapy treatment with mercaptopurine, vincristine, methotrexate, and prednisone (POMP) at the American University of Beirut Medical Center (AUBMC), Lebanon. Four cases of ALL patients (all were males, age range from 20 to 73 years) are reported. Patient 1 presented with sequential vision loss in the 5th month of POMP treatment. Patient 2 presented with fever and diarrhea in the 2nd month of POMP treatment. Patient 3 presented with fever, diarrhea, and respiratory distress in the 11th month of POMP treatment. Patient 4 presented with respiratory distress in the 8th month of POMP treatment. Three patients cleared CMV viremia after first-line treatment with either ganciclovir or valganciclovir, whereas one patient required second-line treatment with Ganciclovir, Foscarnet, and intravenous immune globulin. Our observations and a review of the literature suggest this is a rare entity with potentially high morbidity. The majority of patients develop asymptomatic viremia before manifestations of end-organ damage. Clinicians shall be aware of this entity, especially in patients who are at high risk for developing CMV reactivation and diseases such as those with positive serology and prolonged lymphopenia, which is commonly encountered during the maintenance treatment.