CMV Reactivation Monitoring and the Management of Persistent Cytopenias

Dr Jacobson explains cytomegalovirus (CMV) reactivation risk factors, noting higher incidence in patients requiring extensive corticosteroid treatment for toxicity management or those receiving multiple immunosuppressive agents for immune effector cell–associated HLH-like syndrome. These high-risk patients warrant CMV monitoring for 6 to 8 weeks post treatment, along with potential fungal surveillance using beta-glucan and galactomannan assays. Once immunosuppressive effects resolve, routine monitoring can cease unless patients present with concerning symptoms.

Lynch details inpatient monitoring protocols, where patients receiving 3 or more days of dexamethasone (for cytokine release syndrome, neurotoxicity, or HLH) undergo weekly CMV viral load and fungal marker surveillance during hospitalization and continuing through week 6 to 8 post discharge. This systematic approach helps detect low-level reactivation early, allowing prompt intervention. The monitoring intensity depends on individual risk factors rather than routine application to all patients.

Regarding persistent cytopenias, Dr Jacobson notes that 25% to 33% of patients experience day-30 cytopenias, with most recovering by month 6. Her threshold for bone marrow biopsy is 6 months unless other concerning features suggest underlying marrow pathology. The mechanism appears immune-mediated, explaining responsiveness to granulocyte colony stimulating factors for neutropenia and thrombopoietin mimetics for thrombocytopenia. Intravenous immunoglobulin may help given potential autoimmune components, though corticosteroids typically prove ineffective. Ongoing studies investigate emapalumab (interferon-gamma antibody) based on MD Anderson data suggesting interferon-gamma-producing T cells in affected patients' bone marrow.