Fever During Alemtuzumab Therapy
Clinical Vignette
A 61-year-old man with Sezary syndrome is receiving alemtuzumab as salvage therapy with intent to bridge to allogeneic stem cell transplantation. He had no prior transplant exposure. Baseline CMV serology before treatment is IgG positive.
He is now in week 5 of alemtuzumab therapy. He reports malaise, low-grade fever, anorexia, and increasing fatigue over several days but no dysuria, diarrhea, or focal skin findings. He is taking trimethoprim-sulfamethoxazole prophylaxis.
Examination shows temperature 38.2 C, heart rate 106/min, blood pressure 112/68 mmHg, and oxygen saturation 97% on room air. There is no new rash, no oral ulceration, and no focal pulmonary findings. Chest radiograph is unrevealing. Blood cultures are negative to date.
His absolute neutrophil count is 0.8 x 10^9/L and lymphocyte count is profoundly suppressed. Alemtuzumab-associated disease progression and opportunistic infection are both being considered.
Question
Which opportunistic infection should be highest on the differential?
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Question 2
Serum CMV PCR is checked and returns at 5,400 IU/mL. What is the most appropriate next step in management?
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References
George J, Mozessohn L, Lam PW. Cytomegalovirus infection risk with alemtuzumab therapy in hematological malignancies: a retrospective cohort study in the non-transplant setting. Leukemia & Lymphoma. 2024;65(11):1716-1723.
O'Brien SM, Keating MJ, Mocarski ES. Updated guidelines on the management of cytomegalovirus reactivation in patients with chronic lymphocytic leukemia treated with alemtuzumab. Clin Lymphoma Myeloma. 2006;7(2):125-130.
Ljungman P, de la Camara R, Robin C, et al. Guidelines for the management of cytomegalovirus infection in patients with haematological malignancies and after stem cell transplantation from the 2017 European Conference on Infections in Leukaemia (ECIL 7). Lancet Infect Dis. 2019;19(8):e260-e272.