On Sunday, the Resident doctor told us that if Beth had her second negative CMV result today, she’d get to come home. Well, her CMV results came back negative today, and so we are very hopeful. I will let you know.
Watching the CMV numbers
Dr Rossetti stopped by today, and of all the things Beth is suffering from (“one day at a time”), the thing that represents the most danger is the CMV virus, which manifests no symptoms. Nevertheless, here’s why this is dangerous:
Patients who have received marrow transplants undergo ablative chemotherapy and/or radiation. A period of neutropenia and a loss of specific antigen reactivity follow. All transplant recipients have a period of decreased CMV-specific cell-mediated immunity. The next step is unknown; however, patients at greatest risk for CMV disease develop viremia (virus in the blood). The role viremia plays in the pathophysiology of CMV disease is unknown.
Life-threatening CMV pneumonia may develop in immunocompromised patients, with the incidence varying based on the type of transplant received. Patients who receive marrow, lung, heart, heart-lung, liver, pancreas-kidney, and kidney transplants have different levels of immunosuppression. Those most at risk include bone-marrow transplant recipients and recipients of lung transplants. In patients who have received marrow transplants, CMV disease is most likely 30-60 days after transplant. Fatal CMV pneumonia is much less common in patients who have received solid organ transplants than in those who have received marrow transplants. Patients may initially present with an asymptomatic infiltrate on chest radiograph.
Beth’s numbers on this viral infection are going up and down. She is receiving Ganciclovir (“Cytovene”), an antiviral, for this. We should be getting more “titer” numbers on this tomorrow.
We’re going to have to sit on pins and needles for a bit
This is serious enough to be concerned about it. I mentioned that Beth has tested positive for two viral infections. I’ve got an inquiry into the doctor, but it seems to me that, while they are treating these things aggressively, they can become serious enough to cause serious worry.
BK Virus: “BKV is a particular problem. BKV is a human polyoma virus that is ubiquitous in the environment and infects children at an early age. Although the most effective treatment has not been established, there has been some success with antiviral agents such as cidofovir and vidarabine. Preventive methods include mesna (2-mercaptopurine sodium sulfonate) combined with forced diuresis and continuous bladder irrigation.” An earlier journal says: “Mesna and forced diuresis are equally effective in abrogating the urothelial toxicity of preparative regimens for BMT. Since HC after BMT is virtually always associated with persistent BK viruria, strategies aimed at the prevention or elimination of viruria in BK seropositive recipients are warranted.”
CMV Virus: “As a consequence, T-cell chimerism after BMT should give a positive prognosis with respect to control of CMV.”
She seems to be covered with respect to the T-cell chimerism; as for BK, she’s got the urinary tract infection symptoms, and also, orange urine. They are giving her lots of IV fluids. On top of this, she’s got the old MRSA infection (at least it’s present enough for them to bring out the yellow gowns), and so it seems as if we’re going to have to sit on pins and needles for a bit.