Fludarabine, mitoxantrone, and dexamethasone (FND) and rituximab-FND (R-FND) were the two main regimens used in this period. However, patients.
Ann Hematol DOI 10.1007/s00277-014-2296-5
ORIGINAL ARTICLE
Cytomegalovirus retinitis complicating combination therapy with rituximab and fludarabine Thomas S. Y. Chan & Carol Y. M. Cheung & Ian Y. L. Yeung & Yu-Yan Hwang & Harinder Gill & Ian Y. Wong & Yok-Lam Kwong
Received: 19 May 2014 / Accepted: 27 December 2014 # Springer-Verlag Berlin Heidelberg 2015
Abstract Cytomegalovirus (CMV) retinitis is exceptionally rare outside the clinical context of acquired immunodeficiency syndrome and organ allografting. In a population where seropositivity for past CMV infection exceeded 90 %, CMV retinitis was observed in five of 138 patients (3.6 %) receiving fludarabine-containing regimens together with rituximab, which was significantly more frequent than in 141 patients receiving fludarabine-containing regimens alone, where no case was observed (P=0.029). Treatment of CMV retinitis comprised both intravitreal and systemic ganciclovir/foscarnet. Upon recovery, secondary retinal atrophy occurred in all patients, leading to blindness in 86 % of affected eyes. CMV retinitis is an important complication in patients receiving concomitant rituximab and fludarabine-containing regimens. Keywords Cytomegalovirus retinitis . Fludarabine . Rituximab
Introduction Cytomegalovirus (CMV) retinitis is a manifestation of profound immunosuppression, typically occurring in patients infected with the human immunodeficiency virus (HIV), when the CD4+ T cell count falls below 0.05×109/L [1]. In nonHIV-infected patients, CMV retinitis is exceptional, occurring
mainly in the context of severe iatrogenic immunosuppression, such as after organ allografting or intensive chemotherapy for hematologic malignancies [2]. Even then, it is extremely uncommon. In one of the earliest reports, CMV retinitis occurred in merely 10 (0.17 %) of 5721 hematopoietic stem cell transplantation (HSCT) recipients during a 14-year period [3]. In non-HSCT patients, CMV virologic reactivation was reported to occur in 36 (1.5 %) of 2331 cases of hematologic malignancies during/after chemotherapy, but not a single case of CMV retinitis was recorded [4]. Fludarabine is a potent suppressor of both B and T cells and is mainly used in the treatment of patients with chronic lymphoproliferative disease [5]. Its administration results in severe and protracted suppression of T cells, increasing the risks of opportunistic viral and fungal infections. Rituximab is an anti-CD20 antibody widely used in the treatment of B cell malignancies [6]. Its use is associated with prolonged hypogammaglobulinemia, which predisposes to infections. Fludarabine is most often combined with cyclophosphamide and rituximab (FCR) in treating chronic lymphocytic leukemia (CLL). Although opportunistic infections may occur, CMV retinitis is not a known complication of the FCR regimen. In this report, we describe five cases of CMV retinitis in patients treated with fludarabine and rituximab and discussed the risk factors that might account for its occurrence.
Materials and methods T. S. Y. Chan : C. Y. M. Cheung : Y.
