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Infections are both common complications in myeloma patients as well as potential trigger factors for the disease:

  • Infections can precede the onset of active myeloma. The most commonly recognized infections are shingles (varicella zoster) and pneumonia, which prior to the last two decades was typically pneumococcal in type. The compromised immunity associated the evolution of myeloma predisposes to the infections, which in recent years have become more diverse. Viral infections now include: herpes of different types, mononucleosis (EBV: Epstein Barr Virus), hepatitis (A,B,C,D,E...), cytomegalovirus (CMV) human papilloma virus (HPV), and many others. Non-viral infections include the whole range of bacteria, such as streptococcus ("strep"), staphylococcus ("staph"), E. Coli and the like, plus so-called opportunistic infections such as fungal infection, tuberculosis, pneumocystis, and others.
  • The range of potential infections is truly mind-boggling and ever increasing.
  • As soon as treatment starts, the immune suppression (e.g., with steroids, such as prednisone and dexamethasone) and reduction in white blood cell count (particularly neutrophils) increase the risks. The first three months of treatment carry the greatest risk of infection complications. The main sites of infection are the respiratory system (e.g., pneumonia/bronchitis or sinusitis) urinary infections (bladder or kidneys), and skin.
  • The infections that have been linked to myeloma as trigger or causative factors include herpes virus 8 (HHV8), simian virus 40 (SV40) and a cytomegalovirus (CMV) variant called stealth adapted CMV. The role of these viruses is currently unclear. These viruses are also impacted by treatment and may lead to special complications, particularly neurological, since these viruses grow on the nerve tissue.
TABLE 1
Likelihood of Infection and Myeloma Status
STATUS
% CHANCE OF INFECTION
MGUS
no increased risk
Active myeloma at diagnosis
5-15%
During first three months of treatment
30-40%
Dropping to a remission level of:
5-10%
Increasing progressively with recurrent disease to:
40-60% or higher over time*
*During induction and relapse therapy, the chance and severity of infection depend upon several factors including aggressiveness of myeloma, the type of treatment, the presence of an indwelling catheter, and patient age.



What can be done about this constellation of potential infections? The following strategies are frequently recommended:

  • Be alert and aware about the susceptibility to infection. Since the risk varies considerably from patient to patient (from very low to very high risk), it is very important to discuss with your doctor the level of risk in your case. Maybe minimal or no major precautions are required or perhaps quite the contrary.
  • Caution is required. See Table 2 below.
  • Being proactive is the way to avoid infections and reduce the risks of serious complications.
  • Discuss with your doctor if a small face mask and/or a portable air purifier are indicated at times of high risk.
  • Although it is important to avoid sources of infection in day-to-day life (children with infections; crowded places; eating sushi or shellfish), most infections originate internally because of the repressed immune system associated with active myeloma and treatment. The goal is therefore to achieve remission and keep ongoing maintenance treatments as safe and simple as possible.

TABLE 2
What to Do About Infections?
LOW RISK
POSSIBLE ACTIONS
  • No history of infections
  • No active myeloma treatment
  • Normal blood count values
  • No unusual risks of infection exposure
  • Consider flu vaccination
  • Promptly evaluate all possible infections
  • Carry a course of broad spectrum antibiotics when you travel (e.g., Cipro®, Bactrim®)
HIGH RISK
POSSIBLE ACTIONS
  • One or more infections in the past.
  • Low white cell count
  • Ongoing treatment for myeloma, especially high dose therapy
  • Hickman catheter in place
  • Slow recovery and/or complications with prior infections
  • Strongly consider preventative or prophylactic antibiotics to include possibly: virus (e.g., Zovirax®), bacteria (e.g., Cipro® or Biaxin®), fungal (e.g., Diflucan®) pneumocystis (e.g., Bactrim®*).
  • Consider reducing or stopping steroids such as Prednisone or Dexamethasone.
  • Use Neupogen® to improve the white blood cell count if it is low.
  • Remove any catheter or any "foreign object" if it is a problem.
  • Consider high dose intravenous gamma globulin (IVIG) as a preventative.**
*These antibiotics are just examples: others are available.
**Only used in very high risk settings.