Cytomegalovirus

You're interrogating every major failure point simultaneously.

You've got to immediately pull a comprehensive metabolic panel, ABGs, lactates, full talk screens, and this massive viral panel, not just hep A through E, But Epstein-Barr, CMV, herpes, varicella, plus autoimmune markers like ANA and seroplasmin.

And if they have even a hint of altered mental status, they go straight to the scanner for a head CT.

You have to mobilize those resources immediately.

I use a mnemonic for this exact situation, LUCASS, L-U-C-C-A-A-S-S, lung, urine, cardiac, CNS, arthritis, abdomen, skin, and spine.

You do also need to think about CMV reactivation and invasive fungal disease in patients with multiple myeloma.

Let's move on to musculoskeletal issues.

Osteolytic bone disease is present in 70% of these patients.

Yeah.

I, I just, like, always try to, like, emphasize this, is that, uh, why is it that in patients with DKA, we worry about, like, mucormycosis, while with patients with HIV, we worry, for example, about CMV or Nocardia or, or, uh, et cetera.

So there's, like, very different organisms even though they're both immunocompromised.

And I think it's all about which arm of the immune system is down.

It's possible that they could be related, but I think it would be, um, in the patient's best interest to work them up separately initially.

Um, one way, you know, if we just think of the thrombocytopenia, I think I'm putting the sequestration category low because we're not seeing any evidence of splenomegaly, so I'm really in the, is this an underproduction issue or a peripheral destruction? We're not seeing any evidence of schistocytes or hemolysis, so now I'm wondering, is this more of a bone marrow underproduction, um, process? And when you think of that, I think a next important, um, part of the workup in thrombocytopenia is thinking of infections.

Um, and those include, um, herpes viruses like EBV, CMV, HIV.

You can also think of kind of tick-borne infections.

It filters out the infection, and then it puts ozone into the blood of the person, and then we put the blood back in the person.

It's about a 90-minute session, but when we do that therapy over, let's say you do it three or four times with somebody, I mean, the results with that we, the results that people see, again, with the things we talked about like Lyme or Epstein-Barr virus or CMV, and even seeing results with, you know, to your point, herpes and some of these other types of viral infections, they really are tremendous.

And so there's two things.

I think there's a great benefit of hyperbaric oxygen therapy, of driving oxygen deep into the bone and the organs and those tissues.

You know, of course, it could be what's going on in the lungs, you know, a part of what's going on in the lungs, but, like, a progressive lymphocytosis that's getting worse, uh, over a few days, that's, uh, it would be very atypical for tuberculosis to kinda take off like that from a hematological perspective.

The other infectious causes of lymphocytosis to consider, the mononucleosis, uh, viruses, right? So EBV, CMV.

Is it possible that this patient had CMV pneumonitis because they are immunosuppressed, um, from ha-having IgA myeloma? Remember that patients with IgA myeloma, even before they get chemotherapy, are immunosuppressed, right? Their immunoglobins don't work.

Functionally hypogammaglobulinemic.

So that makes them at risk of a lot of atypical infections.

So could this patient have, yeah, like a CMV pneumonitis? Even EBV can rarely affect the, the lung that is now taking off, 'cause it'd be more typical for a virus to take off as quickly than, like, a tuberculosis or honestly like a subacute granulomatous infection.

The other one that we, is always mentioned is, like, Bordetella pertussis.

[laughs] You know, I just mentioned it 'cause the patient's having some respiratory symptoms, so it's just like in all the, in fact, ID books for, like, lymphocytosis.

You know, seeing that context, speaking of, of subtext as well, it makes sense that people would identify Djokovic as having long COVID.

The tennis player admitted that he had COVID in December 2021, but here's the problem: He's won a number of major tournaments since, so he'd most likely have to have been infected recently for it to be true, or not, as it turns out, because we're gonna turn to some new research out of Boston Children's Hospital that found COVID-19 can reactivate dormant viruses that have been hiding in the body, including Epstein-Barr, as well as CMV and other herpes viruses.

There was a surprising result to this study.

This is a total nightmare.

And looking at even the CD4/CD8 ratio, bigger than two point five, but it-- Now, you can use that as a quick test of really someone's biologic age.

Especially if they're below one, they're in trouble, and those people usually have, like, CMV.

So this is just looking at, we'll talk about immunosenescence.

The cells, they're kinda at the end of their replication life.

What happens is now the cells, the-- you, you tend to have, uh, an ability to suppress infections, so you have all these chronic infections.

Like, let's say someone with Lyme, and then they'll get T-cell exhaustion, also, uh, immunosenescence, so they'll get Epstein-Barr, HHV6, uh, mycoplasma.

Now, CMV is a marker for immunosenescence in particular.

Um, that's well-studied.