What Is the Relationship Between CLL and Infections?

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As part of our “Ask the Expert” series, CLL expert, Dr. William Wierda from MD Anderson Cancer Center in Houston discusses how CLL affects the immune system and the infections or viruses that CLL patients may be at a higher risk for due to their disease. Dr. Wierda also provides advice to patients for monitoring symptoms and when to alert their doctor. 

The Ask the Expert series is sponsored through an educational grant to the Patient Empowerment Network from Pharmacyclics, Inc.

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Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you

Jeff Folloder:

Another question we've received wants to know: What is the relationship between infections and CLL?

Dr. Wierda:

Well, CLL is a malignancy of B cells.  B cells are immune cells of the system.  They are cells that make antibody, and they have some other functions in the immune system.  They are—when they are present with—in patients who have CLL, when they are present they have the unique capability of confusing the immune system and making the immune system so that it doesn't function normally.

And so patients who have a diagnosis of CLL have a suppressed immune system because of the disease and because of the presence of those B cells that are abnormal and can have the unique capability of confusing and disregulating the immune system.  That makes patients at risk for infections, and the infections that we can see are some bacterial infections.  Pneumonia can be a problem.  Skin infections can be a problem.

The other feature—in untreated patients who just have the CLL present the other feature that we see is reactivation of some viruses that the immune system usually keeps dormant, and these are virus—herpes viruses—so herpes virus, herpes simplex virus, but more importantly a virus that's called varicella-zoster, which is the chickenpox virus.

And so for some—for not an insignificant number of patients with CLL in the absence of any treatment, but if the disease is there, they can have reactivation of varicella and develop shingles.  And so varicella reactivation is what causes shingles, which is a skin outbreak due to this virus that's become reactivated. So there's—even in the absence of treatment when there's CLL cells, there the immune system doesn't work normally.

Another feature that we see is patients' antibody levels drop over time in the absence of treatment.  Their antibody levels will trend down.  We don't really know the mechanism for why this happens, but it is—it does put them at increased risk for infections.

And then another compounding factor for patients with CLL is that when they get treatments the treatments deplete the immune system.  They are very effective at getting rid of the leukemia cells, but they also get rid of some of the normal cells that are responsible for immune function and your ability to mount an immune response.

So we see depletion of immunity with treatment and that the immune system doesn't recover real quickly, so it will take many months, sometime a year or two for patients who are in remission, don't have any leukemia there, for their immune system to reconstitute and redevelop so that their risk for infection is back to normal or—or thereabouts.

Jeff Folloder:

So our visitors want to know what do they need to keep an eye out for? What do they need to be reporting to their doctors along these lines?

Dr. Wierda:

So the things that I tell my patients in clinic are with regard to infection, if they have a fever, fever over 101 then, they should be more motivated to call their doctor, let their doctor know that they're having a fever.  And I have lower threshold for patients with CLL to start them on antibiotics if they have fever because they do have a bit harder time throwing off infections, and, as I mentioned, pneumonia can be a significant infection that patients have difficulty—difficulty getting over.  So fever is an important feature to monitor for.

If they have skin outbreak or a rash that likes like zoster, or shingles, then as soon as they have any symptoms or any indications of having a shingles outbreak, they need to call their doctor because you can—patients can be put on an antibiotic for the varicella virus that minimizes the outbreak.

One of the complications from shingles is what's called postherpetic neuralgia.  So after the shingles outbreak resolves, the nerves in the skin become super sensitive and can cause a high degree of pain at the area where the shingles outbreak has occurred.  So doing things to minimize the outbreak and to—to minimize the outbreak will potentially minimize this complication of postherpetic neuralgia.

So if there's a rash—the rash usually happens on one side of the body, it can be a blistering rash—then I would encourage patients to call their doctor and get started on acyclovir or valacyclovir, something of that nature that minimizes the shingles outbreak and can control and reduce the risk for recurrent shingles outbreak.  Those are the two features.

In patients who have a significant infection, if they require intravenous antibiotics or they've been hospitalized for a pneumonia, we do check immunoglobulin levels or antibody levels. And in those individuals who have a low antibody level with a significant infection, I will give replacement antibody or IVIG to build up their antibody levels and in that way minimize their risk for having another significant infection.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you

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Page last updated on July 17, 2014