Cytomegalovirus Reactivation in Myeloma?

Cytomegalovirus reactivation in myeloma treatments can be serious. When I read studies like the ones linked below, I feel like I should know about “cytomegalovirus” and how common they are, yet how they can cause serious problems for the relapsed/refractory MM patient.

As MM patients know, diagnosis, remission, relapse, remission, relapse, etc, etc. takes a serious toll on our immune system. As we also know, most MM patients are older and may have weakened immune systems to begin with.

I know that there will be times when MM patients don’t feel like eating, moving, have difficulty sleeping, and feel stressed. My goal in writing this post is to present MM patients with a possible problem and then present all possible solutions in an effort to give the MM patient as many tools as possible.

CMV and other viral reactivations in patients with RRMM treated with BCMA-targeted bispecifics

The solution? Enhance your immune system. While your oncologist will focus on conventional, FDA-approved therapies, I think the MM survivor should also focus on evidence-based non-conventional immune enhancement practices.

MYELOMA IMMUNE-SUPPORT CHECKLIST

Daily Integrative Plan to Reduce Infection Risk

1. NUTRITION (Daily)

✔ Protein goal: 1.0–1.2 g/kg/day (supports antibody and T-cell recovery)
✔ High-fiber foods (25–35 g/day): beans, lentils, oats, berries, vegetables
✔ 1–2 servings of fermented foods (if ANC > 1.0): yogurt, kefir, kimchi, miso
✔ Anti-inflammatory focus: olive oil, nuts, seeds, leafy greens, berries
✔ Mushrooms (shiitake, maitake, or reishi extract once daily)
✔ Green tea (1–2 cups/day) for antiviral/immune support
✔ Hydration goal: 6–8 cups fluids/day

2. MICRONUTRIENTS (Daily, Based on Labs)

✔ Vitamin D: dose adjusted to keep levels 40–60 ng/mL
✔ Zinc 15–30 mg/day (limit to 8–12 weeks unless monitored)
✔ Vitamin C 500 mg/day (or citrus/berries)
✔ Magnesium glycinate 200–400 mg/day
✔ Omega-3s (if approved by oncologist; avoid pre-transplant)

3. GUT SUPPORT (Daily)

✔ Glutamine powder 5–10 g twice daily (if approved; helps gut barrier)
✔ Probiotics ONLY if ANC > 1.0 and no central line problems
✔ Avoid processed sugar + alcohol (damages gut immunity)

4. MOVEMENT (Daily)

✔ 30 minutes brisk walking OR
✔ Three 10-minute walks
✔ Light resistance exercise 2–3×/week
→ Supports neutrophil mobility, NK cells, and lowers inflammation

5. SLEEP (Nightly)

✔ Target 7–9 hours
✔ Night wind-down: no screens 1 hr before bed
✔ Magnesium glycinate or calming herbal tea
✔ Morning sunlight exposure

6. STRESS REGULATION (Daily)

✔ 5 minutes breathing (box breathing or 4-7-8)
✔ Meditation 5–10 minutes
✔ Nature exposure or short outdoor walk
→ Reduces inflammation and supports immune activity

7. ACUPUNCTURE (Weekly or Bi-Weekly)

✔ For sleep, nausea, anxiety, fatigue, neuropathy
→ Indirect but meaningful immune benefit

8. MEDICAL PROTECTION (Critical)

✔ Take all antivirals (acyclovir/valacyclovir)
✔ Keep vaccinations current: flu, COVID, RSV, pneumococcal
✔ Ask about IVIG if IgG is low or infections recurrent
✔ Follow your oncologist’s antibiotic prophylaxis plan
✔ Report any fever > 100.4°F immediately (do NOT wait)

9. RED FLAGS TO AVOID

✘ Probiotics if neutropenic (ANC < 1.0)
✘ Herbal immune stimulants (echinacea, astragalus) unless oncologist approves
✘ High-dose antioxidants during active chemotherapy without guidance
✘ Raw or unpasteurized foods when immunosuppressed

I am a MM survivor and cancer coach. Living with MM since my diagnosis in 1994 has taught me that MM patients and survivors should focus on both conventional and non-conventional therapies.

Scroll down the page and post a question or comment if you’d like to learn more about managing your MM.

Hang in there,

David Emerson

MM Survivor
MM Cancer Coach
Director PeopleBeatingCancer

Cytomegalovirus (CMV) infection

Overview

A cytomegalovirus (CMV) infection is a condition caused by a common virus. The CMV virus stays in the body for life after infection.

CMV spreads from person to person through body fluids. These include blood, saliva, urine, semen and breast milk.

Symptoms of a CMV infection can include a fever, fatigue and a sore throat. But the virus rarely causes symptoms in healthy people. If you’re pregnant or if your immune system is weakened, CMV is cause for concern. Pregnant people with an active CMV infection can pass the virus to their babies. The babies might then have symptoms.

For people who have weakened immune systems, CMV infection can be fatal. The risk is especially high for people who’ve had an organ, stem cell or bone marrow transplant.

Cytomegalovirus reactivation is frequent in multiple myeloma patients treated with daratumumab‐based regimens

Background

Viral reactivations are frequent in hematologial patients due to their cancer‐related and drug‐induced immunosuppressive status. Daratumumab, an anti‐CD38 monoclonal antibody, is used for multiple myeloma (MM) treatment, and causes immunosuppression by targeting CD38‐expressing normal lymphocytes. In this single‐center two‐arm real‐life experience, we evaluated incidence of cytomegalovirus (CMV) reactivation in MM patients treated with daratumumab‐based regimens as first‐ or second‐line therapy…

Conclusion

Our single‐center retrospective experience showed that daratumumab might significantly increase the risk of CMV reactivation in MM, while currently underestimated and related to morbility and mortality in MM patients under treatments. However, further validation on larger and prospective clinical trials are required…

Cytomegalovirus reactivation during treatment with bispecific antibodies for relapsed/refractory multiple myeloma

Three BsAbs are approved for RRMM treatment, including two targeting B-cell maturation antigen (BCMA), teclistamab and elranatamab, and one targeting G protein–coupled receptor class C group 5 member D (GPRC5D), talquetamab.

While BsAbs are generally safe and well-tolerated, infectious complications are common during treatment [4,5,6]…

Two recent reports of RRMM patients treated with BsAbs, observed CMV reactivation rates as high as 49% [7, 8]…

In conclusion, CMV reactivation is a common occurrence during BsAb therapy for RRMM. Surveillance is best reserved for CMV seropositive patients. We suggest weekly CMV surveillance in patients treated with steroids for CRS during the first month of treatment. Testing frequency may be adjusted depending on the presence and trend of CMV DNAemia but should continue for the first three months. Finally, the potential impact of CMV reactivation on clinical outcomes warrants further investigation.

Cytomegalovirus reactivation in myeloma Cytomegalovirus reactivation in myeloma

Recently Diagnosed or Relapsed? Stop Looking For a Miracle Cure, and Use Evidence-Based Therapies To Enhance Your Treatment and Prolong Your Remission