Cytomegalovirus reactivation during adult acute lymphoblastic leukemia maintenance: do we underestimate (un)expected guest of pediatric approach?

Among acute lymphoblastic leukemia (ALL), 40% of affected patients are diagnosed after the age of 20. Compared to pediatricians, adult hemato-oncologists are less familiar with complex pediatric ALL regimens and have perceived that pediatric ALL regimens are too toxic in the adult population. Meanwhile, multiple retrospective analyzes showed the superiority of pediatric regimens among the older adults and young adolescents (AYAs) group over adult regimens. A series of prospective studies have made it apparent that pediatric-inspired ALL regimens are feasible in AYAs, with manageable toxicities and potentially more encouraging results. However, the complications in the adult population are still to be explored. Although cytomegalovirus (CMV) viremia and infections are increasingly recognized in pediatric ALL cases, we generally do not experience it frequently in adult cases with conventional strategies. Herein we represent a 38-year-old man diagnosed with ALL and treated with pediatric inspired GRAALL-2003 protocol. Following a successful induction phase, he had pancytopenia, deep lymphopenia, fever and diarrhea in the 9th month of maintenance therapy. With increased serum ferritin and triglyceride levels, he had features of macrophage activation syndrome. The bone marrow biopsy did not reveal any relapse or hemophagocytosis. We detected highly increased levels of CMV DNA (657.262 copies/mL) in blood analysis

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“Let food be thy medicine and let medicine be thy food.” This aphorism refers to the pivotal role played by nutrition in medicine. The door of a “nutrition renaissance” has been opened with the striking disclosure of the relationship between nutrition and microbiota in the pathogenesis of many diseases, which has been better understood in the recent years. A person, once again, is “what he/ she eats.” Foods become “functional” after their integration into the unique features of the intestinal immune system, such as oral tolerance, secretory Immunoglobulin A, local lymphoid foci, regulator cellular immunity, and diversity of commensal microbiome. It is possible to achieve strong immunomodulatory effects through an appropriate selection of probiotics, prebiotics, and synbiotics. Animal proteins and plant-derived peptides also exert immunomodulatory effects. It has been reported that the use of glutamine supplements from wheat protein (gluten) in patients helps in lowering the nosocomial infection rate and the duration of mechanical ventilation. Vitamin A contributes immensely in maintaining the mucosal epithelial integrity and aids in strengthening the neutrophil response to infectious agents. Vitamin B12 has a strong immunomodulatory effect and facilitates the increase in CD8+ T lymphocyte count and natural killer cell activity. Vitamin C has well-defined antioxidant efficacy. Vitamin D strengthens the innate immune response by stimulating cell proliferation and differentiation. The regulatory effects of many foods and food ingredients such as turmeric, garlic, carrot, eggplant, kiwi, and honey in our kitchen on both innate and adaptive immunity serve as the foundation for anticancer, anti-inflammatory, and antioxidant nutrition therapies. Thus, our food continues to be our medicine. Keywords: Food, immunomodulator, probiotic, vitamin, minera