Should CD4 Levels be Monitored in a Patient on Temozolomide?

Introduction: Temozolomide is an alkylating agent, indicated in the treatment of refractory anaplastic astrocytoma and newly diagnosed glioblastoma. We describe a case of bacteraemia associated with septic arthritis in the setting of concurrent temozolomide use.

Case: A 67-year-old woman presented with acute onset of bilateral knee pain and swelling. She had a medical history of glioblastoma multiforme treated with temozolomide. Synovial fluid analysis and blood cultures revealed S. typhimurium, confirming a diagnosis of bacteraemia associated with septic arthritis.

Conclusion: We conclude that chemotherapy with temozolomide and corticosteroid use will increase an individual's susceptibility to a wide variety of opportunistic infections akin to HIV-associated acquired immunodeficiency syndrome (AIDS). Furthermore, we hypothesize a possible benefit of monitoring CD4 levels and prophylaxis against opportunistic infections (based on the CD4 levels) in individuals receiving temozolomide-based chemotherapy, similar to HIV-AIDS.

Learning Points: Chemotherapy with temozolomide and corticosteroid use will increase an individual's susceptibility to a wide variety of opportunistic infections akin to HIV-associated acquired immunodeficiency syndrome (AIDS).There may be a benefit in monitoring CD4 levels in patients who are receiving temozolomide.Given selective CD4 lymphopenia while on temozolomide, there may be a possible benefit of prophylaxis against opportunistic infections in individuals based on their CD4 levels, similar to HIV-AIDS (current guidelines recommend considering pneumonia prophylaxis for patients receiving concomitant radiotherapy and temozolomide, and high-dose steroids).