Introduction:
Rituximab is a genetically engineered chimeric murine/human monoclonal IgG1 kappa antibody directed against the CD20 antigen. Rituximab has been associated with hypersensitivity reactions (HSRs), which can be classified as infusion-related, cytokine-release, type I (IgE/non-IgE), mixed, type III, and type IV reactions. Immediate infusion-related reactions to rituximab are quite common and decrease in frequency with subsequent infusions. However, severe infusion-related reactions develop in about 10% of patients, which prevents its use. Some of the immediate infusion reactions are due to cytokine release, but some raise concerns for type I (IgE/non-IgE) hypersensitivity. Recent studies have shown the presence of serum anti-rituximab antibodies, represented by the IgG or IgE isotype.
Methods:
A 17-year-old girl, a known case of Systemic lupus erythematosus was diagnosed in 2021, with antiphospholipid syndrome. A kidney biopsy done in 2022 confirmed the diagnosis of lupus nephritis class IV. She was on tacrolimus 2 mg, mycophenolate mofetil 1 g bid, prednisolone telmisartan-amlodipine 80mg-10mg, and hydroxychloroquine 300 mg daily, unfortunately she was uncompliant with her medications. She presented to the emergency room with complaints of joint pain mainly in the left-hand small joints and left knee. She was admitted with a lupus flare-up with oliguric AKI. Her creatinine on admission was 165 micromol/L peaked at 391 micromol/L with severe acidosis and hyperuricemia 923 micromol/L and she was started on hemodialysis. Her urine analysis showed RBCs >100 x10^6 and a protein creatinine ratio of 5.74 g/g, her C3 and C4 were very low. She underwent a kidney biopsy which showed diffuse lupus nephritis ISN/RPS Class IV-G, active with membranous lupus nephritis ISN/RPS Class V. She was started on plasma exchange for her severe flareup, and received rituximab infusion after the third session which was complicated by severe allergic reaction. She had severe swelling of her tongue with severe oral bleeding complicating her angioedema. She had an emergency tracheostomy underwent bilateral lingual artery embolization and was admitted to intensive care.
Results:
She completed 5 sessions of plasma exchange and remained on dialysis-dependent for 3 months. Her admission was complicated by bilateral thigh cellulitis with necrotic changes and necrotizing fasciitis was ruled out. She underwent multiple surgical debridement and her wound condition improved. Her renal function improved dramatically, her urine output increased gradually to more than 1 L and her repeat lupus markers showed normal double-stranded DNA and high normal C3 and C4. MMF was increased to 1g.
Conclusions:
Rituximab can cause a life-threatening reaction, part of the treatment includes emergency tracheostomy for airway compromise, IV steroids, and plasma exchange following the rituximab exposure that can remove up to 50 % of the amount. Our patient had renal recovery and was dialysis-free at 3 months of her hospitalization.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.