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Please prepare and upload your E-Poster no later than March 14, 2026 11.59PM CET. After this date, you will no longer be able to prepare and upload your E-poster and it will not be displayed and accessible on the congress website.
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Late-onset neutropenia (LON) is an occasionally observed condition following rituximab (RTX) administration. Most reports describe its occurrence once or, at most, twice after RTX administration. Here, we report a case of anti-glomerular basement membrane (anti-GBM) nephritis that developed LON five times after RTX administration.
A 52-year-old woman was admitted to our hospital with gross hematuria. On admission, serum creatinine level was 2.43 mg/dL, C-reactive protein 20.8 mg/dL, and urinalysis showed proteinuria (2+) and hematuria (3+). Despite broad-spectrum antibiotic therapy for a presumed acute pyelonephritis, the inflammatory response did not improve and renal function worsened (creatinine 4.02 mg/dL). Rapidly progressive glomerulonephritis was suspected, and a renal biopsy was performed. Light microscopy revealed crescentic glomerulonephritis, and immunofluorescence demonstrated linear IgG deposits along the glomerular capillary walls. Serum anti-GBM antibody was markedly elevated (> 680 U/mL), confirming the diagnosis of anti-GBM nephritis.Treatment was initiated with methylprednisolone pulse therapy (1 g/day), daily plasma exchange (14 sessions in total), and cyclophosphamide pulse therapy (3 sessions). However, anti-GBM antibody level remained positive (24.8 U/mL), and renal function continued to deteriorate. RTX (375 mg/m²) was therefore administered. Nevertheless, renal function worsened further (creatinine 12.0 mg/dL) with uremic symptoms, requiring arteriovenous shunt creation and initiation of hemodialysis.
Forty-eight days after RTX administration, she developed severe neutropenia (neutrophils 140/μL). We discontinued all medications that could cause neutropenia. Filgrastim was administered, resulting in rapid recovery. Bone marrow examination was normal, suggesting LON. Ninety days after RTX administration, neutropenia recurred (neutrophils 567/μL), which again responded promptly to filgrastim. As urine output increased and renal function improved, dialysis was discontinued 122 days after RTX admission. Anti-GBM antibody subsequently became negative. However, further episodes of neutropenia occurred 186 and 235 days after RTX administration (neutrophils 490/μL and 540/μL, respectively), each resolving after filgrastim administration. Bone marrow aspirations showed no abnormalities. A fifth episode of mild neutropenia (neutrophils 1,090/μL) occurred 382 days after RTX administration, but no further recurrences were observed. Notably, no infectious complications occurred throughout the course.
LON following RTX administration usually occurs once or twice, and recurrent episodes are often associated with repeated rituximab dosing. We report a rare case of five episodes of LON after a single RTX administration. In patients with anti-GBM nephritis, careful monitoring for LON is warranted after treatment with cyclophosphamide and rituximab.
