Delayed-Onset Grade 4 Neutropenia Associated with Rituximab Therapy in a Patient with Lymphoma: Case Report and Literature Review

Abstract

A 53-year-old man developed delayed-onset neutropenia 6 weeks after completing first-line therapy with rituximab, cyclophosphamide, mitoxantrone, vincristine, and prednisone for high-grade B-cell lymphoma. Bone marrow biopsy demonstrated hypercellular marrow with normal maturation. He also developed interstitial pneumonitis, an adverse event associated with rituximab use. Infiltrates of T cells were found in the patient's lungs. For the next 6 months, the patient required subcutaneous granulocyte colony-stimulating factor 300 mug twice/week to maintain a granulocyte count above 1000 cells/mm3. He also received oral antibiotics for mouth sores and thrush. Based on the existing evidence, monitoring blood counts for as long as 8 weeks after rituximab therapy may be advisable, although the literature reports that neutropenia can develop up to 1 year after treatment. The development of a registry and uniform testing may help uncover the cause of this delayed-onset neutropenia.

HIV-Associated Burkitt Lymphoma: Good Efficacy and Tolerance of Intensive Chemotherapy Including CODOX-M/IVAC with or without Rituximab in the HAART Era

“…This complication appears to be rituximab related, as has been described in HIV-negative patients. Although late neutropenia appeared to be equally distributed among patients receiving PI-based versus non-PI-based HAART, interactions between antiretroviral agents and chemotherapy medications resulting in increased marrow toxicity cannot be ruled out [44, 45]. …”

Rituximab associated neutropenia: Description of three cases and an insight into the underlying pathogenesis

“…Whereas some authors described the appearance of RAN during treatment [8,9], this phenomenon was usually reported after the completion of treatment, generally within 28 to 204 days afterwards [3,4,10,11]. The duration of RAN varies between four days and one year [3,10–12].…”

Hyperinfection by Strongyloides stercoralis probably associated with Rituximab in a patient with mantle cell lymphoma and hyper eosinophilia

“…In vitro evidence shows that Rituximab works with the human immune system to induce B-cell lysis through an antibody-dependent cell-mediated cytotoxicity, complement-dependent cytotoxicity and stimulates apoptosis 2 . It can also induce neutropenia 18 . There are reports in which Rituximab alone or its addition to standard chemotherapy schedules for lymphoma has increased the risk of lifethreatening infections, either opportunistic or not, such as bacterial, fungal, protozoan, viral and viral reactivations 3 .…”