Disseminated intravascular coagulation-like reaction following rituximab infusion

Abstract

Rituximab generally is a well-tolerated medication used in a variety of haematological and autoimmune conditions. The safety profile of the medication has been reviewed in the literature. Infusion reactions due to cytokine release are the most common side effects. With the increased use of rituximab, there is an increase incidence of cytopenias, most commonly thrombocytopenia and leucopenia. Coagulopathy is quite rare, reported previously in four cases in the literature. We highlighted the clinical course of a 39-year-old patient with precursor B-cell acute lymphoblastic leukaemia who was started on rituximab infusion. The patient developed a cytokine-release syndrome with haemodynamic instability, followed by rapid-onset cytopenias and disseminated intravascular coagulation abnormalities characterised by coagulopathy with fibrinolysis and mucocutaneous bleeding. The report is followed by a review of the literature. It is important to recognise rituximab-induced coagulopathy early as part of the differential diagnosis of thrombocytopenia and disseminated intravascular coagulation following rituximab administration.

Rituximab-induced Acute Thrombocytopenia in a Patient with Follicular Lymphoma: A Case Report and Review of the Literature

“…There have been several reports on the re-infusion of rituximab in patients with RIAT ( Table ). In some cases (including our own), RIAT recurred ( 4 , 8 , 11 , 12 , 17 ). In other cases, there was no recurrence of RIAT after rituximab re-infusion ( 3 , 14 , 15 ).…”

“…Our hypothesized mechanisms of RIAT are as follows. First, in some RIAT cases, including ours, the patient simultaneously developed coagulopathy ( 7 , 13 , 16 , 17 ). Thus, infused rituximab interacts with lymphoma cells, which might activate immune components and cause consumption coagulopathy, which expends platelets ( 17 ).…”

“…First, in some RIAT cases, including ours, the patient simultaneously developed coagulopathy ( 7 , 13 , 16 , 17 ). Thus, infused rituximab interacts with lymphoma cells, which might activate immune components and cause consumption coagulopathy, which expends platelets ( 17 ). Second, platelets have an Fc receptor ( 20 ); thus, rituximab antibodies, which bind to lymphoma cells, also bind the platelets through their Fc receptors, leading to platelet degradation.…”

“…We searched the PubMed database using the terms “rituximab” and “acute thrombocytopenia”. The search yielded a total of 21 cases, the diagnoses of the cases included mantle cell lymphoma (n=13) ( 4 , 6 , 8 - 12 , 14 , 15 ), hairy cell leukemia (n=3) ( 6 , 7 , 13 ), prolymphocytic leukemia (n=1) ( 5 ), lymphoplasmacytic lymphoma (n=1) ( 3 ), follicular lymphoma (n=1) ( 16 ), pre-B acute lymphoblastic leukemia (n=1) ( 17 ), and autoimmune hemolytic anemia (n=1) ( 18 ). Table shows the reports on RIAT.…”

Genetically enhanced T lymphocytes and the intensive care unit

“…It ranges from mild to life threatening and it is an oncologic emergency. CRS can be observed following the previous administration of immune-based therapy drugs, as is the case of rituximab or other monoclonal antibodies [ 127 , 128 ]. This condition appears due to a massive release of cytokines (high levels of IL-6 and IL-12) into the bloodstream, followed clinically by high fever and a sudden fall in blood pressure, tachycardia, as well as hemophagocytic lymphohistiocytosis or macrophage-activation syndrome [ 129 ], even multi-organ failure with potential fatal outcome [ 130 , 131 ].…”