Early-Onset Neutropenia Induced by Rituximab in a Patient with Lupus Nephritis and Hemolytic Anemia

Abstract

Rituximab is an anti-CD20 monoclonal antibody that has been used to treat several complications of systemic lupus erythematosus (SLE) including nephritis, cerebritis, and hematological disorders. Neutropenia is among the adverse events associated with rituximab; this usually occurs several weeks after therapy. However, early-onset neutropenia has been reported only in a few cases. Herein, we describe a 36-year-old Hispanic SLE woman who developed severe early-onset neutropenia (0.3 × 109/L) after the second weekly rituximab infusion (375 mg/m2 weekly × 4) given for nephritis and hemolytic anemia. She also had early-onset thrombocytopenia after rituximab therapy. Both hematological disorders resolved 12 days after the fourth and final dose. This case, together with few others, suggests that early-onset neutropenia may occur during rituximab therapy. Even though rituximab-induced neutropenia seems to be transient, it may predispose SLE patients to severe complications such as infections.

Death and kidney allograft dysfunction after bacteremia

“…Similar to sepsis, each hour of delay in the initiation of effective antibiotics led to an 18 % increase in the 28-day mortality risk [20]. In addition, we consider that rituximab may induce earlyonset neutropenia in case 3 [21]. The characteristics of Although UTI was the leading cause of bacteremia, respiratory tract infections were the primary cause of infections requiring ICU admission (accounted for 54 %) in KTR [22].…”

Early-onset neutropenia after rituximab therapy for bullous pemphigoid

“…Two forms of rituximab‐induced neutropenia have been described: early‐onset neutropenia (EON) occurs within 4 weeks of treatment initiation, while late‐onset neutropenia (LON) occurs at least 4 weeks after termination of the drug . LON has been described more frequently than EON, which is uncommonly reported . We present a unique case of EON after rituximab in a patient with refractory BP.…”

“…Although rituximab possesses an excellent safety profile, neutropenia is a known idiosyncratic adverse effect (AE) of the drug . Two forms of rituximab‐induced neutropenia have been described: early‐onset neutropenia (EON) occurs within 4 weeks of treatment initiation, while late‐onset neutropenia (LON) occurs at least 4 weeks after termination of the drug . LON has been described more frequently than EON, which is uncommonly reported .…”

“…Rituximab‐induced EON is rare, reported in only six patients; four with systemic lupus erythematosus and two with neuromyelitis optica (Table ). Including our present case, all patients were female, with an average age of 35 years.…”

Favorable outcome of granulocyte colony-stimulating factor use in neuromyelitis optica patients presenting with agranulocytosis in the setting of rituximab

“…One case of LON has been reported in an NMO patient (Plate et al, 2014). In contrast, early-onset rituximab-induced neutropenia has been described in SLE (Gottenberg et al, 2005; Enríquez et al, 2007), and early-onset agranulocytosis has also been reported (Arroyo-Ávila et al, 2015) but early-onset agranulocytosis has not yet been reported in NMO. We reported two cases of early on-set rituximab-induced agranulocytosis in NMO.…”