Posterior reversible encephalopathy syndrome after first rituximab transfusion for treatment of granulomatosis with polyangiitis

Abstract

A woman in her 60s developed acute onset headache, blurry vision and encephalopathy a few hours after rituximab infusion, given to treat granulomatosis with polyangiitis. CT scan showed oedema in the posterior circulation area suggesting the diagnosis of posterior reversible encephalopathy syndrome, and an MRI confirmed it. After being treated with aggressive blood pressure control and other supportive measures, her symptoms improved over 3–4 days. This case highlights the need for awareness and early recognition of this rare but serious adverse effect of rituximab. CT scan can be helpful in diagnosis (also to rule out bleeding), but the MRI provides the most accurate diagnosis.

The Efficacy and Safety of Rituximab in ANCA-Associated Vasculitis: A Systematic Review

“…There are some less common side effects of rituximab, including acute myocardial infarction (AMI) [ 90 ], congestive heart failure (CHF) [ 88 ], ruptured aneurysm [ 108 ], venous thromboembolism (VTE) [ 210 ], anorexia nervosa [ 128 ], primary leukoencephalopathy (PML) [ 242 ], complications of orthopedic conditions such as hip replacement and bone fracture [ 211 ], pyomiosis [ 43 ], pyoderma gangrenosum [ 243 ], inflammatory vaginitis [ 244 ], herpes simplex stomatitis [ 222 ], Crohn’s disease [ 245 ], drug-induced pneumonitis [ 229 ], posterior reversible encephalopathy syndrome (PRES) [ 246 , 247 ], and transient visual disturbance [ 32 ]. Accordingly, to prevent such complications or at least minimize them, it was recommended to consider screening for chronic infection [ 235 ] before RTX administration and the employment of preemptive therapies; if necessary, vaccinating against bacterial and viral pathogens, monitoring white cell count and immunoglobulin levels, and prophylaxis against more frequently reported infections [ 232 ].…”