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

Abstract

Rituximab is a highly effective agent that is used in the treatment of B-cell lymphoma. Rituximab-induced acute thrombocytopenia is a rare side effect that has previously been reported in a small number of patients with malignant lymphoma; its mechanism is still unknown. We herein report the case of a 74-year old man who was diagnosed with follicular lymphoma and who developed severe acute thrombocytopenia the day after the administration of rituximab. Coagulation abnormality, which mimicked disseminated intravascular coagulation, also appeared. When physicians use rituximab to treat high-risk patients, the platelet count should be closely monitored to avoid possible adverse events.

Rapidly increasing off-label use of rituximab in multiple sclerosis in Sweden - Outlier or predecessor?

“…Overviews of the safety profile of RTX in haematology reported infections (PML, spinal epidural abscess, viral hepatitis reactivation), haematologic disorders (acute thrombocytopenia and late onset neutropenia) and secondary malignancies . Importantly, in MS patients treated with RTX, cases with enterovirus encephalitis have been reported (pers.…”

Spontaneous Splenic Rupture and Rituximab-Induced Acute Thrombocytopenia in a Patient with High-Risk Mantle Cell Lymphoma

“…5 of the 22 cases reports developed coagulopathy with the thrombocytopenia [9, 19–21, 24], suggesting consumption coagulopathy; however, our patient's coagulation studies remained normal. 12 cases attempted retrial of rituximab [9, 10, 12, 15–18, 23, 24] with 6 developing recurrence of thrombocytopenia [9, 10, 12, 15, 16, 24], making it difficult to decide clinically whether to continue it or not. It is likely that RIAT is underreported as it is not routine to monitor platelet counts after rituximab as most rituximab is given in the outpatient setting, and if the thrombocytopenia is mild-moderate, it may be overlooked.…”

“…There are 22 case reports of this, and the majority of these have been in mantle cell lymphoma patients [9–25]. Omura et al [9] listed the characteristics of these patients and noted the underlying diagnoses included mantle cell lymphoma ( n =13) [10–18], hairy cell Leukemia ( n =3) [11, 19, 20], follicular lymphoma ( n =2) [9, 21], prolymphocytic Leukemia ( n =1) [22], lymphoplasmacytic Lymphoma ( n =1) [23], pre-B cell acute lymphoblastic leukemia ( n =1) [24], and autoimmune haemolytic anaemia ( n =1) [25]. From the available characteristics given in these case reports, all had bone marrow infiltration and splenomegaly similar to our patient.…”

Pathophysiology and Diagnosis of Drug-Induced Immune Thrombocytopenia

“…A moderately low platelet count is relatively common upon exposure to these agents, but more severe thrombocytopenia has also been reported in a few patients. The drugs involved are efalizumab (anti-CD11a) [63,64], adalimumab [65] and infliximab (anti-TNF, tumor necrosis factor) [28,29], bevacizumab (anti-VEGF) [27,66], rituximab (anti-CD20) [30,31], natalizumab (anti-α 4 β 1 -integrin) [32], and immune checkpoint antibodies to program cell death receptor-1 (PD-1) or cytoxic T-lymphocyte antigen 4 (CTLA-4), such as nivolumab, pembrolizumab, or ipilimumab [33,67]. Although the clinical evolution in most cases suggests that antibodies are involved in platelet destruction, their presence has never been firmly demonstrated.…”