A case of irreversible bradycardia after rituximab therapy for diffuse large B-cell lymphoma
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A case of irreversible bradycardia after rituximab therapy for diffuse large B-cell lymphoma Nway Le Ko Ko*, Nareg Minaskeian and Hicham Z. El Masry
Abstract This is a case of a middle-aged woman with underlying cardiac conduction system with episodes of AV Wenckebach, who subsequently developed significant AV conduction system abnormalities after receiving one standard dose of Rituximab infusion for diffuse large B-cell lymphoma. Rituximab, being a monoclonal antibody against CD-20 antigen, is effective in treatment of B-cell lymphoma but may also cause bradyarrythmias likely due to the calcium ion channel property of CD-20 antigen. Keywords: Rituximab, High grade AV block, Complete AV block, Bradyarrythmia, Diffuse large B cell lymphoma
Introduction Rituximab is a monoclonal antibody directed against the CD20 antigen. The chimeric antibody has been used in the treatment of B-cell lymphoma and binds to the surface antigen activating complement-mediated cell toxicity. Cardiac complications related to Rituximab have been reported including cardiomyopathy and myocardial infarction. Rituximabinduced cardiac arrhythmias have been rarely reported. We report a patient with sinus dysfunction and paroxysmal high-grade AV block after a single dose of Rituximab used for treatment of diffuse large B cell lymphoma. Case Our patient is a 56-year-old lady with no known cardiovascular condition other than controlled hypertension who presented to our hospital with an insidious onset of bilateral lower extremity lymphedema, and an obstructive uropathy with secondary acute kidney injury. Her initial work up was revealing of a large pelvic mass and extensive lymphadenopathy for which she underwent lymph node, pelvic mass and bone marrow biopsies. A confirmed diagnosis of high* Correspondence: [email protected] Department of Cardiovascular Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
grade lymphoma, most likely a follicular lymphoma transformed into diffuse large B cell lymphoma (DLBCL), required her to be started on R-ECPOCH therapy (Rituximab, Etoposide, Prednisone, Vincristine, Cyclophosphamide and Doxorubicin). Patient reported an excellent pre-morbid functional status, and was a regular volleyball player and a walker prior to the last few months. She received the first dose of Rituximab 375 mg/m2 over 36 h along with Methylprednisolone and Doxorubicin as part of her combination chemotherapy. Patient received a total of 800 mg of Rituximab over 36 h. Upon assessment of the patient, her laboratory parameters revealed chronic microcytic anemia with hemoglobin of 6.9 mg/dl and leukocytosis with white blood cell count of 11 × 109/L with neutrophilia and lymphopenia. Her kidney function and electrolytes were normal. Her echocardiogram was evident for normal biventricular function and global longitudinal strain without any significant valvular anomalies. Initial EKG was apparent for underlying conduction system disease with episodes of AV Wenckebach. In telemetry records, the rhythm had been predominantly in
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