Severe pneumonia with formation of a pulmonary cavity associated with long-term rituximab therapy in multiple sclerosis
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(2020) 2:30
Neurological Research and Practice
LETTER TO THE EDITOR
Open Access
Severe pneumonia with formation of a pulmonary cavity associated with long-term rituximab therapy in multiple sclerosis Carolin Schwake and Ralf Gold*
Abstract Nowadays B-cell depletion via anti-CD20 antibodies is commonly applied in the treatment of multiple sclerosis (MS). Yet, not much is known about infection risks associated with long-term B-cell depletion in the specific context of MS. We present the case of a 45-year-old male patient who developed severe pneumonia following 6 years of rituximab treatment for highly active relapsing-remitting MS. The patient had no additional chronic disease as well as no history of foreign travel. Although the unusual formation of a pulmonary cavity raised suspicion for tuberculosis, repeated testing via bronchoscopy and sputum remained negative. Prolonged antibiotic therapy with piperacillin/tazobactam and amoxicillin/ clavulanate led to complete recovery from symptoms. This case shows the potential risk of serious infections following continuous B-cell depletion in MS and illustrates the importance of future vigilance. Keywords: Multiple sclerosis, Rituximab, Pneumonia, Pulmonary cavity
Introduction Initially emerging from the therapy of B-cell neoplasms, the mouse/human chimeric anti-CD20 antibody rituximab opened new pathways in treatment of autoimmune disease. Off-label use of rituximab was shown to be effective and well-tolerated in relapsing-remitting multiple sclerosis (RRMS) [1]. Nevertheless, data on the safety of long-term rituximab administration in MS are scarce. We herein report the case of a 45-year-old male patient who developed severe pneumonia with formation of a pulmonary cavity following 6 years of rituximab treatment for highly active RRMS. Case report The patient presented to our outpatient clinic for the first time in 2014. He had a history of previously diagnosed, untreated RRMS and suffered from brain stem * Correspondence: [email protected] Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791 Bochum, Germany
symptoms with vertical nystagmus and loss of visual acuity. Because of high clinical and gadoliniumenhancing activity B-cell depleting therapy with rituximab was implemented. The patient received regular infusions of rituximab (500 mg) every six to eight months. Treatment intervals were individualized based on CD19+ B-cell monitoring. Over the time span of 6 years the patient suffered from trigeminal neuralgia and an increasing gait ataxia, but overall his clinical condition remained relatively stable (EDSS 3,5). He had no other chronic disease and no history of foreign travel. In January 2020 the patient developed progressive weakness and night sweats. Because of a productive cough, chest x-ray was performed and revealed an infiltration of the right upper lung. Empiric antibiotic treatment with ampicillin/sulbactam was prescribed for 7 days for community acquired pneumonia. However, 6 weeks later, another x-ray documented t
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