Infective endocarditis complicating rituximab (anti-CD20 monoclonal antibody) treatment in an SLE patient with a past history of Libman–Sacks endocarditis: a case for antibiotic prophylaxis?

Infective endocarditis complicating rituximab in a lupus patient with lupus nephritis and dilated cardiomyopathy: case report and review of literature

Background

Systemic lupus erythematosus is a chronic multisystem disease that has a considerable morbidity and mortality. Rituximab is used in treating some severe manifestations of systemic lupus erythematosus; however, it may expose patients to serious infections. We report a case of post rituximab infective endocarditis as the second case in literature described in patients with SLE.

Case presentation

A 17-year-old male diagnosed as systemic lupus erythematosus with lupus nephritis and dilated cardiomyopathy received rituximab and underwent upper endoscopy and colonoscopy investigating iron deficiency anemia. Later on the patient developed septic shock secondary to infective endocarditis and passed away.

Conclusions

Infective endocarditis is a possible complication after rituximab therapy in lupus patients with lupus nephritis and dilated cardiomyopathy. Prophylactic antibiotics may be considered in those patients in the settings of gastrointestinal endoscopies.

Infective endocarditis in a patient with lupus nephritis who was undergoing immunosuppressive therapy: A case of survival

Systemic lupus erythematosus is an autoimmune disease associated with mild valvular regurgitation. However, there have been no detailed reports of infective endocarditis in patients with systemic lupus erythematosus. Here, we describe a case of a 55-year-old woman without any cardiac abnormalities who was diagnosed with lupus nephritis by renal biopsy; she contracted infective endocarditis while receiving immunosuppressive therapy. Our case emphasizes that special consideration of the occurrence of infective endocarditis, and its early diagnosis and treatment are mandatory for patient survival. We propose that echocardiography should be performed before treating patients with systemic lupus erythematosus who have an uncertain cardiac status.

Risk of infective endocarditis in patients with systemic lupus erythematosus in Taiwan: a nationwide population-based study

Objectives Patients with systemic lupus erythematosus are considered vulnerable to infective endocarditis and prophylactic antibiotics are recommended before an invasive dental procedure. However, the evidence is insufficient. This nationwide population-based study evaluated the risk and related factors of infective endocarditis in systemic lupus erythematosus. Methods We identified 12,102 systemic lupus erythematosus patients from the National Health Insurance research-oriented database, and compared the incidence rate of infective endocarditis with that among 48,408 non-systemic lupus erythematosus controls. A Cox multivariable proportional hazards model was employed to evaluate the risk of infective endocarditis in the systemic lupus erythematosus cohort. Results After a mean follow-up of more than six years, the systemic lupus erythematosus cohort had a significantly higher incidence rate of infective endocarditis (42.58 vs 4.32 per 100,000 person-years, incidence rate ratio = 9.86, p < 0.001) than that of the control cohort. By contrast, the older systemic lupus erythematosus cohort had lower risk (adjusted hazard ratio 11.64) than that of the younger-than-60-years systemic lupus erythematosus cohort (adjusted hazard ratio 15.82). Cox multivariate proportional hazards analysis revealed heart disease (hazard ratio = 5.71, p < 0.001), chronic kidney disease (hazard ratio = 2.98, p = 0.034), receiving a dental procedure within 30 days (hazard ratio = 36.80, p < 0.001), and intravenous steroid therapy within 30 days (hazard ratio = 39.59, p < 0.001) were independent risk factors for infective endocarditis in systemic lupus erythematosus patients. Conclusions A higher risk of infective endocarditis was observed in systemic lupus erythematosus patients. Risk factors for infective endocarditis in the systemic lupus erythematosus cohort included heart disease, chronic kidney disease, steroid pulse therapy within 30 days, and a recent invasive dental procedure within 30 days.

Double-valve replacement for mitral and aortic regurgitation in a Patient with Libman-Sacks endocarditis

A 53-year-old woman with systemic lupus erythematosus and antiphospholipid syndrome presented with central nervous system (CNS) lupus and vegetation of the mitral and aortic valves. Her CNS lupus was relieved with methylprednisolone pulse therapy; however, her mitral regurgitation worsened, and she developed acute decompensated heart failure. The mitral and aortic valves were replaced with mechanical heart valves. Microscopic examination of the excised valves showed no bacterial invasion, and Libman-Sacks (LS) endocarditis of both valves was confirmed. This was a case of LS endocarditis with clear vegetation that spread over the mitral and aortic valves.

Rituximab in systemic lupus erythematosusA systematic review of off-label use in 188 cases

The complexity of the therapeutic approach in systemic lupus erythematosus (SLE) is increased by the large number of patients who do not respond to the first-line therapies and by relapses after initial clinical remission. In these patients, second-line drugs are often prescribed according to individual clinical decisions. The emergence of biological therapies has increased the therapeutic armamentarium available in these complex situations, but their use is limited by the lack of licensing. Available data on the use of rituximab in SLE rely on a large number of case reports and some observational studies. We analyzed current evidence on the therapeutic use of rituximab in adult SLE patients by a systematic review of reports included in the PubMed database between 2002 and 2007. A total of 188 SLE patients treated with rituximab were identified; 171 (91%) patients showed a significant improvement in one or more of the systemic SLE manifestations. There were 103 patients with lupus nephritis, with an overall rate of therapeutic response of renal involvement of 91%. Adverse events were reported in 44 (23%) patients; the most frequent were infections (19%). Although it is not yet possible to make definite recommendations, the global analysis of all cases reported to date support the off-label use of rituximab in severe, refractory SLE cases, whereas its use as a first-line therapy or in patients with a predominantly mild form of the disease is not advised.

[Anti-B-cell strategies in vasculitides and collagenoses]

B-cells play a central role in the pathogenesis of autoimmune diseases. As already discussed in other articles, besides the production of potentially pathogenic autoantibodies, B-cells may function as antigen-presenting cells, may induce T-cell activation and produce various cytokines. The feasibility of targeting B-cells in patients with severe and refractory autoimmune disorders, especially in patients with vasculitis or connective tissue diseases, has met growing interest among rheumatologists in recent years. The use of rituximab as a monoclonal antibody directed against CD20 positive B-cells has been reported in case reports and small patient series; however, these are hard to compare as different diseases are described and different doses and schedules of rituximab were used. It has to be considered that positive reports are more likely to be reported than patients who do not improve or experience side effects. Data on only a few indications from randomized, double-blind studies are available; however, even these results should be evaluated critically.