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Filikci Z, Jensen RM, Thorup Sellebjerg F. Inflammatory vaginitis associated with long-term rituximab treatment in a patient with multiple sclerosis. BMJ Case Rep 2022; 15:15/11/e250425. [DOI: 10.1136/bcr-2022-250425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We describe inflammatory vaginitis as a potential side effect of long-term rituximab treatment for multiple sclerosis in the absence of any other systemic disease or underlying malignancy.More studies are needed to characterise the incidence of inflammatory vaginitis among women on long-term rituximab therapy.
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Breneman AN, Eber AE, Haque H, Levine L, Askanase A, Riley CS, Pomeranz MK, Hassan D, Mancebo SE, Polin M, Melamed A, Bordone LA, Rosser M, Gockley A, Gallitano SM. Vulvovaginal Pyoderma Gangrenosum in a Patient Treated With Ocrelizumab for Multiple Sclerosis. J Low Genit Tract Dis 2022; 26:189-191. [PMID: 35256568 DOI: 10.1097/lgt.0000000000000661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Alyssa N Breneman
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Ariel E Eber
- Department of Dermatology, Columbia University Irving Medical Center, New York, NY
| | - Hoosna Haque
- Division of Gynecology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Libby Levine
- Department of Neurology and Multiple Sclerosis Center, Columbia University Irving Medical Center, New York, NY
| | - Anca Askanase
- Department of Rheumatology, Columbia University Irving Medical Center, New York, NY
| | - Claire S Riley
- Department of Neurology and Multiple Sclerosis Center, Columbia University Irving Medical Center, New York, NY
| | - Miriam Keltz Pomeranz
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY
| | - Dahlia Hassan
- Department of Rheumatology, Columbia University Irving Medical Center, New York, NY
| | - Silvia E Mancebo
- Department of Dermatology, Weill Medical College of Cornell University, New York, NY
| | - Melanie Polin
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Alexander Melamed
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Lindsey A Bordone
- Department of Dermatology, Columbia University Irving Medical Center, New York, NY
| | - Mary Rosser
- Division of Gynecology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Allison Gockley
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
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Abstract
OBJECTIVE To summarize clinical outcomes of paradoxical pyoderma gangrenosum (PG) onset in patients on biologic therapy. METHODS The authors conducted MEDLINE and EMBASE searches using PRISMA guidelines to include 57 patients (23 reports). RESULTS Of the included patients, 71.9% (n = 41/57) noted PG onset after initiating rituximab, 21.1% (n = 12/57) noted tumor necrosis factor α (TNF-α) inhibitors, 5.3% (n = 3/57) reported interleukin 17A inhibitors, and 1.8% (n = 1/57) reported cytotoxic T-lymphocyte-associated protein 4 antibodies. The majority of patients (94.3%) discontinued biologic use. The most common medications used to resolve rituximab-associated PG were intravenous immunoglobulins, oral corticosteroids, and antibiotics, with an average resolution time of 3.3 months. Complete resolution of PG in TNF-α-associated cases occurred within an average of 2.2 months after switching to another TNF-α inhibitor (n = 1), an interleukin 12/23 inhibitor (n = 2), or treatment with systemic corticosteroids and cyclosporine (n = 3), systemic corticosteroids alone (n = 1), or cyclosporine alone (n = 1). CONCLUSIONS Further investigations are warranted to determine whether PG onset is associated with underlying comorbidities, the use of biologic agents, or a synergistic effect. Nevertheless, PG may develop in patients on rituximab or TNF-α inhibitors, suggesting the need to monitor and treat such adverse effects.
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Yockey L, Dowst S, Zonozi R, Huizenga N, Murphy P, Laliberte K, Rosenthal J, Niles JL, Mitchell CM. Inflammatory vaginitis in women on long-term rituximab treatment for autoimmune disorders. BMC WOMENS HEALTH 2021; 21:285. [PMID: 34353326 PMCID: PMC8340364 DOI: 10.1186/s12905-021-01423-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 07/07/2021] [Indexed: 12/04/2022]
Abstract
Background Consequences of long-term B cell depletion with rituximab are not well understood. We describe inflammatory vaginitis as a potential side effect of long-term rituximab treatment, distinct from previously described vulvovaginal pyoderma gangrenosum. Methods We performed a retrospective analysis of women treated with rituximab for more than 1 year to determine the prevalence and clinical characteristics of vaginitis cases. We conducted a case–control analysis with up to 3 controls for each vaginitis case. Results We identified sixteen inflammatory vaginitis cases. Women with vaginitis were age 23–68 (median 42), primarily being treated for ANCA-associated vasculitis (11/16; 69%). Most reported copious vaginal discharge (100%) and pain with sex (75%). All women with return of circulating B-cells to > 10 cells/mL had complete (5/9) or significant (4/9) improvement in symptoms. In case–control analysis there was no significant difference in length of B-cell depletion, immune parameters, creatinine levels, and history of neutropenia. Conclusion Inflammatory vaginitis is a potential side effect of prolonged continuous B cell depletion with rituximab. More studies are needed to characterize the incidence and etiology of vaginitis among women on long term rituximab therapy and establish a causal relationship.
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Affiliation(s)
- Laura Yockey
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sarah Dowst
- Division of Nephrology, Vasculitis and Glomerulonephritis Clinic, Massachusetts General Hospital, Boston, MA, USA
| | - Reza Zonozi
- Division of Nephrology, Vasculitis and Glomerulonephritis Clinic, Massachusetts General Hospital, Boston, MA, USA
| | - Noah Huizenga
- Division of Nephrology, Vasculitis and Glomerulonephritis Clinic, Massachusetts General Hospital, Boston, MA, USA
| | - Patrick Murphy
- Division of Nephrology, Vasculitis and Glomerulonephritis Clinic, Massachusetts General Hospital, Boston, MA, USA
| | - Karen Laliberte
- Division of Nephrology, Vasculitis and Glomerulonephritis Clinic, Massachusetts General Hospital, Boston, MA, USA
| | - Jillian Rosenthal
- Division of Nephrology, Vasculitis and Glomerulonephritis Clinic, Massachusetts General Hospital, Boston, MA, USA
| | - John L Niles
- Division of Nephrology, Vasculitis and Glomerulonephritis Clinic, Massachusetts General Hospital, Boston, MA, USA
| | - Caroline M Mitchell
- Department of Obstetrics and Gynecology, Vincent Center for Reproductive Biology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
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Sotzen JR, Stratman EJ. Vulvovaginal pyoderma gangrenosum associated with rituximab use in 2 patients with rheumatoid arthritis. JAAD Case Rep 2021; 10:75-77. [PMID: 33778138 PMCID: PMC7985273 DOI: 10.1016/j.jdcr.2021.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Erik J. Stratman
- Correspondence to: Dr. Erik J. Stratman, Department of Dermatology, Marshfield Clinic, 3P2, 1000 N Oak Ave, Marshfield, WI 54449.
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Abstract
Neutrophilic drug reactions are unique eruptions that can affect hospitalized patients and share a common pathophysiology with neutrophils as the key mediators of inflammation. They range in clinical presentation from papules and plaques to bullae and erosions to pustules. Although there is some overlap in presentation, each has distinguishing features that aid the clinician in differentiation from one another and from other drug hypersensitivity reactions. Much of the data on these reactions are from case reports and series or retrospective review studies. There are limited prospective observational studies dedicated to these adverse drug reactions. We review the more common and life-threatening neutrophilic drug reactions, their proposed mechanism of action, and their management.
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Affiliation(s)
- Alexandra J Coromilas
- Department of Dermatology, Columbia University Medical Center, New York, New York, USA
| | - Stephanie M Gallitano
- Department of Dermatology, Columbia University Medical Center, New York, New York, USA.
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Aggarwal P. Pyoderma gangrenosum adverse event with Rituximab use: A postmarketing pharmacovigilance analysis. Dermatol Ther 2020; 33:e13221. [PMID: 31925868 DOI: 10.1111/dth.13221] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 12/29/2019] [Indexed: 12/11/2022]
Abstract
Rituximab is a monoclonal antibody that is used for the treatment of certain malignancies and autoimmune conditions. Pyoderma gangrenosum is a rare painful ulcer that can be fatal in some cases and can also reoccur after treatment. The objective of this paper was to analyze whether a statistically significant signal exists between Rituximab and pyoderma gangrenosum in the Food and Drug Administration Adverse Event Reporting System (FAERS). A disproportionality analysis was carried out on cases from January 1, 2004 to March 31, 2019 in the FAERS. Frequentist methods of relative reporting ratio, reporting odds ratio (ROR), and proportional reporting ratio (PRR) and the Bayesian-based IC025 metric were used in order to assess the adverse event signal. Thirty-two cases were found in FAERS in which the drug Rituximab was administered and pyoderma gangrenosum was reported as an adverse event. The lower 95% CI of the information component was 0.97, the lower 95% CI of ROR was 2.18, the PRR was 3.09 and Chi-squared was 42.16, which indicates a statistically significant signal. The signal is supported by six case reports in the literature that describe a total of 14 patients who developed pyoderma gangrenosum after Rituximab administration. When administering Rituximab, clinicians should monitor for the occurrence of symptoms representing pyoderma gangrenosum.
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DaCunha M, Siscos S, Downing M, Tarantino I, Hall J. Pyoderma gangrenosum controlled with rituximab. JAAD Case Rep 2019; 5:593-595. [PMID: 31312710 PMCID: PMC6610635 DOI: 10.1016/j.jdcr.2019.04.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Matthew DaCunha
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Spyros Siscos
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Malia Downing
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Isadore Tarantino
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
| | - John Hall
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
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Sadowsky LM, Clark MA, Schlosser BJ. Pyoderma gangrenosum of the vulva treated with mycophenolate mofetil and infliximab. Dermatol Ther 2019; 32:e12905. [DOI: 10.1111/dth.12905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 04/05/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Lauren M. Sadowsky
- Department of DermatologyNorthwestern University Feinberg School of Medicine Chicago Illinois
| | - Melanie A. Clark
- Department of DermatologyMedical College of Wisconsin Milwaukee Wisconsin
| | - Bethanee J. Schlosser
- Department of DermatologyNorthwestern University Feinberg School of Medicine Chicago Illinois
- Department of Obstetrics and GynecologyNorthwestern University Feinberg School of Medicine Chicago Illinois
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