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Pradhan SK, Nayak S. Rituximab Induced Rare Cystic Lesion in Lungs in a Nephrotic Child: A Case Report. Indian J Nephrol 2024; 34:528-532. [PMID: 39372608 PMCID: PMC11450870 DOI: 10.25259/ijn_576_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 06/06/2023] [Indexed: 10/08/2024] Open
Abstract
Rituximab has been extensively used for managing B-cell lymphomas due to its anti-CD20 monoclonal antibody activity. Over the last decade, its application has been extended to manage frequent relapsing or steroid-dependent nephrotic syndrome. Its use has been comparatively safe, but few cases of adverse effects on the lung have been reported in the adult population. These lung injury presentations are rarely reported in a pediatric group with only four cases in the literature. Below is a rare case of rituximab-induced lung injury in a 9-year-old boy with frequent relapse of nephrotic syndrome, which developed after four days of rituximab infusion. Suspecting infection and sepsis, several antibiotics were started, but with no improvement in respiratory complaints, even antifungal and antituberculosis treatments were initiated. Finally, setting up a casual relation with the time of infusion to the development of complaints, association with rituximab was suspected. The patient responded to steroid therapy with complete resolution of respiratory complaints. To our knowledge, this is the first reported case of rituximab-induced cystic lesion in lungs from India.
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Affiliation(s)
- Subal K. Pradhan
- Division of Pediatric Nephrology, SVP Post Graduate Institute of Pediatrics (SVPPGIP) and Sriram Chandra Bhanja (SCB) Medical College, Cuttack, Odisha, India
| | - Snehamayee Nayak
- Division of Pediatric Nephrology, SVP Post Graduate Institute of Pediatrics (SVPPGIP) and Sriram Chandra Bhanja (SCB) Medical College, Cuttack, Odisha, India
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Srinivasan S, Roy Moulik N, Kc A, Narula G, Sankaran H, Prasad M, Dhamne C, Cheriyalinkal Parambil B, Shah S, Shet T, Sridhar E, Gujral S, Banavali S. Increased toxicities in children with Burkitt lymphoma treated with rituximab: Experience from a tertiary cancer center in India. Pediatr Blood Cancer 2020; 67:e28682. [PMID: 32865865 DOI: 10.1002/pbc.28682] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/16/2020] [Accepted: 08/18/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Even though rituximab has emerged as standard of care for the management of high-risk pediatric Burkitt lymphoma (BL), its safety in children from the low-middle-income countries (LMICs) remains to be proven. We herein report our experience of using rituximab in children with BL. METHODS All patients diagnosed with BL between January 2015 and December 2017 were treated in a risk-stratified manner with either the modified MCP-842 or modified LMB protocol. Patients with poor response to MCP-842 were switched to the LMB-salvage regimen. In addition, rituximab was given to selected high-risk patients. RESULT Forty-two (49.4%) of 85 patients with BL received rituximab. The incidence of febrile neutropenia (90.5% vs 67.4%; P = 0.02), pneumonia (38.1% vs 11.6%; P = 0.005), intensive care unit admissions (54.5% vs 17.6%; P = 0.002), and toxic deaths (26.2% vs 9.3%; P = 0.04) was higher among BL patients who received rituximab. Pneumonia was fatal in 11 of 16 (69%) patients who received rituximab. On multivariate analysis, rituximab continued to be significantly associated with toxic deaths ( OR: 11.45 [95% CI: 1.87-70.07; P = 0.008]). The addition of rituximab to intensive chemotherapy resulted in an inferior one-year event-free survival (49.4% ± 8.1% vs 79.3% ± 6.5%; P = 0.025) and one-year overall survival (63.1% ± 8.5% vs 91.8% ± 4.5%; P = 0.007) with no improvement in one-year relapse-free survival (78.3% ± 7.3% vs 83.9% ± 6.0%; P = 0.817). CONCLUSION Rituximab was associated with increased toxicities and toxic deaths in our patients. The potential immunomodulatory effect of rituximab and increased susceptibility to infections in patients from LMICs have to be carefully considered while choosing this drug in the treatment of BL in resource-constrained settings.
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Affiliation(s)
- Shyam Srinivasan
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Nirmalya Roy Moulik
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Anand Kc
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Gaurav Narula
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Hari Sankaran
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Maya Prasad
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Chetan Dhamne
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Badira Cheriyalinkal Parambil
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sneha Shah
- Department of Nuclear Medicine, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Tanuja Shet
- Department of Pathology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Epari Sridhar
- Department of Pathology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sumeet Gujral
- Department of Pathology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shripad Banavali
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Kallash M, Smoyer WE, Mahan JD. Rituximab Use in the Management of Childhood Nephrotic Syndrome. Front Pediatr 2019; 7:178. [PMID: 31134169 PMCID: PMC6524616 DOI: 10.3389/fped.2019.00178] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/17/2019] [Indexed: 12/19/2022] Open
Abstract
Childhood nephrotic syndrome is a challenging and often persistent renal disorder, and its incidence varies between different ethnicities and regions. Corticosteroids have been the main treatment for decades and are effective in most children with idiopathic NS, although 10-15% of these children become steroid resistant. Furthermore, some initially steroid sensitive children follow a steroid dependent or frequently relapsing course and are therefore at increased risk for developing steroid toxicity. In such children, alternative immunosuppressive medications are used to induce and/or maintain remission of NS. One such drug, rituximab, is a monoclonal antibody directed against the B lymphocyte CD20 marker which induces depletion of B cells, and has shown promising results in the management of NS in children. In this review, we summarize recent studies on the efficacy and safety of rituximab in the different types of childhood nephrotic syndrome, the known and potential mechanisms of action of rituximab, its possible complications and side effects, and the available and potential biomarkers of rituximab activity.
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Affiliation(s)
- Mahmoud Kallash
- Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
| | - William E Smoyer
- Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
| | - John D Mahan
- Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
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Bonanni A, Calatroni M, D'Alessandro M, Signa S, Bertelli E, Cioni M, Di Marco E, Biassoni R, Caridi G, Ingrasciotta G, Bertelli R, Di Donato A, Bruschi M, Canepa A, Piaggio G, Ravani P, Ghiggeri GM. Adverse events linked with the use of chimeric and humanized anti-CD20 antibodies in children with idiopathic nephrotic syndrome. Br J Clin Pharmacol 2018; 84:1238-1249. [PMID: 29436729 PMCID: PMC5980330 DOI: 10.1111/bcp.13548] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 01/19/2018] [Accepted: 02/04/2018] [Indexed: 12/27/2022] Open
Abstract
AIMS Anti-CD20 antibodies are increasingly being used to treat idiopathic nephrotic syndrome (INS) in children. While they may allow steroid and calcineurin inhibitor withdrawal, repeated infusions of anti-CD20 antibodies are often required to maintain remission. Data on their potential toxicity in INS are needed, to consider repeated infusions. METHODS We investigated the side effects associated with the use of rituximab (a chimeric antibody; 130 patients) and ofatumumab (a humanized antibody; 37 patients) in children with INS (steroid-dependent and steroid/calcineurin inhibitor-dependent disease) treated at a national referral centre over a 9-year period (400 treatments; follow-up 1-9 years). RESULTS Infusion reactions were mainly absent in children with steroid-dependent disease. Rash, dyspnoea, fever, cough and itchy throat (5% and 18% following rituximab and ofatumumab infusion, respectively) were resolved by using premedication with salbutamol. Other short-term reactions (up to 3 months), including arthritis (2%) and lung injury (1%), were more common with rituximab. Infections were observed 3-9 months following infusion, were similarly common in the two groups and resolved with targeted therapies [antibiotic, fluconazole, immunoglobulins (Igs), etc.]. The number of circulating CD19/20 cells fell to 0 at month 1 and were reconstituted at month 3; circulating IgG antibodies remained within the normal range for 1 year. Tetanus and hepatitis B virus immunization was not modified by either treatment; Epstein-Barr virus and John Cunningham virus activation markers were occasionally observed. CONCLUSION Overall, the toxicity of anti-CD20 monoclonal antibodies was limited to post-infusion side effects in children with more complex disease. The relatively safe profile of anti-CD20 antibodies supports their use as steroid-sparing agents in children with INS.
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Affiliation(s)
- Alice Bonanni
- Division of Nephrology, Dialysis, TransplantationIRCCS Giannina GasliniVia Gerolamo Gaslini 5Genoa16148Italy
- Laboratory of Molecular NephrologyIRCCS Giannina GasliniGenoaItaly
| | - Marta Calatroni
- Dialysis and Transplantation Policlinico IRCCS Fondazione San Matteo and University of PaviaPaviaItaly
| | - Matteo D'Alessandro
- Division of Nephrology, Dialysis, TransplantationIRCCS Giannina GasliniVia Gerolamo Gaslini 5Genoa16148Italy
| | - Sara Signa
- Division of Nephrology, Dialysis, TransplantationIRCCS Giannina GasliniVia Gerolamo Gaslini 5Genoa16148Italy
| | - Enrica Bertelli
- Division of Nephrology, Dialysis, TransplantationIRCCS Giannina GasliniVia Gerolamo Gaslini 5Genoa16148Italy
| | - Michela Cioni
- Laboratory of Molecular NephrologyIRCCS Giannina GasliniGenoaItaly
| | - Eddi Di Marco
- Department of Translational MedicineIstituto Giannina GasliniLargo G. Gaslini 5Genoa16147Italy
| | - Roberto Biassoni
- Department of Translational MedicineIstituto Giannina GasliniLargo G. Gaslini 5Genoa16147Italy
| | - Gianluca Caridi
- Laboratory of Molecular NephrologyIRCCS Giannina GasliniGenoaItaly
| | - Giulia Ingrasciotta
- Division of Nephrology, Dialysis, TransplantationIRCCS Giannina GasliniVia Gerolamo Gaslini 5Genoa16148Italy
- Specialization School in PediatricsUniversity of BresciaItaly
| | - Roberta Bertelli
- Laboratory of Molecular NephrologyIRCCS Giannina GasliniGenoaItaly
| | | | - Maurizio Bruschi
- Laboratory of Molecular NephrologyIRCCS Giannina GasliniGenoaItaly
| | - Alberto Canepa
- Division of Nephrology, Dialysis, TransplantationIRCCS Giannina GasliniVia Gerolamo Gaslini 5Genoa16148Italy
| | - Giorgio Piaggio
- Division of Nephrology, Dialysis, TransplantationIRCCS Giannina GasliniVia Gerolamo Gaslini 5Genoa16148Italy
| | - Pietro Ravani
- Division of NephrologyUniversity of Calgary1403‐29th Street NWCalgaryABT2N 2T9Canada
| | - Gian Marco Ghiggeri
- Division of Nephrology, Dialysis, TransplantationIRCCS Giannina GasliniVia Gerolamo Gaslini 5Genoa16148Italy
- Laboratory of Molecular NephrologyIRCCS Giannina GasliniGenoaItaly
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Bonanni A, Bertelli E, Panicucci C, D'Alessandro M, Moscatelli A, Lampugnani E, Sacco O, Magnano GM, Ravani P, Ghiggeri GM. Ofatumumab-associated acute pneumonitis: Not new but still the first case. Pharmacol Res Perspect 2016; 5:e00267. [PMID: 28596831 PMCID: PMC5461639 DOI: 10.1002/prp2.267] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 08/18/2016] [Accepted: 08/26/2016] [Indexed: 11/28/2022] Open
Abstract
Ofatumumab is an anti‐CD20 humanized monoclonal antibody utilized in the treatment of several clinical conditions resistant to other treatments. In spite there was a general expectation that ofatumumab was less toxic compared to rituximab, side effects have been reported that resemble those of its anti‐CD20 chimeric precursor. Here, we describe the first case of Ofatumumab associate lung injury occurring in a 14‐year‐old boy affected by nephrotic syndrome dependent to prednisone plus cyclosporine A who had been treated with the dose of drug utilized in nephrotic syndrome (1500 mg/173 m2). The patient developed the full blown picture of rituximab associated lung injury (RALI) after 45 days from ofatumumab infusion at the end of the steroid tapering: severe exertional dyspnea, mild fever and cyanosis, with CT scan showing diffuse ground glass areas in both lungs and DLCO (diffusing capacity of transfer factor of the lung for carbon monoxide) test suggestive for reduction of CO diffusion. Clinical outcome was good with rapid improvement and normalization of all parameters without any specific therapy. After 60 days, chest CT and CO diffusion tests were normal. In conclusion, we describe here the first case of acute pneumonitis associated with ofatumumab that presents the same clinical, laboratory, and radiology features of the lung injury reported for rituximab. Like RALI occurring in patients treated for nephrotic syndrome, this case had a mild clinical expression and recovered in a few months.
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Affiliation(s)
- Alice Bonanni
- Division of Nephrology, Dialysis, Transplantation Giannina Gaslini Children's Hospital Via Gerolamo Gaslini 5 Genoa 16148 Italy
| | - Enrica Bertelli
- Division of Nephrology, Dialysis, Transplantation Giannina Gaslini Children's Hospital Via Gerolamo Gaslini 5 Genoa 16148 Italy
| | - Chiara Panicucci
- Division of Nephrology, Dialysis, Transplantation Giannina Gaslini Children's Hospital Via Gerolamo Gaslini 5 Genoa 16148 Italy
| | - Matteo D'Alessandro
- Division of Nephrology, Dialysis, Transplantation Giannina Gaslini Children's Hospital Via Gerolamo Gaslini 5 Genoa 16148 Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric ICU Department of Critical Care and Perinatal Medicine Giannina Gaslini Children's Hospital Via Gerolamo Gaslini 5 Genoa 16148 Italy
| | - Elisabetta Lampugnani
- Neonatal and Pediatric ICU Department of Critical Care and Perinatal Medicine Giannina Gaslini Children's Hospital Via Gerolamo Gaslini 5 Genoa 16148 Italy
| | - Oliviero Sacco
- Division of Pneumology Giannina Gaslini Children's Hospital Via Gerolamo Gaslini 5 Genoa 16148 Italy
| | - Gian Michele Magnano
- Division of Radiology Giannina Gaslini Children's Hospital Via Gerolamo Gaslini 5 Genoa 16148 Italy
| | - Pietro Ravani
- Division of Nephrology University of Calgary 1403-29th Street NW Calgary Alberta T2N 2T9 Canada
| | - Gian Marco Ghiggeri
- Division of Nephrology, Dialysis, Transplantation Giannina Gaslini Children's Hospital Via Gerolamo Gaslini 5 Genoa 16148 Italy
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