Rituximab

Abstract

Lack of efficacy: case report A 44-year-old woman exhibited lack of efficacy following treatment with rituximab for systemic lupus erythematosus (SLE)associated thrombotic thrombocytopenic purpura like microangiopathic haemolytic anaemia [route and dosage not stated]. The woman who had a history of SLE and mechanical mitral valve replacement presented to the hospital for abdominal pain and black stools. Hence, to control SLE, she was treated with mycophenolate mofetil, prednisone, and azathioprine. Upon further investigation; acute renal failure, pancytopenia, thickened gallbladder and small erosions in the stomach was noted. Further rheumatology findings showed elevated dsDNA and low C3/C4 which were attributed to SLE flare-up. Hence, for the 3 days, she was treated with IV methylprednisolone. Subsequently, temporarily improvement was noted in thrombocytopenia, however, no improvement was noted in renal failure. Hence, a renal biopsy was performed which showed IV lupus nephritis with crescentic glomerulonephritis. Thereafter, for lupus nephritis, she was treated with mycophenolate mofetil and prednisone. Later, her warfarin was replaced with heparin drip. In this period, her thrombocytopenia got aggravated, and she developed acute encephalopathy into the hospital. Further, low haptoglobin and high lactate dehydrogenase (LDH) was noted, which were consistent with the hemolytic process. Her all laboratory findings consisted of underlying anaemia of chronic inflammation and antiphospholipid syndrome. The reason for her altered mental status was unknown. Hence, for possible SLE-associated ITP, she was treated with rituximab. However, she did not respond to rituximab. Her renal function and azotemia got worsen. Hence, hemodialysis was initiated. Thrombotic thrombocytopenic purpura (TTP)-like microangiopathy associated with her SLE was treated preemptively with PLEX. Further, to confirm the diagnosis, mycophenolate mofetil was kept on hold. Following it, gradual improvement was noted in her platelets. Also, after the second session of PLEX, her LDH became normal. Later, mycophenolate-mofetil was restarted. She remained on hemodialysis and PLEX with significant improvement in her platelets and renal function. Her clinical course was consistent with SLE-associated TTP-like microangiopathic haemolytic anaemia. Later, her hemodialysis discontinued.