Chari Rohit, Abdelghany Youmna, Purcell Madeleine, Kenaa Blaine
University of Maryland School of Medicine, Baltimore, MD, USA.
Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, 110 S Paca Street, 2nd Floor, Baltimore, MD, USA.
BMC Pulm Med. 2025 Jul 28;25(1):359. doi: 10.1186/s12890-025-03802-x.
Rituximab is a chimeric human-mouse immunoglobulin monoclonal antibody with high affinity for CD20 surface antigens expressed by pre-B and B cells that is commonly used as the mainstay for the treatment of B cell non-Hodgkin's lymphomas, including diffuse large B-cell lymphoma (DLBCL). As the drug has become more widely used, rituximab associated Interstitial Lung disease (RTX-ILD) is being recognized as potential complication (Non-infectious pulmonary toxicity of rituximab: a systematic review| Rheumatology| Oxford Academic).
We discuss a 73-year-old woman with newly diagnosed DLBCL who underwent chemotherapy and immunotherapy with rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine sulphate, and prednisone (R-CHOP). Following her initial rituximab infusion, she developed shortness of breath, chills, rigors, flushing, and agitation. The rituximab infusion was paused, and hypersensitivity reaction medications were given per protocol. The infusion was resumed at a slower rate. Two weeks after initial infusion, she was hospitalized for shortness of breath and hypoxemia to 88% on pulse oximeter requiring 2 L of nasal cannula oxygen. Chest imaging showed new diffuse ground glass opacities (GGOs) on top of apical scarring, upper lobe emphysema, and few calcified granulomas. Patient underwent bronchoscopy for bronchoalveolar lavage (BAL) which was negative for infections and malignancy. Given the temporal relationship, chemotherapy induced lung injury was high on the differential, with rituximab being the possible offending agent. She was started on prednisone 60 milligram for 5 days with a follow up chest imaging showing resolution of the acute GGO. Her O2 requirements decreased from 3 L to 1 L and she was sent home with oxygen. Given the curative intent of R-CHOP, after shared decision making with the patient and her medical team, a treatment plan with a longer course of high and low prednisone was incorporated as part of her chemotherapy session. She was able to successfully finish her treatment with no additional episode, at which point she was able to be successfully tapered off her prednisone.
Rituximab induced ILD is rare but given its severity requires a high index of suspicion for diagnosis. Given the potential for long term complication, once suspected, treatment should be discontinued. Here we detail how a prolonged steroid course could be used as adjunct therapy of ILD if therapy with rituximab is considered curative and essential.
Rituximab and Cyclophosphamide are well described causes of acute pneumonitis post R-CHOP administration. Given curative effect of R-CHOP, careful changes in management plan and co-treatment with steroids could help preserve lung function while allowing for full continuation of the chemotherapy regimen.
利妥昔单抗是一种嵌合型人鼠免疫球蛋白单克隆抗体，对前B细胞和B细胞表达的CD20表面抗原具有高亲和力，常用于治疗B细胞非霍奇金淋巴瘤，包括弥漫性大B细胞淋巴瘤（DLBCL）。随着该药物的使用越来越广泛，利妥昔单抗相关的间质性肺病（RTX-ILD）被认为是一种潜在并发症（《利妥昔单抗的非感染性肺毒性：一项系统评价》|《风湿病学》|牛津学术）。
我们讨论一名73岁新诊断为DLBCL的女性患者，她接受了利妥昔单抗、环磷酰胺、盐酸多柔比星、硫酸长春新碱和泼尼松（R-CHOP）的化疗和免疫治疗。在首次输注利妥昔单抗后，她出现了呼吸急促、寒战、畏寒、脸红和烦躁不安。利妥昔单抗输注暂停，并按方案给予过敏反应药物。输注以较慢速度恢复。首次输注两周后，她因呼吸急促和低氧血症住院，脉搏血氧饱和度降至88%，需要鼻导管吸氧2升。胸部影像学显示在肺尖瘢痕、上叶肺气肿和少数钙化肉芽肿的基础上出现新的弥漫性磨玻璃影（GGO）。患者接受了支气管镜检查以进行支气管肺泡灌洗（BAL），结果显示感染和恶性肿瘤均为阴性。鉴于时间关系，化疗引起的肺损伤在鉴别诊断中可能性较大，利妥昔单抗可能是致病因素。她开始服用60毫克泼尼松，持续5天，后续胸部影像学显示急性GGO消退。她的氧气需求量从3升降至1升，然后带氧出院。鉴于R-CHOP的治疗目的，在与患者及其医疗团队共同决策后，将一个疗程更长的高剂量和低剂量泼尼松治疗方案纳入她的化疗疗程。她能够成功完成治疗，没有再出现其他情况，此时她能够成功减停泼尼松。
利妥昔单抗诱导的ILD很少见，但鉴于其严重性，诊断时需要高度怀疑。鉴于存在长期并发症的可能性，一旦怀疑，应停止治疗。在这里，我们详细介绍了如果认为利妥昔单抗治疗具有治愈性且必不可少，延长类固醇疗程如何用作ILD的辅助治疗。
利妥昔单抗和环磷酰胺是R-CHOP给药后急性肺炎的常见病因。鉴于R-CHOP的治疗效果，仔细改变管理计划并联合使用类固醇有助于保护肺功能，同时允许化疗方案的全面继续。
