Diffuse Alveolar Hemorrhage: A Fatal Complication of Rituximab

Abstract

Pulmonary toxicity is a rare but severe adverse effect of Rituximab, associated with significant morbidity and mortality. Despite increased reporting, few case reports associated with alveolar hemorrhage due to Rituximab have been published. The authors present the case of a 61 year old Caucasian male with a diagnosis of small lymphocytic lymphoma who recently completed chemotherapy with Rituximab and Bendamustine. The patient presented to the emergency room with a one week history of nonproductive cough associated with shortness of breath and low grade fevers. Differential diagnosis at the time of presentation included health care associated pneumonia, Rituximab-induced pulmonary toxicity, and Pneumocystis jiroveci infection given his history of lymphoma and treatment with Rituximab. The patient was initiated on intravenous (IV) broad-spectrum antibiotics, oral atovaquone, and IV methylprednisolone. A CT scan showed bilateral diffuse pulmonary opacities and a video-assisted thorascopic surgery guided lung biopsy revealed early diffuse alveolar hemorrhage with no evidence for infection. However, the remaining work-up consisting of blood cultures, blood tests, and bronchopulmonary lavage did not produce any suggestive findings. Despite initiating the above aggressive therapies, the patient continued to rapidly deteriorate. An autopsy revealed diffuse alveolar hemorrhage of the lungs, thought to be secondary to Rituximab toxicity. The authors recommend emphasizing the importance of early identification of worsening pulmonary symptoms in patients receiving Rituximab, with diagnostic consideration given to Rituximab-related toxicity.