A Case of Rituximab-Induced Necrotizing Fasciitis and a Review of the Literature

Abstract

Necrotizing fasciitis is a fulminant soft tissue infection characterized by rapid progression and high mortality. Rituximab is a generally well-tolerated immunosuppresive medication used for B-cell malignancies and some rheumatological disorders. We report a case of a 69-year-old male with chronic lymphocytic leukemia who suffered necrotizing fasciitis of his left lower extremity secondary to Clostridium septicum 7 weeks after treatment with rituximab. Despite immediate intravenous antimicrobial therapy and emergent fasciotomy with extensive debridement, his hospital course was complicated by septic shock and he required an above-the-knee amputation. Physicians need to be aware of the possibility of necrotizing fasciitis in patients presenting with skin infections after rituximab therapy.

Necrotizing Fasciitis—Severe Complication of Bullous Pemphigoid: A Systematic Review, Risk Factors, and Treatment Challenges

“…Destructive, invasive, and especially fulminant in immunocompromised individuals, they can be fatal with the outcome mainly depending on timely diagnosis and management [47]. Previous studies of other autoimmune diseases such as rheumatoid arthritis, systemic lupus, and scleroderma have proven the major role immunosuppression plays in necrotizing fasciitis, but given the disruption of the skin as the main characteristic of BP and other chronic skin blistering diseases, this BP manifestation as well as comorbidities found in BP patients in the studies included in Tables 1 and 2, such as diabetes mellitus, chronic renal disease, stroke, Parkinson's disease, and dementia, could also be major contributing risk factors for NF [48][49][50][51]. Shared risk factors for poor outcomes in patients with bullous pemphigoid, the most common of the autoimmune bullous diseases, and necrotizing fasciitis are shown in Figure 2.…”

Necrotizing Fasciitis: A Side Effect of Rituximab Administration in Steroid-Dependent Nephrotic Syndrome

“…Eight years later, he was re-treated with a 4-week course of rituximab for CLL relapse, which resulted in the development of Clostridium septicemia, manifesting as NF and requiring amputation. 20 …”

“…Eight years later, he was re-treated with a 4-week course of rituximab for CLL relapse, which resulted in the development of Clostridium septicemia, manifesting as NF and requiring amputation. 20 Another study that further highlighted the association between rituximab and NF was a case of a 76-year-old man who was diagnosed with Waldenström macroglobulinemia on the basis of elevated serum levels of IgM (1944 mg/dL) and relevant findings on bone marrow biopsy. Chemotherapy with bortezomib, dexamethasone, and rituximab was initiated for rapid disease control, resulting in reduced IgM levels.…”

“…It is agreed that further studies are required to investigate the link between rituximab therapy in nephrotic syndrome and NF. 20–23 …”

“…It is agreed that further studies are required to investigate the link between rituximab therapy in nephrotic syndrome and NF. [20][21][22][23] After obtaining Informed written consent from the parents of the patient for the publication of the case report. Here we present a case of a 4-year-old girl with SDNS, who started to develop septic shock secondary to NF after receiving the first dose of rituximab therapy.…”