Delayed Reduction in Left Ventricular Function following Treatment of Non-Hodgkin’s Lymphoma with Chemotherapy and Rituximab, Unrelated to Acute Infusion Reaction

Abstract

We report 3 cases of reduced cardiac function with complications in non-Hodgkin’s lymphoma patients who were treated with rituximab. Patients experienced reduced cardiac functions after the administration of rituximab; there was no evidence of any preceding infusion reactions. Reticulin fiber was observed diffusely in cardiac muscles. Transforming growth factor-β levels were elevated after the administration of rituximab. We believe that continuous elevation of transforming growth factor-β may promote the growth of reticulin fiber in cardiac muscles. Reduction in cardiac functions is a severe complication that must be considered when rituximab is administered.

Non-ischemic cardiomyopathy after rituximab treatment for membranous nephropathy

“…Secondly, our case had a coronary angiogram which demonstrated clean coronary artery. Thus, we could confirm the diagnosis of non-ischemic cardiomyopathy, unlike previously reported cases (16). Thirdly, our case study showed the new finding that a reduction in cardiac function can occur early within 48 hours.…”

“…Kanamori et al (16) reported delayed effect (>2 weeks following rituximab infusion) of reduced LVEF in 3 cases with NHL (Table 1). The prognosis was different in each reported case.…”

“…Although the pathophysiology of rituximab induced non-ischemic cardiomyopathy remains unclear, the finding from Kanamori et al (16) raised an important observation. After rituximab infusion, patients’ cardiac myocytes were noted to have diffuse amounts of reticulin fiber along with increased serum transforming growth factor-β levels.…”

“…After rituximab infusion, patients’ cardiac myocytes were noted to have diffuse amounts of reticulin fiber along with increased serum transforming growth factor-β levels. The investigators suggested that the transforming growth factor-β levels could have led to increased reticulin fiber formation causing a decrease in myocardial contractility leading to non-ischemic cardiomyopathy (16). Also, Takotsubo cardiomyopathy (stress cardiomyopathy), an important type of non-ischemic cardiomyopathy has recently been reported after rituximab infusion (Table 1).…”

Biologics and the Cardiovascular System: A Double-Edged Sword

“…For example, one patient with dilated cardiomyopathy died after RTX infusion [93] and three cases of reduced cardiac function in non-Hodgkin's lymphoma patients treated with RTX were reported [94]. Other case reports reported a cardiogenic shock in a young patient suffering from thrombotic thrombocytopenic purpura, where HF discharged after therapeutic plasma exchange [95], and a fatal MI in a 60-year-old diabetic patient who received RTX, whereas the baseline echocardiography and electrocardiogram were normal [96].…”