Non-ischemic cardiomyopathy after rituximab treatment for membranous nephropathy

Abstract

Rituximab is an anti-CD20 monoclonal antibody frequently used for the treatment of non-Hodgkin’s lymphoma, chronic lymphocytic leukemia (CLL), rheumatoid arthritis (RA), and anti-neutrophilic cytoplasmic antibody (ANCA)-associated vasculitis. In addition, rituximab has recently been increasingly used as an off-label treatment in a number of inflammatory and systemic autoimmune diseases. It is advised that rituximab infusion may cause infusion reactions and adverse cardiac effects including arrhythmia and angina, especially in patients with prior history of cardiovascular diseases. However, its detailed cardiotoxicity profile and effects on cardiac function were not well described. We report a 51-year-old man who developed non-ischemic cardiomyopathy after rituximab treatment for membranous nephropathy. The patient experienced reduced cardiac functions within 48 hours after the initial infusion, which remained markedly reduced at 9-month follow-up. As the utility of rituximab expands, physicians must be aware of this serious cardiovascular adverse effect.

Takotsubo cardiomyopathy in cancer patients

“…Rituximab has been reported to cause adverse cardiac events including arrhythmia and rarely myocardial infarction. However, its detailed cardiotoxicity profile and effects on cardiac function are not well described [32]. Two postulated mechanisms explaining the pathophysiology of rituximab-induced TCM have been proposed: 1) Neurohormonal activation that leads to stimulation of the sympathetic system leading to coronary vasospasm, and 2) direct cardiotoxic effect leading to ventricular dysfunction [32].…”

“…However, its detailed cardiotoxicity profile and effects on cardiac function are not well described [32]. Two postulated mechanisms explaining the pathophysiology of rituximab-induced TCM have been proposed: 1) Neurohormonal activation that leads to stimulation of the sympathetic system leading to coronary vasospasm, and 2) direct cardiotoxic effect leading to ventricular dysfunction [32]. Diffuse reticulin fibers along with increased levels of transforming growth factors (TGF)-β were present in cardiac myocytes after treatment with rituximab.…”

Bicarbonate refractory QRS prolongation and left bundle‐branch block following escitalopram and lamotrigine overdose: A case report and literature review of toxic left bundle‐branch block

“…Including our case, a total of 16 incidences of toxicologic LBBB were identified (Table 1), with an average age of 44 (range 20-86); 7 patients were female and 9 were male. The agents reported as the causative agent in LBBB were diverse, including psychiatric medications as in this case, antispasmodics (fenoverine), 7 immunomodulators (rituximab), 8,9 metals (colloidal gold and silver), 10 analgesics (propoxyphene), 11 cardiac glycosides (digoxin) 12 and calcium channel blockers (verapamil, diltiazem and nifedipine). 13 Regarding the agents involved in our case, overdose of lamotrigine has been previously reported to cause LBBB 6 ; whereas there are no prior reports of LBBB in the setting of escitalopram overdose, there are two which have QRS prolongation secondary to sodium channel blockade from tricyclic antidepressants and other classes of medication, which typically manifests with RBBB morphology, responds to bicarbonate therapy.…”

Phase II clinical trial testing the safety of a humanised monoclonal antibody anti-CD20 in patients with heart failure with reduced ejection fraction, ICFEr-RITU2: study protocol

“…We considered a convenience sample of 10 patients from our heart failure clinic since the previously reported incidence of acute coronary syndrome (ACS) and atrial and ventricular arrhythmias with the use of rituximab is <0.1% and 7.6%, respectively 8. Regarding the worsening of left ventricle ejection fraction (LVEF) attributed to rituximab, the incidence is limited to case reports only, wherefore it is impossible to precisely determine the incidence 9. Moreover, with the strategic safety measures that we will take before, during and following the rituximab administration, we aim to reduce the risk of potential cardiovascular adverse events (AEs).…”