Potential Infectious Complications of B-Cell Depleting Therapies-a Focus on Rituximab in Multiple Sclerosis
B-cell depleting therapies have gained considerable interest in MS. While such therapies have proven to be effective in reducing inflammation and slowing down disease progression, the ramifications associated with long-term B-cell depletion in MS are not well known or understood.
To describe the course of serious infectious complications resulting in rituximab interruption/discontinuation among MS patients.
Retrospective review of health records of all MS patients managed with rituximab by a single provider (SS) at the Johns Hopkins MS Center (JHMSC) since 2012. Charts were screened for infectious complications potentially related to rituximab.
5/30 patients treated with rituximab developed serious infectious complications. Case 1 is a 30-year-old female with relapsing remitting MS (RRMS), treated with rituximab since 2013. Treatment was interrupted in 2017 due to recurrent pneumonia. Case 2 is a 42-year-old male with RRMS who switched from natalizumab to rituximab due to JCV seroconversion. After one year, rituximab was discontinued due to ringworm and two bouts of staph aureus septic arthritis. Case 3 is a 65-year-old female with RRMS and Sjogren’s syndrome who started rituximab in 2014 and discontinued it in 2016 due to sinusitis, pneumonia and left eye herpes simplex virus keratitis. Case 4 is a 38-year-old female with RRMS who started rituximab in 2014. It was discontinued in 2016 due to recurrent urosepsis, sinusitis, and pyrexia of unknown origin. Case 5 is a 56-year-old female with RRMS who started rituximab in 2015. This was stopped in 2017 due to intractable sinusitis and pneumonia resulting in empyema, requiring a thoracotomy.
B-cell depleting therapies are effective treatments for MS, but their potential for infectious complications need to be considered. In the current era of MS treatment much of the consideration for infectious complications focuses on opportunistic infections such as progressive multi-focal leukoencephalopathy. However, our findings highlight the need to be vigilant for all infections and serve as a reminder that potentially life-threatening, non-opportunistic infectious complications may occur with sustained B-cell depletion in MS. We plan to determine the incidence of all serious infectious complications related to rituximab use among MS patients attending the JHMSC, and the influence of different dosing protocols between MS providers in this regard.