title: Fulminant viral myocarditis after rituximab therapy in pediatric nephrotic syndrome.
abstract: BACKGROUND
  We report a 7-year-old boy with high-degree steroid-dependent idiopathic nephrotic syndrome (SDNS) who went into remission with rituximab (RTX) maintenance therapy.
  
  
  METHODS
  Four months after this patient received his first RTX infusion, there was a progressive and sustained decrease of immunoglobulin (Ig)G and IgM levels. Thirteen months after the initiation of RTX therapy he was in sustained remission without any steroid or oral immunosuppressive therapy; however, B cell depletion was still present. At this time he developed a fulminant myocarditis due to enterovirus. Despite aggressive treatment and the administration of intravenous polyvalent immunoglobulins there was no clinical improvement. He successfully underwent heart transplant surgery.
  
  
  CONCLUSIONS
  We conclude that B cell depletion with RTX is efficacious in the treatment of paediatric SDNS but that it may be associated with severe infectious complications. Therefore, we recommend a close monitoring of Ig levels in children who have received RTX therapy and a supplementation with intravenous Ig as soon as the Ig levels fall below the lower limit of the normal range.
authors.affiliation: Department of Pediatric Nephrology, Hôpital Femme-Mère-Enfants, Hospices Civils de Lyon, Bron, France.
authors.forename: Anne-Laure
authors.initials: AL
authors.lastname: Sellier-Leclerc
authors.forename: Emre
authors.initials: E
authors.lastname: Belli
authors.forename: Valérie
authors.initials: V
authors.lastname: Guérin
authors.forename: Peter
authors.initials: P
authors.lastname: Dorfmüller
authors.forename: Georges
authors.initials: G
authors.lastname: Deschênes
mesh_terms: D058846:Antibodies, Monoclonal, Murine-Derived / Q000009:adverse effects* / Q000627:therapeutic use; D018941:Antigens, CD19 / Q000378:metabolism; D001402:B-Lymphocytes / Q000187:drug effects; D002648:Child; D005434:Flow Cytometry; D016027:Heart Transplantation; D006801:Humans; D007074:Immunoglobulin G / Q000032:analysis; D007166:Immunosuppressive Agents / Q000009:adverse effects* / Q000627:therapeutic use; D008297:Male; D009205:Myocarditis / Q000150:complications* / Q000601:surgery / Q000821:virology*; D009206:Myocardium / Q000473:pathology; D009404:Nephrotic Syndrome / Q000150:complications* / Q000188:drug therapy; D011239:Prednisolone / Q000627:therapeutic use; D000069283:Rituximab
chemical_list: D058846:Antibodies, Monoclonal, Murine-Derived; D018941:Antigens, CD19; D007074:Immunoglobulin G; D007166:Immunosuppressive Agents; D000069283:Rituximab; D011239:Prednisolone