title: Treatment strategy for reducing the risk of rituximab-induced cytokine release syndrome in patients with intravascular large B-cell lymphoma: a case report and review of the literature.
abstract: BACKGROUND
  Intravascular large B-cell lymphoma is a rare aggressive disseminated disease characterized by the presence of lymphoma cells in small vessels without lymphadenopathy. Rituximab, a novel monoclonal antibody against the CD20 B-cell antigen, has been reported to be effective in treating intravascular large B-cell lymphoma. However, adverse events have been reported in association with rituximab infusion.
  
  
  METHODS
  We report the case of a 54-year-old Japanese man diagnosed with Asian variant intravascular large B-cell lymphoma who died within five hours of the initiation of a first course of chemotherapy including rituximab. Autopsy results suggested that the patient died of severe systemic inflammatory response syndrome. A literature review revealed that rituximab administered during the second course of chemotherapy (instead of during the first course) appears to reduce the incidence of infusion reactions (from 48% to 15%) without altering the frequency of complete remission outcomes.
  
  
  CONCLUSIONS
  Our data indicate that the incidence of adverse reactions to rituximab can be markedly decreased if the tumor load is first reduced with an initial course of chemotherapy excluding rituximab. Future prospective studies of the timing of rituximab administration are warranted.
authors.affiliation: Department of General Medicine, Tokyo Metropolitan Police Hospital, 4-22-1 Nakano, Nakano-ku, Tokyo 164-8541, Japan. katsuhiromakino@gmail.com.
authors.forename: Katsuhiro
authors.initials: K
authors.lastname: Makino
authors.forename: Jumi
authors.initials: J
authors.lastname: Nakata
authors.forename: Satoru
authors.initials: S
authors.lastname: Kawachi
authors.forename: Tatsuyuki
authors.initials: T
authors.lastname: Hayashi
authors.forename: Atsuo
authors.initials: A
authors.lastname: Nakajima
authors.forename: Munehiro
authors.initials: M
authors.lastname: Yokoyama