title: Cardiovascular adverse events complicating the administration of rituximab: report of two cases.
abstract: Rituximab is a murine/human chimeric monoclonal antibody directed against the CD20 antigen. It is widely used in combination with polychemotherapy regimens for the treatment of hematological disorders. There is no evidence of direct cardiotoxicity of the drug but a few cases of cardiovascular adverse events have been reported in the literature. We report on two patients affected by stage IV non-Hodgkin lymphoma with bone marrow infiltration and peripheral blood involvement who experienced cardiovascular accidents temporally related to rituximab infusion. In both cases the monoclonal antibody was administered in association with a polychemotherapy regimen but administration was postponed several days later in order to avoid severe cytokine release syndrome because of the high tumor burden. The first case concerns an episode of atrial fibrillation in a patient with a diagnosis of small B-cell lymphoma. The episode happened immediately after rituximab infusion. In the second case there was an episode of chest pain associated with fever and chills during rituximab infusion in a patient with a diagnosis of mantle cell lymphoma. In both cases we noticed an unusual correlation between symptom recurrence and the speed of rituximab infusion. Both patients presented several cardiovascular risk factors but preliminary cardiac function assessment excluded signs of heart dysfunction. The pathogenesis of cardiovascular events during rituximab infusion remains unclear. A key role might be played by cytokine release from B cells as a consequence of rituximab activity. Moreover, pre-existing silent cardiac damage could be co-responsible for the clinical manifestations we reported. We consider our clinical experience relevant because it raises an issue of good clinical practice: despite rituximab's good tolerability profile, patients with cardiovascular risk factors should undergo accurate cardiac assessment so that silent heart disease can be detected. If the suspicion of cardiac damage is high, more extensive cardiac assessment is recommended.
authors: Caterina
authors: C
authors: Passalia
authors: Paola
authors: P
authors: Minetto
authors: Eleonora
authors: E
authors: Arboscello
authors: Enrico
authors: E
authors: Balleari
authors: Andrea
authors: A
authors: Bellodi
authors: Lisette
authors: L
authors: Del Corso
authors: Elisa
authors: E
authors: Molinari
authors: Irene
authors: I
authors: Ponassi
authors: Caterina
authors: C
authors: Oneto
authors: Vera
authors: V
authors: Sicbaldi
authors: Riccardo
authors: R
authors: Ghio
mesh_terms: D000368:Aged; D000787:Angina Pectoris / Q000097:blood / Q000139:chemically induced* / Q000150:complications; D058846:Antibodies, Monoclonal, Murine-Derived / Q000008:administration & dosage* / Q000009:adverse effects*; D000970:Antineoplastic Agents / Q000008:administration & dosage* / Q000009:adverse effects*; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000097:blood / Q000139:chemically induced*; D002318:Cardiovascular Diseases / Q000209:etiology; D016207:Cytokines / Q000097:blood*; D004334:Drug Administration Schedule; D005260:Female; D005334:Fever / Q000209:etiology; D006801:Humans; D007262:Infusions, Intravenous; D016393:Lymphoma, B-Cell / Q000188:drug therapy / Q000473:pathology; D020522:Lymphoma, Mantle-Cell / Q000188:drug therapy / Q000473:pathology; D008228:Lymphoma, Non-Hodgkin / Q000097:blood / Q000188:drug therapy* / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D000069283:Rituximab; D047368:Tumor Burden
chemical_list: D058846:Antibodies, Monoclonal, Murine-Derived; D000970:Antineoplastic Agents; D016207:Cytokines; D000069283:Rituximab