title: Agranulocytosis under biotherapy in rheumatoid arthritis: three cases hypothesis of parvovirus B19 involvement in agranulocytosis observed under tocilizumab and rituximab for the treatment of rheumatoid arthritis.
abstract: Leukopenia is a considerably common complication of tocilizumab [TCZ] and rituximab [RTX] therapy. RTX-induced leukopenia typically exhibits delayed onset. While agranulocytosis has been reported linked to RTX treatment of lymphoma, this complication rarely occurs in rheumatoid arthritis (RA) treatment and, to our knowledge, has never been reported in association with TCZ therapy. We herein report four agranulocytosis cases in three patients, with the first two cases suspected to be secondary to human parvovirus B19 (PVB19) infection. Agranulocytosis manifested in the first patient 2 months following a third RTX course. Bone marrow (BM) polymerase chain reaction (PCR) was positive for PVB19. The patient relapsed after three TCZ courses, with her PCR again positive for PVB19. Both episodes resolved under granulocyte-macrophage colony-stimulating factor (GM-CSF). In the second patient, agranulocytosis manifested after the 74th TCZ course. Bone marrow PCR was positive for PVB19, and the evolution was favorable under intravenous immunoglobulin administration. The third case was a 53-year-old female patient with seropositive RA who presented agranulocytosis after the first infusion of her fourth RTX course. Unfortunately, no PCR PVB19 was made on myelogram. Evolution was favorable after 5 days of GM-CSF. PVB19 infection should be investigated in patients suffering from agranulocytosis manifesting during biotherapy. In cases manifesting from the 15th day of RTX treatment onwards, hemogram must be conducted before readministering the infusion.
authors.affiliation: Department of Rheumatology, Hôpital Gabriel Montpied, 58 Montalembert street, 63000, Clermont-Ferrand, France. c1giraud@chu-clermontferrand.fr.|Department of Rheumatology, Hôpital Gabriel Montpied, 58 rue Montalembert street, 63000, Clermont-Ferrand, France. c1giraud@chu-clermontferrand.fr.
authors.forename: C
authors.initials: C
authors.lastname: Giraud
authors.affiliation: Department of Rheumatology, Hôpital Gabriel Montpied, 58 rue Montalembert street, 63000, Clermont-Ferrand, France.
authors.forename: Z
authors.initials: Z
authors.lastname: Tatar
authors.affiliation: Department of Rheumatology, Hôpital Gabriel Montpied, 58 rue Montalembert street, 63000, Clermont-Ferrand, France.
authors.forename: M
authors.initials: M
authors.lastname: Soubrier
mesh_terms: D000328:Adult; D000368:Aged; D000380:Agranulocytosis / Q000139:chemically induced / Q000188:drug therapy / Q000821:virology*; D061067:Antibodies, Monoclonal, Humanized / Q000009:adverse effects* / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000009:adverse effects* / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D005260:Female; D016178:Granulocyte-Macrophage Colony-Stimulating Factor / Q000627:therapeutic use; D006801:Humans; D008875:Middle Aged; D016732:Parvovirus B19, Human; D000069283:Rituximab / Q000009:adverse effects* / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D000069283:Rituximab; D016178:Granulocyte-Macrophage Colony-Stimulating Factor; C502936:tocilizumab
keywords: Agranulocytosis; Drug-related side effects and adverse reactions; Human; Parvovirus B19; Rheumatoid arthritis