Rituximab-induced bronchiolitis obliterans organizing pneumonia

Abstract

Rituximab-induced lung disease (R-ILD) is a rare entity that should be considered in patients treated with rituximab who present with dyspnea, fever, and cough, but no clear evidence of infection. A variety of pathologic findings have been described in this setting. Bronchiolitis obliterans organizing pneumonia (BOOP) is the most common clinicopathologic diagnosis, followed by interstitial pneumonitis, acute respiratory distress syndrome (ARDS), and hypersensitivity pneumonitis. Prompt diagnosis and treatment with corticosteroids are essential as discussed by Wagner et al. (2007). Here we present a case of an 82-year-old man who was treated with rituximab for recurrent marginal zone lymphoma. After the first infusion of rituximab, he reported fever, chills, and dyspnea. On computed tomography imaging, he was found to have bilateral patchy infiltrates, consistent with BOOP on biopsy. In our patient, BOOP was caused by single-agent rituximab, in the first week after the first infusion of rituximab. We reviewed the relevant literature to clarify the different presentations and characteristics of R-ILD and raise awareness of this relatively overlooked entity.

Figure 1

Computed tomography (CT) of the chest at the initial presentation of patient on the fifth day following rituximab treatment (a) and 20 days after initiation of steroid treatment (b). Arrows show bilateral pulmonary patchy infiltrates.

Figure 2

Transbronchial biopsy of the lung. Arrows point at myxoid fibroblastic plugs of bronchiolitis obliterans organizing pneumonia (BOOP).