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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2021  |  Volume : 32  |  Issue : 5  |  Page : 1505-1506
Coronavirus Disease-19 in a patient with minimal change nephrotic syndrome undergoing rituximab monotherapy


1 Department of Nephrology, Kameda Medical Center, Kamogawa, Japan
2 Department of Infectious Diseases, Kameda Medical Center, Kamogawa, Japan

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Date of Web Publication4-May-2022
 

How to cite this article:
Suzuki T, Nagaoka K, Takahashi Y, Osawa R, Hosokawa N. Coronavirus Disease-19 in a patient with minimal change nephrotic syndrome undergoing rituximab monotherapy. Saudi J Kidney Dis Transpl 2021;32:1505-6

How to cite this URL:
Suzuki T, Nagaoka K, Takahashi Y, Osawa R, Hosokawa N. Coronavirus Disease-19 in a patient with minimal change nephrotic syndrome undergoing rituximab monotherapy. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 May 25];32:1505-6. Available from: https://www.sjkdt.org/text.asp?2021/32/5/1505/344780


To the Editor,

The coronavirus disease 2019 (COVID-19) is raging worldwide. Extra caution is required for treating COVID-19 positive patients undergoing chronic immunosuppressive therapy, who are at a higher risk of worsening COVID-19 infection. Rituximab that works by suppressing B-cells, is widely used for the first-line treatment of autoimmune disorders and B-cell-related cancers. Reports on COVID-19 infection in patients undergoing rituximab monotherapy are scarce.

Herein, we present a case of COVID-19 in a patient with minimal change nephrotic syndrome (MCNS) undergoing rituximab monotherapy. A 24-year-old female patient with a three-year history of MCNS underwent initial therapy with prednisolone. After the first remission, the disease relapsed twice in the first two years. Therefore, maintenance therapy was initiated and rituximab (500 mg) was administered once every six months for the past one year; the patient remained in remission.

The patient had a low-grade fever (BT: 37.2°C), sore throat, and cough on August 1, 2020, and tested positive for COVID-19 through the polymerase chain reaction assay. She was admitted to our hospital on August 3. Her medical history was unremarkable except for MCNS; she was not on oral medications and had no known drug allergies. Her vital signs at admission were normal: blood pressure (122/60 mm Hg), heart rate (72 times/min), respiratory rate (16 times/min), blood temperature (36.8°C), and oxygen saturation (100% in ambient conditions). Physical examination revealed no remarkable abnormalities. Laboratory tests showed the following concentrations: white blood cell (4500/μL), serum total protein (6.6 g/dL), normal serum creatinine (0.64 mg/dL), C-reactive protein (1.12 mg/dL), ferritin (13.2 ng/Ml), and D-dimer (0.0 ng/mL). Serological tests showed that IgG (786 mg/dL), IgM (142 mg/dL), and IgA (169 mg/dL) levels were normal. CD19 and CD20 in the peripheral blood lymphocyte subset were absent. We did not perform any imaging tests. She had no worsening symptoms and was discharged on August 11. Post-discharge, no medications were administered and routine follow-ups were performed. After one month, she was administered rituximab again.

Complications of rituximab treatment include severe neutropenia and hepatitis B reactivation.[1] However, the effect of COVID-19 in patients undergoing rituximab monotherapy is unclear.COVID-19 increased the rates of severe rheumatic disease (in 61.5%, eight of 13 patients) and persisting COVID-19 viremia in patients after rituximab therapy.[2],[3] Similar results have also been reported with other immunosuppressive agents. The safety of COVID-19 infection in 159 children with nephrotic syndrome treated with rituximab has been reported; ongoing immunosuppressive therapies in 66% of the children were terminated.[4] The clinical course of COVID-19 in patients with agammaglobulinemia, who lack B lymphocytes, was characterized by mild symptoms, with favorable outcomes.[5] Therefore, B-cell depletion due to rituximab monotherapy may not aggravate COVID-19 and hence, might be a good option for treating nephrotic syndromes. A larger descriptive study of COVID-19 in patients using rituximab is required.

Conflict of interest: None declared.



 
   References Top

1.
Mikulska M, Lanini S, Gudiol C, et al. ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: An infectious diseases perspective (Agents targeting lymphoid cells surface antigens [I]: CD19, CD20 and CD52). Clin Microbiol Infect 2018;24 Suppl 2:S71-82.  Back to cited text no. 1
    
2.
Loarce-Martos J, García-Fernández A, López-Gutiérrez F, et al. High rates of severe disease and death due to SARS-CoV-2 infection in rheumatic disease patients treated with rituximab: A descriptive study. Rheumatol Int 2020;40:2015-21.  Back to cited text no. 2
    
3.
Tepasse PR, Hafezi W, Lutz M, et al. Persisting SARS-CoV-2 viraemia after rituximab therapy: Two cases with fatal outcome and a review of the literature. Br J Haematol 2020;190:185-8.  Back to cited text no. 3
    
4.
Angeletti A, Drovandi S, Sanguineri F, et al. COVID-19 in children with nephrotic syndrome on anti-CD20 chronic immunosuppression. Clin J Am Soc Nephrol 2020;15:1494-5.  Back to cited text no. 4
    
5.
Quinti I, Lougaris V, Milito C, et al. A possible role for B cells in COVID-19? Lesson from patients with agammaglobulinemia. J Allergy Clin Immunol 2020;146:211-3.e4.  Back to cited text no. 5
    

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Correspondence Address:
Tomo Suzuki
Department of Nephrology, Kameda Medical Center, Kamogawa
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-2442.344780

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