Main Author: Hiba Ibrahim Khogali
Al Ain, United Arab Emirates
Rituximab is an effective potent biological medication used to neutralize SLE severity with good outcome. However, Rituximab can result in a serious complication such as PRES. Posterior reversible encephalopathy syndrome (PRES) is a rare neurological manifestation; where it is characterized by the alteration in mental status, headaches, visual disturbances, and seizures.
The syndrome can be associated with an acute onset of high blood pressure.
The objective of reporting these two cases is to highlight the undesired side effect of RTX in its usage to treat significant SLE manifestations.
These are two cases report
We are reporting two cases that have fulfilled the SLE criteria according to ACR/SILCC 2012 and were treated with rituximab. After initiation of Rituximab therapy both patients developed PRES.
Both cases, a 20-year-old Egyptian female and a 32-year-old Emirati female, satisfy the clinical and laboratory criteria for severe SLE (SLEDAI CK score of 32and 39 respectively) and were managed with plus steroids ( 1000 mg daily for three consecutive days ) , full dose of hydroxychloroquine and two doses of RTX 1000mg respectively.
Each of the beforementioned cases responded well clinically to the emergency management and demonstrated a significant improvement in the laboratory markers of SLE.
However, the two cases have developed PRES after taking the second dose of rituximab. The 20- year-old Egyptian female developed PRES within 2 days of receiving the second dose of rituximab whereas the 32-year-old Emirati patient developed PRES within 31 days.
The cases illustrated manifestations of altered mental status, confusion, seizures, and acute high blood pressure. Radiological imaging such as CT,EEG, MRA as well as MRV were all negative, whereas an MRI of the brain showed enhanced hypertense lesions at the parietooccipital region and the cerebellum. These signs and symptoms were consistent with Posterior Reversible Encephalopathy Syndrome.
Both patients did not exhibit any signs of sepsis and were not on any other medications as well they did not have any pre-exiting medical illness.
Rituximab treatment in severely ill SLE patients can induce PRES both acutely and at long term