Life-threatening disseminated enterovirus infection during combined rituximab and ibrutinib maintenance treatment for mantle cell lymphoma: a case report

• Published in: Journal of medical case reports 2020-08, Vol.14 (1), p.135-135, Article 135
• Main Authors: Higer, Maximilian, Cana, Denis, Podlech, Juergen, Schadmand-Fischer, Simin, Schwarting, Andreas, Teschner, Daniel, Theobald, Matthias, Wölfel, Thomas, Hess, Georg
• Format: Article
• Language: English
• Subjects: Adenine - analogs & derivatives; Adult; Analgesics; Antibodies; Antigens; Antigens, CD20; Antimitotic agents; Antineoplastic agents; B cells; B lymphocytes; Bacterial infections; Biopsy; Bone marrow; Case Report; Case reports; Clinical trials; Drug therapy; Edema; Electrocardiography; Enterovirus; Enterovirus diseases; Enterovirus Infections - drug therapy; Gastroenteritis; Health aspects; Heart beat; Hepatitis; Humans; Ibrutinib; Immunoglobulins; Immunotherapy; Infection; Infections; Inflammatory diseases; Inhibitor drugs; Kidneys; Kinases; Laboratories; Lymphatic system; Lymphoma; Lymphoma, Mantle-Cell - drug therapy; Magnetic resonance imaging; Middle Aged; Monoclonal antibodies; Musculoskeletal diseases; Myositis; Non-Hodgkin lymphoma; Non-Hodgkin's lymphomas; Patients; Piperidines; Rituximab; Rituximab - adverse effects; Targeted cancer therapy; Tyrosine; Viral infections; Viruses
• ISSN: 1752-1947; 1752-1947
• DOI: 10.1186/s13256-020-02457-y

Rituximab is a well-established component of treatment regimens for B-cell non-Hodgkin lymphoma. Rituximab binds the CD20 antigen on the surface of B lymphocytes, causing an enhanced clearance of malignant and benign B cells. Thus, rituximab leads to depletion of normal B lymphocytes as well, which can cause substantial immunodeficiency. Ibrutinib inhibits the Bruton tyrosine kinase and thereby B-cell activity. It is used for the treatment of different B-lymphocyte malignancies, such as mantle cell lymphoma. Recently, the combination of both drugs has been tested in various clinical scenarios. We present a case of disseminated enterovirus infection resulting from combined rituximab and ibrutinib maintenance treatment in a 57-year-old Caucasian patient. with mantle cell lymphoma. Initially presenting with myositis symptoms, further diagnostic investigation revealed myocarditis, enteritis, myeloencephalitis, and hepatitis. These organ manifestations led to potentially life-threatening complications such as rhabdomyolysis, delirium, and heart rhythm disturbances. After treatment with high-dose intravenous immunoglobulins, virus clearance was achieved and organ functions could be restored. This case emphasizes the risk of combined therapy with rituximab/ibrutinib for severe immune-related side effects with the necessity of continuous patient monitoring. High-dose intravenous therapy should be considered as treatment for severe enterovirus infection. In severe enterovirus infections, we recommend subtyping for the development of efficient preventive and therapeutic strategies.