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Ulcerative Colitis Exacerbation after Rituximab Treatment in Posttransplant Lymphoproliferative Disease

2022; Radiological Society of North America; Volume: 4; Issue: 4 Linguagem: Inglês

10.1148/rycan.220033

2638-616X

Maximiliano Klug, Sara Apter, Yael Eshet, Edith M. Marom,

Systemic Lupus Erythematosus Research

HomeRadiology: Imaging CancerVol. 4, No. 4 Previous Images in CancerFree AccessUlcerative Colitis Exacerbation after Rituximab Treatment in Posttransplant Lymphoproliferative DiseaseMaximiliano Klug , Sara Apter, Yael Eshet, Edith Michelle MaromMaximiliano Klug , Sara Apter, Yael Eshet, Edith Michelle MaromAuthor AffiliationsFrom the Division of Diagnostic Imaging, The Chaim Sheba Medical Center, Tel Hashomer, 2 Derech Sheba St, Ramat Gan, 5265601, Israel; and Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel.Address correspondence to M.K. (email: [email protected]).Maximiliano Klug Sara ApterYael EshetEdith Michelle MaromPublished Online:Jul 1 2022https://doi.org/10.1148/rycan.220033MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked InEmail Rituximab is an anti-CD20 monoclonal antibody medication that targets B cells and is part of the current recommended regimen for posttransplant lymphoproliferative disease (PTLD) (1). A randomized placebo-controlled trial demonstrated that B-cell depletion after rituximab induction treatment had no significant effect on ulcerative colitis (UC) (2). However, there have been reports that rituximab may exacerbate UC by depleting CD20-positive mucosal B cells associated with suppression of local IL-10 production (3,4). Figures 1 and 2 demonstrate exacerbation of UC after rituximab induction treatment for PTLD.Figure 1: Fluorodeoxyglucose (FDG) PET/CT image in a 27-year-old woman with ulcerative colitis and sclerosing cholangitis who presented with fever and fatigue. She underwent liver transplantation 3 years prior and was receiving immunosuppressive treatment with tacrolimus. Her chest radiograph (not shown) showed basilar pulmonary masses, which were FDG avid on PET/CT image (black arrows). Histologic confirmation following a CT-guided core biopsy indicated pulmonary posttransplant lymphoproliferative disease.Figure 1:Download as PowerPointOpen in Image Viewer Figure 2: Follow-up imaging in the same patient after tacrolimus withdrawal and initiation of rituximab induction therapy. Despite initial improvement, the patient presented with fever, abdominal pain, and bloody diarrhea after 2 months, before starting chemotherapy. (A) PET/CT image reveals improved uptake levels of the pulmonary masses (black arrows), but intense, diffuse, pancolonic fluorodeoxyglucose uptake was detected, compatible with active colitis (yellow arrow). (B) Corresponding coronal CT image reveals characteristic “lead-pipe” colon (white arrow), indicating clinical suspicion of ulcerative colitis exacerbation secondary to rituximab. Laboratory test results ruled out infection. Low-dose corticosteroid treatment was started with immediate clinical improvement.Figure 2:Download as PowerPointOpen in Image Viewer PTLD treatment is complex, involving withdrawal of immunosuppression and administration of rituximab and chemotherapy. When patients are also experiencing UC, the condition may be challenging to treat, and patients should be followed up periodically. Although fluorodeoxyglucose colonic uptake may appear as a physiologic phenomenon or in patients treated with metformin (5), a diffuse pattern with intense uptake favors diagnosis of UC exacerbation secondary to rituximab, requiring treatment adaptation.Disclosures of conflicts of interest: M.K. Trainee editorial board member of Radiology: Imaging Cancer. S.A. No relevant relationships. Y.E. No relevant relationships. E.M.M. Honorarium for giving a lecture from Boehringer Ingelheim and Merck Sharp & Dohme.Keywords: PET/CT, Lymphatic, Thorax, Abdomen/GI, Monoclonal AntibodiesAuthors declared no funding for this work.References1. Trappe R, Oertel S, Leblond V, et al. Sequential treatment with rituximab followed by CHOP chemotherapy in adult B-cell post-transplant lymphoproliferative disorder (PTLD): the prospective international multicentre phase 2 PTLD-1 trial. Lancet Oncol 2012;13(2):196–206. Crossref, Medline, Google Scholar2. Leiper K, Martin K, Ellis A, et al. Randomised placebo-controlled trial of rituximab (anti-CD20) in active ulcerative colitis. Gut 2011;60(11):1520–1526. Crossref, Medline, Google Scholar3. Goetz M, Atreya R, Ghalibafian M, Galle PR, Neurath MF. Exacerbation of ulcerative colitis after rituximab salvage therapy. Inflamm Bowel Dis 2007;13(11):1365–1368. Crossref, Medline, Google Scholar4. El Fassi D, Nielsen CH, Kjeldsen J, Clemmensen O, Hegedüs L. Ulcerative colitis following B lymphocyte depletion with rituximab in a patient with Graves’ disease. Gut 2008;57(5):714–715. Crossref, Medline, Google Scholar5. Gontier E, Fourme E, Wartski M, et al. High and typical 18F-FDG bowel uptake in patients treated with metformin. Eur J Nucl Med Mol Imaging 2008;35(1):95–99. Crossref, Medline, Google ScholarArticle HistoryReceived: Mar 1 2022Revision requested: Apr 13 2022Revision received: Apr 18 2022Accepted: May 27 2022Published online: July 01 2022 FiguresReferencesRelatedDetailsRecommended Articles Unintended Consequences of Systemic and Ablative Oncologic Therapy in the Abdomen and PelvisRadioGraphics2018Volume: 38Issue: 4pp. 1158-1179Beyond the Bowel: Extraintestinal Manifestations of Inflammatory Bowel DiseaseRadioGraphics2017Volume: 37Issue: 4pp. 1135-1160Malignancy after Solid Organ Transplantation: Comprehensive Imaging ReviewRadioGraphics2016Volume: 36Issue: 5pp. 1390-1407Posttransplant Lymphoproliferative Disorder in Children: A 360-degree PerspectiveRadioGraphics2019Volume: 40Issue: 1pp. 241-265Case 260: Endobronchial Posttransplantation Lymphoproliferative DiseaseRadiology2018Volume: 289Issue: 3pp. 876-880See More RSNA Education Exhibits Post-Transplant Lymphoproliferative Disorder (PTLD) in Children: A 360-Degree PerspectiveDigital Posters2018Abdominal Complications of Hematopoietic Stem Cell TransplantationDigital Posters2020Practical Approach to Liver Transplant Complications in the Emergency Department - What a Radiologist Needs to Know!Digital Posters2020 RSNA Case Collection Ulcerative colitisRSNA Case Collection2021Intrahepatic Cholangiocarcinoma RSNA Case Collection2020Post-transplant lymphoproliferative disorderRSNA Case Collection2021 Vol. 4, No. 4 Metrics Downloaded 327 times Altmetric Score PDF download