Reversible Rituximab-Induced Bronchiectasis: A Pediatric Case Report and Literature Review

BACKGROUND Rituximab (RTX) is a chimeric IgG monoclonal antibody directed against the CD20 antigen expressed on normal and malignant B cells. It is used for treating a variety of neoplastic, autoinflammatory, and autoimmune pathologies, including disorders occurring in the pediatric population. It has been proven that rituximab can induce pulmonary complications including interstitial lung disease, bronchiectasis and pulmonary toxicities, predominantly in adults. By describing this case, we aim to raise awareness among pediatricians given the limited literature on rituximab-induced bronchiectasis in pediatrics, aiding in early recognition for better outcomes. CASE REPORT We present the case of a 12-year-old girl with relapsing steroid-dependent nephrotic syndrome who was diagnosed at age 6 years. When rituximab was introduced, remission was achieved. A year later, she developed a persistent wet cough. Initial imaging suggested pneumonia, and subsequent admissions revealed recurrent respiratory infections. Workup showed hypogammaglobulinemia, attributed to rituximab-induced humoral immunosuppression. High-resolution computed tomography (HRCT) revealed segmental atelectasis and bronchiectatic changes. Pulmonology testing diagnosed chronic suppurative lung disease, likely secondary to immunosuppression. Rituximab was discontinued, and the patient was started on azithromycin and airway clearance therapy. Intravenous immunoglobulin (IVIG) was initiated due to persistent hypogammaglobulinemia. Repeated HRCT showed complete resolution of bronchiectasis, with minimal residual scarring. CONCLUSIONS While it is a more common complication in adults, it is important to recognize rituximab as a culprit in pediatric patients with respiratory symptoms after prolonged use for various indications. Prompt recognition and intervention are crucial for mitigating further lung damage and perhaps full recovery. Pediatricians are encouraged to monitor for rituximab-induced pulmonary complications, particularly in naive lungs.