Fatal late-onset Pneumocystis pneumonia after rituximab: administration for posttransplantation recurrence of focal segmental glomerulosclerosis--case report.

Recurrence of focal segmental glomerulosclerosis (FSGS) is an important cause of graft loss after kidney transplantation. The management of patients with recurrent FSGS is not well established because there are no prospective randomized studies with a view to the impact of FSGS on graft survival. Recent studies suggest that rituximab, an anti-B-CD20 monoclonal antibody, may be a therapeutic alternative in selected cases resistant to conventional therapy. Opportunistic infections with rituximab have not been studied extensively, but recent studies suggest an increased risk for Pneumocystis jirovecii pneumonia (PJP) after rituximab therapy. We report the case of a kidney transplant recipient with recurrence of FSGS in the graft, in whom fatal PJP developed subsequent to treatment with rituximab. Our patient was treated with plasmapheresis and a complex immunosuppressive drug scheme for the recurrence of FSGS in transplanted kidney. However, this treatment had no effect on the amount of proteinuria, which increased to a maximum of 15 g/d after 18 session of plasmapheresis. Thereafter, 500 mg intravenously (IV) of rituximab was administered at 4-week intervals. The number of CD19-positive B lymphocytes decreased from 9% to 0.57%. Two months after the second dose of rituximab, proteinuria decreased to 2.1 g/d. Ten months after transplantation and 5 months after the first dose of rituximab was administered, severe PJP pneumonia developed and the patient died despite all efforts with antibiotic therapy. It seems essential that all renal transplant recipients treated with rituximab should currently be considered at an increased risk for PJP. This case suggests that prolonged or restarted prophylaxis for PJP should be recommended not only after conventional treatment for acute rejection episodes but also after use of rituximab in combination with other immunosuppressive therapy as well.