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Tumor lysis syndrome and acute respiratory distress syndrome in a patient with non-Hodgkins lymphoma in leukemic phase treated with a low dose of rituximab



Tumor lysis syndrome and acute respiratory distress syndrome in a patient with non-Hodgkins lymphoma in leukemic phase treated with a low dose of rituximab



Blood 102(11): 298b



Tumor lysis syndrome (TLS) and acute respiratory distress syndrome (ARDS) have been reported in patients after receiving rituximab (375 mg/m2). To prevent TLS and ARDS in patients with large tumor burden, a reduced dose (100 mg/m2) is recommended. With this dose TLS or ARDS has not been reported. We present a case of a low initial dose of rituximab-induced TLS and ARDS. The patient is a 50 year old man with stage IVB diffuse large B-cell lymphoma (CD20+). He was first treated with cyclophosphamide, doxorubicin, vincristine and prednisone. With recovery from the myelosuppression, the WBC increased rapidly up to 119,000 cells/microliterl with 94% circulating lymphoblasts. He was given a reduced dose of rituximab (60 mg/m2) with standard TLS precautions (IV hydration, alkalinization, allopurinol). After 6 hours the WBC fell to 2,600 cells/microliter; he demonstrated TLS with a fall in the serum calcium (9.4 to 7.0), with a rise in the phosphorous (1.8 to 8.0) and LDH (18,617 to 125,757). He developed ARDS. With aggressive clinical management the TLS and ARDS resolved. He subsequently received full-dose rituximab and chemotherapy. This case demonstrates that TLS and ARDS can occur in the patient with a large tumor burden even treated with a low-dose of rituximab.

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