An 82-year-old patient with p-ANCA positive Wegener’s granulomatosis under treatment with glucocorticoids and methotrexate since 2005 being rejected cyclophosphamide due to high toxicity and limited lung disease. The patient was admitted to the hospital with hemoptysis and dyspnea. On physical examination, rhonchus was discovered in both lungs. Laboratory assessment revealed an elevation of erythrocyte sedimentation rate (119 mm/h), C-reactive protein [106 mg/l (normal range <10 mg/l)] and anemia (hemoglobin 8.9 g/dl). Chest computed tomography showed multiple nodules of alveolar consolidation with air bronchogram and ground glass halo in both hemithorax (Figure 1A). Intra-alveolar hemorrhage due to capillarity was demonstrated in transbronchial biopsy. After dismissing infectious etiologies, the patient was treated successfully with three bolus of glucocorticoids and 100 mg of rituximab in four sessions with radiological improvement (Figure 1B).
Rituximab is an anti-CD20 monoclonal antibody that was approved by US Food and Drug Administration in 2011 in combination with glucocorticoids for treatment of Wegener’s granulomatosis, also called granulomatosis with poliangeitis. The combination of cyclophosphamide and glucocorticoids has been the standard treatment for induction of remission in these patients. A single course of rituximab is as effective for treatment of Wegener’s granulomatosis as standard immunosuppressive therapy with cyclophosphamide with less side efects.1 Moreover, it may be superior for remission induction in severe relapsing disease as intra-alveolar hemorraghe.2
Conflict of interest: None declared.