A preventable severe influenza A pneumonia after rituximab therapy for pemphigus vulgaris: a case report highlighting the critical role of vaccination
DOI:
https://doi.org/10.18203/issn.2454-2156.IntJSciRep20262820Keywords:
Pemphigus vulgaris, Rituximab, Influenza pneumonia, VaccinationAbstract
Rituximab is an effective first-line therapy for pemphigus vulgaris (PV) but causes prolonged B-cell depletion, increasing susceptibility to infections. We report a 38-year-old man with PV who developed severe influenza A (H3) pneumonia 20 days after his second rituximab infusion, having declined influenza vaccination. Prior to rituximab, he received corticosteroids and azathioprine, but lesions persisted. Upon presentation, he experienced headache, myalgia, arthralgia, and fatigue. Laboratory tests revealed lymphopenia and elevated C-reactive protein, and a respiratory viral panel confirmed influenza A H3. Imaging showed bilateral basal infiltrates with ground-glass opacities. The patient required hospitalization, antiviral therapy with oseltamivir, antibiotics, and supplemental oxygen. He recovered without intensive care admission. This case highlights the critical importance of influenza vaccination before rituximab therapy. Vaccination should not be left to patient discretion, and rituximab should never be administered without prior immunization, especially during winter months, to prevent severe or potentially fatal influenza complications.
References
Shahrigharahkoshan S, Dadkhahfar S, Mozafari N, Shahidi-Dadras M. A review of reported infectious events following rituximab therapy in pemphigus patients. Dermatol Ther. 2022;35(3):e15264. DOI: https://doi.org/10.1111/dth.15264
Aryanian Z, Balighi K, Daneshpazhooh M, Karamshahi E, Hatami P, Goodarzi A, et al. Rituximab exhibits a better safety profile when used as a first line of treatment for pemphigus vulgaris: A retrospective study. Int Immunopharmacol. 2021;96:107755. DOI: https://doi.org/10.1016/j.intimp.2021.107755
Balighi K, Ashtar Nakhaei N, Daneshpazhooh M, Aryanian Z, Aslani S, Balighi S, et al. Pemphigus patients with initial negative levels of anti-desmoglein: A subtype with different profile? Dermatol Ther. 2022;35(4):e15299. DOI: https://doi.org/10.1111/dth.15299
Uyeki TM, Bernstein HH, Bradley JS, Englund JA, File TM, Fry AM, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa. Clin Infect Dis. 2019;68(6):895-902. DOI: https://doi.org/10.1093/cid/ciy874
Kridin K, Zelber Sagi S, Bergman R. Mortality and cause of death in patients with pemphigus. Acta Derm Venereol 2017;97:607-11. DOI: https://doi.org/10.2340/00015555-2611
Kelesidis T, Daikos G, Boumpas D, Tsiodras S. Does rituximab increase the incidence of infectious complications? A narrative review. Int J Infect Dis. 2011;15(1):e2-16. DOI: https://doi.org/10.1016/j.ijid.2010.03.025
Kridin K, Mruwat N, Amber KT, Ludwig RJ. Risk of infections in patients with pemphigus treated with rituximab versus azathioprine or mycophenolate mofetil: a large-scale global cohort study. Br J Dermatol. 2023;188(4):499-505. DOI: https://doi.org/10.1093/bjd/ljac118
Cho A, Bradley B, Kauffman R, Priyamvada L, Kovalenkov Y, Feldman R, et al. Robust memory responses against influenza vaccination in pemphigus patients previously treated with rituximab. JCI Insight. 2017;2(12):e93222. DOI: https://doi.org/10.1172/jci.insight.93222
World Health Organization. Influenza. Available at: https://www.who.int/news-room/fact-sheets/detail /influenza-(seasonal). Accessed on 14 April 2026.
Welch VL, Metcalf T, Macey R, Markus K, Sears AJ, Enstone A, et al. Understanding the Barriers and Attitudes toward Influenza Vaccine Uptake in the Adult General Population: A Rapid Review. Vaccines (Basel). 2023;11(1):180. DOI: https://doi.org/10.3390/vaccines11010180
Cuningham W, Geard N, Fielding JE, Braat S, Madhi SA, Nunes MC, et al. Optimal timing of influenza vaccine during pregnancy: A systematic review and meta-analysis. Influenza Other Respir Viruses. 2019;13(5):438-52. DOI: https://doi.org/10.1111/irv.12649
Joly P, Horvath B, Patsatsi Α, Uzun S, Bech R, Beissert S, et al. Updated S2K guidelines on the management of pemphigus vulgaris and foliaceus initiated by the european academy of dermatology and venereology (EADV). J Eur Acad Dermatol Venereol. 2020;34(9):1900-13. DOI: https://doi.org/10.1111/jdv.16752
Downloads
Published
How to Cite
Issue
Section
