First experience with obinutuzumab in a juvenile-onset systemic lupus erythematosus patient with rituximab-associated posterior reversible encephalopathy syndrome
- 1Department of Pediatric Rheumatology, Gazi University Faculty of Medicine, Ankara, 06560 Turkey
- 2Department of Pediatric Immunology and Allergy, Gazi University Faculty of Medicine, Ankara, Turkey
Abstract
Background: Juvenile-onset systemic lupus erythematosus (JSLE) is characterized by higher disease activity and greater treatment burden than adult-onset disease, often requiring intensive immunosuppression. Rituximab is used in refractory cases, but re-exposure may not be possible when adverse events such as posterior reversible encephalopathy syndrome (PRES) occur. Obinutuzumab, a type II anti-CD20 monoclonal antibody, has shown efficacy in adult patients with lupus nephritis and in those with active SLE, yet pediatric experience is limited.
Case presentation: We report an 11-year-old boy with JSLE and lupus nephritis who developed lupus pneumonitis and increased renal activity while receiving conventional therapy. Rituximab was initiated but complicated by PRES six hours after the first infusion, leading to discontinuation. Despite cyclophosphamide induction and mycophenolate mofetil plus cyclosporine maintenance, he later experienced a disease flare with malar rash, low complement levels, and rising anti-dsDNA titres. Because rituximab re-use was avoided, obinutuzumab was selected as an alternative anti-CD20 agent in the setting of a disease flare. A body-surface-area-adjusted regimen derived from the adult protocol was administered in two infusions under close monitoring. Following obinutuzumab, complement levels normalized, anti-dsDNA declined, and SLEDAI-2K decreased from 6 to 2, and peripheral B-cell depletion was confirmed at eight weeks and maintained at six months, without neurological or infectious complications over six months of follow-up.
Conclusions: This case suggests that obinutuzumab may be a feasible alternative anti-CD20 option in rituximab-intolerant JSLE, pending results from ongoing pediatric clinical trials.
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BibTeX
@article{ahmadova2026first,
title = {{First experience with obinutuzumab in a juvenile-onset systemic lupus erythematosus patient with rituximab-associated posterior reversible encephalopathy syndrome}},
author = {Khadija Ahmadova and Batuhan Küçükali and Çisem Yıldız and Nuran Belder and Merve Kutlar Tanıdır and Büşra Acun and Övgü Özenli Yağcı and Avniye Kübra Baskın and Deniz Gezgin Yıldırım and Sevcan A. Bakkaloğlu},
journal = {Pediatric Rheumatology},
year = {2026},
month = aug,
doi = {10.1186/s12969-026-01258-9},
url = {https://doi.org/10.1186/s12969-026-01258-9},
note = {CC BY-NC-ND 4.0},
}
RIS
TY - JOUR
TI - First experience with obinutuzumab in a juvenile-onset systemic lupus erythematosus patient with rituximab-associated posterior reversible encephalopathy syndrome
AU - Khadija Ahmadova
AU - Batuhan Küçükali
AU - Çisem Yıldız
AU - Nuran Belder
AU - Merve Kutlar Tanıdır
AU - Büşra Acun
AU - Övgü Özenli Yağcı
AU - Avniye Kübra Baskın
AU - Deniz Gezgin Yıldırım
AU - Sevcan A. Bakkaloğlu
PY - 2026
DA - 2026/08/07
JO - Pediatric Rheumatology
DO - 10.1186/s12969-026-01258-9
UR - https://doi.org/10.1186/s12969-026-01258-9
AB - Background: Juvenile-onset systemic lupus erythematosus (JSLE) is characterized by higher disease activity and greater treatment burden than adult-onset disease, often requiring intensive immunosuppression. Rituximab is used in refractory cases, but re-exposure may not be possible when adverse events such as posterior reversible encephalopathy syndrome (PRES) occur. Obinutuzumab, a type II anti-CD20 monoclonal antibody, has shown efficacy in adult patients with lupus nephritis and in those with active SLE, yet pediatric experience is limited. Case presentation: We report an 11-year-old boy with JSLE and lupus nephritis who developed lupus pneumonitis and increased renal activity while receiving conventional therapy. Rituximab was initiated but complicated by PRES six hours after the first infusion, leading to discontinuation. Despite cyclophosphamide induction and mycophenolate mofetil plus cyclosporine maintenance, he later experienced a disease flare with malar rash, low complement levels, and rising anti-dsDNA titres. Because rituximab re-use was avoided, obinutuzumab was selected as an alternative anti-CD20 agent in the setting of a disease flare. A body-surface-area-adjusted regimen derived from the adult protocol was administered in two infusions under close monitoring. Following obinutuzumab, complement levels normalized, anti-dsDNA declined, and SLEDAI-2K decreased from 6 to 2, and peripheral B-cell depletion was confirmed at eight weeks and maintained at six months, without neurological or infectious complications over six months of follow-up. Conclusions: This case suggests that obinutuzumab may be a feasible alternative anti-CD20 option in rituximab-intolerant JSLE, pending results from ongoing pediatric clinical trials.
SN - 1546-0096
ER -