Rituxin and Low White Blood Cell Counts

I had four rituxin treatments about 5 months ago. Platelets have been normal since then, but recent test shows very low white blood cell count and dropping platelets. I had a normal bone marrow 6 months ago, so hematologist said that the low white blood cell count is side effect of rituxin killing B cells. I am told that this often happens 5-6 months after rituxin, and that this can go on for weeks, while the "immune system reconstitutes itself" , and to avoid infection as white count is low and immune system suppressed.
Anyone else have experience with rituxin-induced neutropenia (low white counts)? How long did it last for you? Did you experience serious infections while white count was low? Any tips for how to manage this ?

The aim of Rituxan is to kill off the white B cells which it does immediately. The B cells should start coming back after 6 to 9 months although rarely they never come back. The B cells are responsible for making antibodies so you will be open to infections from the start.

If as you say the neutrophils as well as the B lymphocytes are low then that is more of a problem. If they are very low, say 0.3 then there is a risk of septicaemia. A bit higher and the risk is not nearly so great. There are injections you can have to stimulate the production of neutrophils but it's not something they like to do unless really necessary.

To add.. the B cells, T cells and neutrophils are all white blood cells so you need to know specifically which are low to know the risks of particular infections.

meyes, I was just reading about Parvovirus B19 today. Apparently Rituxan treatment can cause a resurgence of the virus and it is that virus that causes neutropenia. Google is your friend. As I recall, getting the virus under control will alleviate the neutropenia.

Thanks, Hal. The parvovirus angle is interesting...though I am reading that most of those cases are associated with red blood cell effects as well (which I dont have). Hematologist thinks this may be part of the "immune reconstitution syndrome" after rituxin. As B cells repopulate, it effects kinetics of neutrophils. Not sure if anyone really knows mechanism. Duration appears to range from 1-49 days . Thanks again.

Since I had my spleen out in August 2018 I have had some pretty low Neutrophil counts. They have been at been as low as 0.4 and now hover around 0.8 to 1.2. They are always low for some reason. I wonder if it is because of my splenectomy? I have struggled with a lot of infections in the past, so not having a spleen and low Neutrophil count makes me worried. I have been okay as far as serious infections go.

Splenectomy doesn't usually cause neutropenia. It could be autoimmune like ITP or something else. I'd insist on more investigation.

I agree there is probably no correlation between splenectomy and Neutropenia. I just noticed that it arose sometime after my splenectomy instead of before. My Hematologist is not even really doing much on the white blood count front. As long as I have no serious infections and do not get sick, she is focusing on the platelet count for now.

I had an ITP doctor like that, who was only interested in platelets. I changed to another last year and she is so much more interested in the whole of me and not just my platelets. I'm so much happier there, it was worth the move.

Csmid I agree with JJ the neutropenia is something to investigate. You want to lower your risk of getting an infection and be able to fight an infection if you get one. The neutropenia may be something easily remedied (if, for example, it is caused by a medication that can be stopped or substituted)...ask your hematologist to look into it. Did you have a bone marrow?

Hi Meyes and JJ. I have inquired about the Neutropenia and I do worry about my ability to fight a nasty infection, especially since I do not have a spleen anymore. I will inquire more into this with my Hematologist. I know there are some bad doctors out there that cause anxiety within the patient over and above the actual disease. However, I do love my hematologist. She lights up the room when she comes and exudes a positivity and confidence that is much appreciated. She is also not opposed to me getting a second opinion. She herself is a researcher who administers clinical trials, is an associate professor, and a recipient of a number of awards. She knows her stuff and seems to have a passion for wanting to figure this puzzle out. I wish every doctor was like her.

As for bone marrow, Meyes, I have had two of them to just to rule out an problems with the marrow. Everything checked out fine. They are not fun however

I don't find I get any more infections than I did before my splenectomy. And if I do get one, anti biotics take care of it pretty quick.

So glad you have confidence in your hematologist (who sounds wonderful) and that she is not opposed to second opinions. This is a tough disease; great to have clinicians to whom you can relate, and many minds, to support you.

I agree. I have not had any trouble with infections since splenectomy. I may have been on antibiotics once and they always do the trick.

meyes wrote: Thanks, Hal. The parvovirus angle is interesting...though I am reading that most of those cases are associated with red blood cell effects as well (which I dont have). Hematologist thinks this may be part of the "immune reconstitution syndrome" after rituxin. As B cells repopulate, it effects kinetics of neutrophils. Not sure if anyone really knows mechanism. Duration appears to range from 1-49 days . Thanks again.

Meyes, I think it is the other way around. Parvovirus affecting red blood cells is 'less common'.
"About Parvovirus B19"
www.cdc.gov/parvovirusb19/about-parvovirus.html

Apparently Vitamin C is good for treating it.
"Persistent parvovirus B19 viremia with chronic arthralgia treated with ascorbic acid: a case report"
www.ncbi.nlm.nih.gov/pmc/articles/PMC4326192/

CindyL, if you don't mind me asking. What vitamins/supplements do you take?