Patient's Query
Hello Doctor,
I am 29 years old and was diagnosed with NMOSD last year after experiencing two attacks, one episode of optic neuritis and one of transverse myelitis. My AQP4-IgG antibodies were positive at a 1:320 titer. My spine MRI shows a longitudinal lesion from T6 to T10, and my brain MRI is normal. My most recent CBC showed mild lymphopenia, with WBC at 3.2 × 10⁹/L. My ALT was slightly elevated at 54 U/L. I am currently receiving Rituximab every six months.
Is mild lymphopenia expected with Rituximab treatment? Should I be worried about the rise in liver function? Also, how is disease activity monitored between relapses? Do I need an annual MRI even if I remain stable?
Kindly help.
Hello,
Welcome to icliniq.com.
I understand your concern.
Mild lymphopenia, which means a low white blood cell count, especially a decrease in B cells, is expected with Rituximab treatment. This is because Rituximab works by depleting CD20-positive B cells. A white blood cell count of 3.2 × 10⁹ per liter is on the lower side but not uncommon during this therapy.
An alanine aminotransferase (ALT) level of 54 units per liter is mildly elevated. This can occasionally happen due to immunosuppressant treatment or from other causes like fatty liver or viral infections. This should be monitored, but it is not urgent unless the level rises further or stays elevated for a long time.
It is recommended to check liver function tests every three to six months while receiving Rituximab. If not done already, testing for hepatitis B and hepatitis C should also be considered.
Monitoring disease activity between relapses mainly depends on clinical signs. New symptoms such as changes in vision, numbness, weakness, or problems with bladder or bowel control may suggest active disease.
A brain and spine magnetic resonance imaging (MRI) is generally recommended once a year in people with neuromyelitis optica spectrum disorder, even if they feel stable. This helps in identifying any changes that may not cause immediate symptoms.
Repeating serum aquaporin-4 immunoglobulin G (AQP4-IgG) titers is not usually useful for tracking disease activity. These levels are not reliable indicators and are generally not repeated unless there is a specific reason.
Make sure you are up to date with all recommended non-live vaccines before or between Rituximab infusions, since the treatment suppresses the immune system.
Watch out for signs of infusion reactions or infections. If you have a persistent fever, cough, or unexplained weight loss, you should report it promptly.
You should continue regular follow-up with a neurologist who has experience in treating neuromyelitis optica spectrum disorder. If possible, get care at a medical center that specializes in autoimmune neurology.
I hope you are satisfied with my answer. For further queries, you can consult me at iCliniq.
Thank you.
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Answered byDr. Merriyet. M. B
Medically reviewed byiCliniq medical review team
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