Neuromuscular Disorders 32 (2022) 664–671

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Neuromuscular Disorders
journal homepage: www.elsevier.com/locate/nmd

Rituximab in myasthenia gravis: efficacy, associated infections and risk

of induced hypogammaglobulinemia
Marta Caballero-Ávila a,b, Rodrigo Álvarez-Velasco a,b, Esther Moga c, Ricard Rojas-Garcia a,b,
Janina Turon-Sans a,b, Luis Querol a,b, Montse Olivé a,b, David Reyes-Leiva a,b, Isabel Illa a,b,
Eduard Gallardo a,b, Elena Cortés-Vicente a,b,∗
a
Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau; Department of Medicine, Universitat Autònoma de
Barcelona; and Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
b
Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
c
Department of Immunology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain

a r t i c l e i n f o a b s t r a c t

Article history: The aim of this study is to evaluate the long-term efficacy, safety, and impact on immunoglobulin
Received 23 February 2022 G (IgG) levels of rituximab in patients with myasthenia gravis (MG). A retrospective, observational
Revised 15 June 2022
study of drug-refractory MG patients treated with rituximab was done. The MG Foundation of America
Accepted 17 June 2022
postintervention status (MGFA-PIS) was used to evaluate clinical response. Serum IgG levels were
determined at baseline and post-treatment. Hypogammaglobulinemia was defined as IgG<7g/L. Thirty
Keywords: patients were included, 12 with anti-MuSK and 18 with anti-AChR antibodies. Mean (SD) follow-up
Myasthenia gravis was 85.5 (48) months. All 12 MuSK+ patients but only six (33%) AChR+ patients achieved minimal
Rituximab manifestations or remission (p<0.01). Nine severe infections were observed in five patients (17%). One
Infection
patient was diagnosed with progressive multifocal leukoencephalopathy. At baseline, two patients (2/24;
Hypogammaglobulinemia
8%) had hypogammaglobulinemia. During follow-up, hypogammaglobulinemia was observed in 60% (3/5)
Adverse events
Autoimmune of patients who developed an infection and in 33% (7/21) who did not. Two of these patients died of
infection-related complications. This study supports the effectiveness of rituximab in patients with MG,
especially those with anti-MuSK antibodies. Severe infections may appear after rituximab treatment and
hypogammaglobulinemia might play a role on it. A standard protocol would be needed to closely monitor
IgG levels in MG patients treated with rituximab.
© 2022 Elsevier B.V. All rights reserved.

1. Introduction Rituximab is an anti-human CD20 monoclonal antibody that

Myasthenia gravis (MG) is an autoimmune disease affecting
the postsynaptic neuromuscular junction. Its clinical presentation
is characterized by fatigable weakness. Most patients present
antibodies against the acetylcholine receptor (AChR), muscle-
specific kinase (MuSK), and/or lipoprotein-related protein 4
(LRP4) [1]. The treatment of MG consists of a combination
of symptomatic treatments, immunosuppressive (IS) therapies,
thymectomy, and immunomodulatory treatments (plasma-
exchange and intravenous immunoglobulin) [1,2]. Most patients
achieve a good clinical response with conventional IS therapies.
However, in approximately 10% to 30% of patients, response is
insufficient, leading to refractory MG (defined as a non-response
after corticosteroids and ≥ 2 other IS agents) [3].
∗
Corresponding author.
E-mail address: ecortes@santpau.cat (E. Cortés-Vicente).
induces depletion of B cells. Rituximab has been approved for the
treatment of multiple immune-mediated disorders [4], but it is
also commonly prescribed off-label to treat various neurological
diseases, including refractory MG. Many studies have found that
rituximab is beneficial in patients with refractory MG [5–8],
especially in those with MuSK antibodies, in whom the clinical
benefit appear to be greater and longer lasting [5,6,9].
Rituximab reduces the pre-plasma B cell count, thus
depleting immunoglobulin secretion. In turn, this may induce
hypogammaglobulinemia, which is associated with an increased
risk of infection [10]. Patients treated with rituximab have a
high risk of developing prolonged hypogammaglobulinemia.
This rituximab-associated risk has been widely reported in
several hematological disorders, but is most marked in patients
with lymphoma treated with multiple courses of rituximab
[11–13]. Rituximab has also been associated with a higher
risk of hypogammaglobulinemia in patients with rheumatoid

https://doi.org/10.1016/j.nmd.2022.06.006
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M. Caballero-Ávila, R. Álvarez-Velasco, E. Moga et al.
arthritis [14], ANCA-associated vasculitis, and other multisystemic
autoimmune disorders [15,16].
In patients with neurological disorders, rituximab-induced
hypogammaglonulinemia is well described in multiple sclerosis
[17]. In other neurological disorders, the evidence is lower. One
series involving 15 patients with neuromyelitis optica spectrum
disorders found severe hypogammaglobulinemia in three of
the 15 patients, two of whom developed serious infectious
complications [18]. To our knowledge, no studies have yet
evaluated the incidence and clinical implications of rituximab-
induced hypogammaglobulinemia in patients with refractory MG.
In this context, the main objective of this study was to
evaluate the efficacy and safety of rituximab in a retrospective
series of patients diagnosed with refractory MG. A second aim
was to describe the incidence and severity of rituximab-induced
hypogammaglobulinemia in these patients.
2. Methods
2.1. Patients and clinical assessment
This was a retrospective, observational study performed at the
Neuromuscular Unit of a tertiary care centre (Hospital de la Santa
Creu i Sant Pau; Barcelona, Spain).
Inclusion criteria were as follows: diagnosis of refractory MG
defined according to the criteria established by international
consensus [3]; treatment with rituximab between January 2006
and January 2020; and minimum follow-up of 6 months. For the
purposes of this study, the final follow-up was August 31, 2020.
Patients who were not treated at our centre and/or in whom
follow-up was performed at another hospital were excluded. All
cases missing essential data or lost to follow up were excluded.
Sociodemographic and clinical data were obtained from the
patients’ medical records. The following variables were registered:
sex; date of disease onset and diagnosis; AChR, MuSK and LPR4
antibody status; presence of thymoma; and previous treatments.
Clinical response was assessed through the MGFA Task Force
Post-Intervention Status (MGFA-PIS) scale. This scale classifies
patients as follow: remission (complete stable or pharmacological),
minimal manifestations, or symptomatic. In all cases, the treatment
objective was minimal manifestation status or better on the MGFA-
PIS with no or minor side effects.
2.2. Treatment regimen
All patients received the standard dose of rituximab
(375 mg/m2 ) administered weekly for four consecutive weeks
and then monthly for the next two months [19]. Additional
infusions were administered in patients who relapsed, which
was defined as clinical worsening with a negative impact on
activities of daily living. The total number of rituximab infusions
administered to each patient during follow-up was registered.
2.3. Immunoglobulin levels
Serum immunoglobulin G (IgG) concentration was measured as
part of routine clinical care before and after rituximab treatment.
IgG levels were determined at the immunology laboratory
at our hospital using quantitative nephelometry. We defined
hypogammaglobulinemia as IgG levels < 7 g/L, graded as mild
(5–6.9 g/L), moderate (3–4.9 g/L), or severe (<3 g/L) following
the approach described by other authors [15]. IgG levels obtained
within three months of intravenous immunoglobulin therapy or
plasma exchange were excluded from the analysis.
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Neuromuscular Disorders 32 (2022) 664–671
2.4. Infections
We reviewed the clinical records of the study participants
to check of post-rituximab infections. Any infection requiring
hospitalisation was considered severe. Infections that lead to
hospitalization due to MG worsening were not considered severe
and were excluded. We recorded the type of infection (focus and
pathogen), time from last rituximab infusion, and status (resolved
or not). Suspected but not confirmed infections were excluded
from the analysis.
2.5. Statistical analysis
A descriptive data analysis was performed. Symptom
frequencies are reported as absolute numbers with percentages.
Demographic characteristics are given as means with standard
deviation (SD). Differences in baseline characteristics (categorical
variables) between subgroups were evaluated with the χ 2 test
or Fisher exact test. Analysis of variance (ANOVA) or the Mann-
Whitney U test were used, as appropriate, to compare quantitative
variables. Statistical significance was set at p < 0.05. Data analysis
was carried out using SPSS statistical software program, v. 21.0
(SPSS-IBM Inc.; Chicago, IL; USA).
Follow-up ranged from 6 to 48 months after the first infusion.
Given this heterogeneity, the analysis was performed by grouping
the follow-up period into two intervals: 3–15 and 24–48 months.
2.6. Protocol approval and informed consent
The treating neurologists obtained informed consent from the
patients. The study was approved by the ethics committee at the
Hospital de la Santa Creu i Sant Pau.
3. Results
3.1. Patient characteristics
A total of 33 patients with refractory MG received rituximab
during the study period. Three patients were excluded from the
study due to follow-up in a different hospital (n=2) or insufficient
follow-up (< 6 months; n=1). Therefore, the final sample consisted
of 30 patients who met all inclusion criteria.
Most patients (n=27, 90%) were women. The mean (SD) age at
onset was 37.1 (19.2) years. Eighteen patients (60%) were AChR+
and 12 (40%) anti-MuSK+. All patients were anti-LRP4 negative. Of
the patients with anti-AChR antibodies, four had thymoma (22%)
and all of them were thymectomized.
The patients’ demographic and clinical data are shown
in Table 1. A mean (SD) of 3.4 [1] immunosuppressive
drugs were prescribed apart from rituximab, most commonly
prednisone (30/30; 100%) and azathioprine (22/30; 73.3%). Other
immunosuppressive drugs included cyclosporine (n=19 patients;
63%), mycophenolate mofetil (n=17; 56%), tacrolimus (n=6; 20%),
and cyclophosphamide (n=5; 17%). Concurrent treatment while
rituximab was: prednisone in 90% of the patients (n=27),
cyclosporine in 13% (n=4), azathioprine (n=3) and mycophenolate
mofetil (n=3) in 10%. The mean (SD) age at initiation of rituximab
treatment was 45.4 (18.2) years. The mean disease duration before
treatment with rituximab was 99 (85) months. As Table 1 shows,
there were no significant clinical differences between the patients
with AChR and MuSK antibodies prior to treatment initiation.
3.2. Disease response
Mean follow-up after the first rituximab infusion was 85.5
(48) months. Twenty-seven patients (90%) presented clinical
M. Caballero-Ávila, R. Álvarez-Velasco, E. Moga et al.
Table 1
Demographic and clinical data of patients with anti-AChR and anti-MuSK antibodies.
Sex
Male, n (%)
Female, n (%)
Age at onset, mean (SD)
Thymoma, n (%)
Number of other IS apart from rituximab, mean (SD)
Prednisone, n (%), mean Tx duration (SD)
Azathioprine n (%), mean Tx duration (SD)
Cyclosporine n (%), mean Tx duration (SD)
Mycophenolate mofetil n (%), mean Tx duration (SD)
Tacrolimus, n (%), mean Tx duration (SD)
Cyclophosphamide, n (%), mean Tx duration (SD)
Age at rituximab, mean (SD)
Disease duration prior to rituximab, mean (SD)
Abbreviations: IS, immunosuppressants; Tx , treatment; SD, standard deviation; m, months; y, years.
improvement after rituximab administration and 18 patients (60%)
achieved the treatment objectives.
Significant differences (p<0.01) in disease response between
the immunological groups were observed: all patients with anti-
MuSK antibodies achieved minimal manifestation status (MMS) or
remission versus only 33% (6/18) of the patients with anti-AChR
antibodies. At one year of follow up, most of the anti-MuSK+
patients (11/12; 92%) and half of the anti-AChR+ patients (3/6;
50%) remained in MMS or remission.
Additional infusions were needed in six (50%) of the anti-
MuSK+ patients and in 10 of the anti-AChR+ patients (56%) after
a mean (SD) follow-up of 68.3 (58) months and 32 [24] months,
respectively (p=0.2). Overall, a mean of 0.8 (0.9) reinfusions of
rituximab were required during follow up, with no significant
differences between the anti-MuSK+ (0.8) and anti-AChR+ patients
(0.9).
3.3. Adverse events: infections
Nine severe infections were observed in five patients (17%)
after a median of 17 months (range 1-130) from last rituximab
infusion (Table 2). These infections were classified as follows:
pneumonia (n=4), gastrointestinal infection (n=2), systemic (n=2;
cytomegalovirus and methicillin-resistant Staphylococcus aureus
[MRSA]), and progressive multifocal leukoencephalopathy (PML)
(n=1). The infections resolved in three of the five patients. The
other two patients (patients 4 and 5) died.
Patient 4 presented severe infections leading to death many
years after rituximab infusions. He was a 61-year-old patient with
an anti-AChR+ MG associated with thymoma. He was diagnosed
with MG at age 33. Previous treatments included: thymectomy,
prednisone, azathioprine, cyclosporine, mycophenolate mofetil, and
intravenous immunoglobulin. Rituximab treatment was started at
age 48. He required three reinfusions in the following two years.
Although his myasthenic symptoms remained stable, from age
55 he was hospitalised several times due to infections. The first
one requiring hospital admission was due to a Campylobacter
Jejuni gastrointestinal infection, followed by cytomegalovirus colitis
(leading to five hospital admissions), and finally MRSA-related
sepsis, which was responsible for the patient’s death.
PML was diagnosed in patient 5, and suspected in another
patient. Patient 5, a 57-year-old woman, was diagnosed with anti-
AChR+ MG associated with thymoma at age 33. Previous treatment
included: thymectomy; prednisone; azathioprine; cyclosporine;
mycophenolate mofetil; intravenous immunoglobulins; and
plasmapheresis. She received the first rituximab infusion at age 54
and required reinfusion at age 55. A month after the last rituximab
infusion she was hospitalised with a systemic cytomegalovirus
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Neuromuscular Disorders 32 (2022) 664–671
Anti-AChR (n=18) Anti-MuSK (n=12) p
3 (17%) 0
15 (83%) 12 (100%) 0.255
32.6y (19.1) 44y (18.1) 0.062
4 (22%)
3.6 (0.9) 3 (1.2) 0.127
18 (100%), 150m (91) 12(100%), 153m (100)
15 (83%), 51m (60) 7 (58%), 40m (64)
13 (72%), 28m (38) 6 (50%), 66m (68)
13 (72%), 22m (26) 4 (33%), 15m (20)
5 (28%), 23m (27) 1 (8%), 62m
1 (6%), 9m 4 (33%), 43m (34)
40.9y (19.3) 52y (14.6) 0.065
99m (83) 99m (93) 0.611
infection. At age 56, she presented clinical worsening and
recurrent thymoma. Cyclophosphamide was initiated. Seven
months later, she was admitted for respiratory failure associated
with pneumonia caused by legionella pneumophila. Eight months
after initiation of cyclophosphamide treatment and 17 months
after the last rituximab infusion, she developed right arm paresis
and action myoclonus requiring hospitalisation. A cranial MRI
showed multifocal, periventricular and subcortical involvement,
hypointense in T1 and hyperintense in T2, suggestive of PML
(Fig. 1A). The CSF-JCV PCR test was positive. The patient died two
months after the PML diagnosis.
Finally, in one patient PML was suspected but not confirmed. A
32-year-old woman, was diagnosed with anti-AChR+ MG at age 11.
Her medical history included the following MG-related treatments:
thymectomy, prednisone, mycophenolate mofetil, cyclosporine,
and intravenous immunoglobulin. Due to failure of previous
treatments, she was prescribed rituximab. The first infusion,
administered at age 20, produced a partial response. At age
21, she needed a reinfusion due to clinical worsening. By age
24, her peripheral B cells were completely depleted. At age 28,
the symptoms of MG had worsened and she received another
rituximab infusion, but without clinical or laboratory response
(B-cell levels were normal after treatment). Neutralizing anti-
rituximab antibodies were positive. A cranial MRI was performed,
revealing an incidental subcortical frontal lesion affecting the
U-fibers and sparing the cortex; the MRI was hypointense in
the T1-weighted sequence, and hyperintense in T2 and without
contrast enhancement (Fig. 1B,C). No clinical repercussion was
observed and a polymerase chain reaction (PCR) test for JC virus
(JVC) DNA in cerebrospinal fluid (CSF) was negative. Anti-JC virus
antibodies index was highly positive (3.75). Since then, the image
has remained stable on annual MRI tests (Fig. 1D,E). Given the
lack of an alternative diagnosis, a PML was suspected. Due to the
suspicion, the patient is now been treated with periodic plasma
exchanges and no other immunosuppressants have been initiated.
Notably, all of patients who developed infections were anti-
AChR+. Compared to patients who did not develop infections,
those with infections were older at disease onset and at rituximab
infusion, had received more immunosuppressant drugs and more
rituximab infusions. However, the only difference that reached
statistical significances was the age of rituximab infusion (Table 3).
3.4. Immunoglobulin levels
Overall, median (SD) pre-treatment IgG levels were 10.7 (0.3)
g/L, 9.1 g (0.3) g/L at 3–15 months after treatment initiation and
8.5 (0.3) g/L at 24–48 months posttreatment.
M. Caballero-Ávila, R. Álvarez-Velasco, E. Moga et al. Neuromuscular Disorders 32 (2022) 664–671

Serum immunoglobulin levels before the start of rituximab

Abbreviations: IS, immunosupressions; PDN, prednisone; AZA, azathioprine; MMF, Mycophenolate mofetil; CYA, Cyclosporine; TAC, tacrolimus; CPH, cyclophosphamide; MTX, methotrexate; PML, progressive multifocal
were available in 23 of the 30 (76.7%) patients. At baseline (pre-
because of
infection
rituximab), two patients, both of which were anti-AChR+, had
Death

mild hypogammaglobulinemia. Of these two patients, one had

Yes

Yes
No

No

No
a thymoma and had received six different immunosuppressants
while the other had received four drugs. The cause of this baseline
after rituximab
Hypogamma-
globulinemia

hypogammaglobulinemia was not reported in the medical records.

Moderate
One patient (patient 5) with baseline hypogammaglobulinemia
experienced a 30% decrease in IgG levels after rituximab infusion
Mild

Mild
No

No

and later developed infections during follow up (Table 2).

Data on IgG levels during follow-up was available in 26 of 30
Time from last

patients at 3–15 months from the first rituximab infusion and in

rituximab

20 of 30 patients at 24–48 months. Ten patients (37%) developed

infusion

106 hypogammaglobulinemia at some point during follow-up; of these

130
44

16
17
40

cases, seven (70%) were mild and three (30%) moderate. No severe
1

1 cases of hypogammaglobulinemia were reported.

Pneumonia (influenza virus

Systemic infection (CMV)

leukoencephalopathy; CMV, cytomegalovirus; GIT, gastrointestinal; MRSA, methicillin-resistant Staphylococcus Aureus; m, months ; ∗ IS that were maintained after infection
After 3–15 months post-rituximab infusion,
(Staphylo-coccus Aureus)
Pneumonia (unknown)

Esophagitis and colitis

Pneumonia (legionella
pneumo-phila) PML hypogammaglobulinemia was present in seven patients
(27%), considered mild in six cases and moderate in the
(Campylo-bacter)

remaining one. Of these seven patients, five had persistent

GIT infection

MRSA sepsis
Pneumonia

hypogammaglobulinemia 24–48 months after the initial infusion.

Infections

Two patients who had normal IgG levels at 3–15 months from the
(CMV)

first rituximab infusion later developed hypogammaglobulinemia

A)

between months 24–48, without having received a reinfusion.

In the patients who developed an infection (n=5), 60%
Number of
rituximab
infusions

presented hypogammaglobulinemia at some point during follow-

up versus 33% of patients without an infection, a non-significant
1

difference (Table 3). Mean IgG levels before and after rituximab
infusion were significantly lower in patients who developed an
(latency between stop

infection (11.2 g/L vs 8.2 g/L before rituximab [p=0.035], 9.4 g/L vs.
IS after rituximab

5.8 g/L at 3–15 months [p=0.030]; and 8.9 g/L vs. 5.9 g/L at 24–
CPH (7 months)
and infection)

48 months [p=0.036]), (Figure 2). Both patients who died from an

infection had hypogammaglobulinemia during follow-up. Patient
MMF∗

4 developed moderate hypogammaglobulinemia after the first

PDN∗

PDN∗

PDN∗

PDN∗

PDN∗
CYA∗

TAC∗

rituximab infusion, which required immunoglobulin replacement

treatment every six weeks due to severe infections.
treatment with
Concurrent IS

4. Discussion
rituximab

MMF
PDN

PDN

PDN

PDN

PDN
CYA

The findings of this study confirm the beneficial effects of

rituximab in patients with refractory MG. The value of rituximab
was particularly evident in patients with antibodies against
Previous IS before rituximab
(latency between stop and

MuSK, with all 12 (100%) of these patients achieving minimal

MMF (67m, 129m,153m)
Clinical data from patients who developed an infection after rituximab infusion.

AZA (70m, 132m, 156m)

CYA (70m, 132m, 156m)

manifestation or remission status (MGFA-PIS) versus only 33%

AZA (36m, 51m, 52m)

CYA (12m, 27m,28m)

of those with AChR+ MG (p<0.01). However, post-rituximab

infections were common, with five patients developing at least one
MMF (1m,16m,

severe infection (17%) after a median follow-up of 17 months from

AZA (95m)

AZA (74m)

CYA (15m)
MMF (2m)
TAC (44m)

AZA (9m)
infection)

the last rituximab infusion. A total of 10 patients (37%) developed

rituximab-induced hypogammaglobulinemia during follow-up and
17m)

patients who developed an infection had lower levels of IgG before

and after rituximab treatment. One patient was diagnosed with
Yes (relapsed)

Yes (relapsed)

progressive multifocal leukoencephalopathy and in another was

Thymoma

suspected but not confirmed.

As noted above, and consistent with prior studies [9,21–23],
No

No

No

treatment response was significantly better in patients with anti-

MuSK+ MG. Importantly, response in the anti-MuSK+ patients was
rituximab

also more durable, with all but one of these patients remaining in
Patient Anti-bodies Age at

MMS or remission at the one-year follow-up and with a longer

81

58

72

48

53

time interval until reinfusion versus anti-AChR+ patients. It is

widely accepted that differences in response to rituximab might
be related to the pathophysiology of anti-MuSK+ MG, which is
AChR+

AChR+

AChR+

AChR+

AChR+

an IgG4-related disorder [1,9]. In our cohort, of the 18 patients

with AChR antibodies, only six (33%) achieved the treatment aim,
a response rate that is consistent with the findings reported in
Table 2

the largest systematic review conducted to date [6], but lower

1

than described in other studies, in which up to 80% of anti-AChR+

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M. Caballero-Ávila, R. Álvarez-Velasco, E. Moga et al. Neuromuscular Disorders 32 (2022) 664–671

Fig. 1. MRI of patient 5: A) Hyperintense T2 FLAIR multifocal lesions. MRI of patient with suspected PML: B) Hyperintense T2 flair lesion. C) Hypointense T1 lesion without
contrast enhancement. D) Control MIR at one year. E) Control MRI at 2 years.

Table 3
Comparison between patients with and without a post-rituximab infection.

No infection (n=24) Infection (n=5) p

Antibodies 50% anti-AChR+, 50% anti-MuSK+ 100% anti-AChR+ 0.059

Age at onset, mean (SD) 35.6 years (18.2) 49.6 years (20) 0.129
Age at rituximab infusion, mean (SD) 43 years (16.9) 62.4 years (13.7) 0.02∗
Other immunosuppressant drugs, mean (SD) 3.3 (1.1) 4.2 (0.4) 0.078
Number of rituximab infusions, mean (SD) 1.8 (0.9) 1.8 (1.3) 0.850
Hypogammaglobulinemia during follow-up 7 (7/21, 33%) 3 (3/5, 60%) 0.326

patients responded to treatment [23–25]. These large differences in
response rates are likely attributable to differences in the criteria
used to define rituximab efficacy. We defined efficacy as MMS or
better on the MGFA-PIS scale, whereas most other studies used
clinical improvement as the efficacy outcome measure.
Rituximab is usually well-tolerated, with a low rate of side
effects and post-treatment infections. Previous studies in patients
with MG treated with rituximab have reported infection rates
ranging from 2% to 21.4% [5,6,23,27]. Other studies performed
in these patients have not specifically report adverse events
[9,21,24,26]. In our cohort, 17% of the patients developed a severe
infection during follow-up and two patients died. In two patients,
the infections developed several months after the last rituximab
infusion and thus it is not clear whether the infections were
directly related to the treatment or not. Patients who developed
an infection were older than the ones who did not. This could be
explained by the fact that older patients have more comorbidities
that may contribute to the risk of infection.
One patient in our series, representing 3% of the cohort,
developed PML, a surprisingly high rate. In this patient the
diagnosis was considered definite due to the presence of
compatible clinical and radiologic findings with a positive CSF-
JCV PCR test [28]. In another patient, the diagnosis was suspected
but not confirmed (negative CSF-JCV PCR test). The MRI was

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M. Caballero-Ávila, R. Álvarez-Velasco, E. Moga et al.
Fig. 2. Mean IgG levels from baseline to months 3–15 and months 24-48 post-rituximab according to infection versus no infection (baseline mean IgG level 11.92 vs 8.14g/L,
p<0.05; at 3-15 months 5.80 vs 9.43g/L, p<0.05; at 24–48 months 5.87 vs 8.90g/L, p<0.05).
compatible with PML and all other diagnoses had been ruled
out. Moreover, the patient had anti-JC virus antibodies which
indicate past contact with the virus. This patient was excluded
from the analysis because of not confirmed infection. In this
second patient, we hypothesize that normalization of B-cell
levels prevented the infection from progressing, which would
explain the negative PCR test. Both patients had received
other immunosuppressant therapies (azathioprine, mycophenolate
mofetil, cyclosporine, methotrexate and cyclophosphamide) apart
from rituximab. To our knowledge, only four cases of PML have
been reported in patients with MG to date [29–32]. Interestingly,
two of those patients had been treated with rituximab (as well as
azathioprine and mycophenolate mofetil) [31,32], while the other
two received only azathioprine and steroids [29,30]. Importantly
both cases (confirmed and suspected case) in our series had
received numerous immunosuppressants apart from rituximab,
and thus the role of rituximab in the development of this condition
is not clear.
Hypogammaglobulinemia is a known risk factor for infection,
which is why we evaluated the frequency and severity of this
variable. The cut-off point to define hypogammaglobulinemia
varies, ranging from IgG < 5g/L to IgG <7 g/L (the threshold
applied in our series) [14,15,17,20]. Prior to starting rituximab, two
of the 23 patients (8%) in our series had low IgG levels. This
proportion is lower than observed in patients with hematological
disorders (15%) [13] and multisystemic autoimmune diseases such
as primary systemic vasculitis (26%, 13%) [15,16], and higher than
in patients with rheumatoid arthritis (2.2%, 4.6%) [33,35].
The etiology of hypogammaglobulinemia is likely multifactorial,
potentially associated with the disease itself and/or with previous
treatment. However, mean IgG levels in our cohort decreased
after rituximab infusion, leading to an increase in the proportion
of patients (37%) with hypogammaglobulinemia. In the published
literature, hypogammaglobulinemia following rituximab treatment
669
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Neuromuscular Disorders 32 (2022) 664–671
ranges from 13% to 56% in patients with non-Hodgkin lymphoma
and multisystemic autoimmune diseases [13,15,16,33,34,36]. Some
studies suggest that other factors may contribute in the induction
of hypogammaglobulinemia, including high dose chemotherapy
[13] and the number of rituximab infusions [36]. In our study, we
were unable to identify any predictors of low IgG levels. However,
it is clear that a larger sample would be needed to do so.
Rituximab-induced hypogammaglobulinemia is well described
in multiple sclerosis [17], but scant in other neurological
conditions. Our study is the first to assess rituximab-induced
hypogammaglobulinemia in patients with MG. A few previous
studies have found that infections appear to be more likely to
occur in patients with lower IgG levels after rituximab treatment
[35,37]. Our data show that patients who developed an infection
were more likely to present hypogammaglobulinemia, although the
between-group differences were not statistically significant. The
association between low IgG levels and infection is not surprising
given that IgG is the most important serum immunoglobulin
for immunity. Nevertheless, more data are needed to develop
a risk classification system for hypogammaglobulinemia and the
consequent risk of infection in order to identify which patients
would most benefit from IgG replacement therapy.
At present, rituximab does not have a clear role in most
treatment algorithms for MG. In our study, all of the patients who
were treated with rituximab met criteria for refractory MG and had
received a mean of 3.4 immunosuppressants apart from rituximab.
The latest American Academy of Neurology guidelines recommend
rituximab as an early therapeutic option in anti-MuSK+ patients
who present an unsatisfactory response to initial immunotherapy
[3]. In anti-AChR+ patients, rituximab is usually reserved as
an advanced option of treatment. However, a recent study
[26] compared 72 patients (without MuSK antibodies) treated with
rituximab (33% with new-onset disease) to a control group (n=26)
with new-onset disease who were treated with conventional
M. Caballero-Ávila, R. Álvarez-Velasco, E. Moga et al.
immunotherapy. In that trial, the mean time to remission was
shorter in patients with new-onset disease treated with rituximab
versus those who received conventional immunotherapy, leading
the authors to conclude that treatment with rituximab might
be more beneficial if administered earlier in the disease course.
Larger, prospective studies are needed to determine the optimal
timing of rituximab treatment in each immunological subgroup.
The present study has several limitations, mainly the
retrospective design, the small sample size and the absence of a
control group. Due to the retrospective design, we were unable to
obtain standardized IgG levels. This meant that immunoglobulin
levels before rituximab were not available in all patients and
that we had to use a wide range of time from treatment when
analysing IgG concentrations. By contrast, the main strength
of this study is that it is the first to assess rituximab-induced
hypogammaglobulinemia in patients with MG after a long follow-
up.
In conclusion, our data confirm previous reports showing that
rituximab is highly effective in patients with MG, especially those
with anti-MuSK antibodies. However, we observed a relatively
non-negligible infection rate after administration of rituximab,
potentially due to low IgG levels. A standard protocol would be
needed to closely monitor IgG levels to better define the patients
would most benefit from immunoglobulin replacement therapy.
Funding
This work was funded by the Instituto de Salud Carlos
III through the project PI19/01774 (cofunded by the European
Union ERDF), PI I. Illa and E. Gallardo. E. Cortés-Vicente was
supported by a Juan Rodés grant (JR19/0 0 037) from the Fondo de
Investigación en Salud, Instituto de Salud Carlos III and co-funded
by European Union (ERDF/ESF, "A way to make Europe"/"Investing
in your future"), Ministry of Health (Spain). M. Caballero-Ávila
was supported by a Rio Hortega grant (CM21/00101) from the
Instituto de Salud Carlos III. R. Álvarez-Velasco was supported by
grant SLT0 08/18/0 0207 from the Health Research and Innovation
Strategic Plan (PERIS).
Acknowledgments
The authors thank Bradley Londres for language support.
Marta Caballero-Ávila, E. Gallardo, R. Rojas-Garcia, J. Turon-
Sans, L. Querol, M. Olivé, R. Álvarez-Velasco, D. Reyes-Leiva, I. Illa,
and E. Cortés-Vicente are members of the European Reference
Network for Neuromuscular Diseases; work on a CSUR (centro,
servicio, unidad de referencia) on rare neuromuscular diseases;
and are members of XUECs (Xarxes d’unitats d’expertesa clínica en
malalties minoritàries).
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