CTICasesNecrotizing Granulomatous Pulmonary Nodules Following Rituximab Withdrawal
Imaging findings
A young woman previously treated with rituximab for ITP develops widespread, centrally distributed, airway-predominant consolidation shortly after finishing therapy; on serial follow-up CTs over subsequent months, the central consolidation resolves while numerous well-defined, basal-predominant peripheral nodules and masses develop, which on biopsy show necrotizing granulomas without evidence of infection, EGPA, or lymphoma on extensive workup.
Key takeaways
Evolution from central airway-predominant consolidation to numerous necrotizing granulomatous nodules after stopping rituximab, with an extensive negative infectious and autoimmune workup, raises the possibility of a paradoxical immune reconstitution inflammatory syndrome (IRIS) or a sarcoid-like granulomatous drug reaction triggered by withdrawal of B-cell-depleting therapy; the number and distribution of lesions here was considered atypical for the more limited, one-or-two-lesion pattern usually seen with necrotizing sarcoidosis.
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