A 60-year-old woman with fibrosing mediastinitis showed marked improvement after receiving rituximab injections directly into mediastinal lymph nodes combined with pulmonary artery angioplasty, according to researchers reporting inAnnals of Internal Medicine.
The patient, who had 10 years of worsening exertional dyspnea following occupational iron dust exposure, was unable to complete a 6-minute walk test at baseline. Two months after the second rituximab injection, she achieved a distance of 230 m, which further improved to 282 m 2 months after angioplasty. Contrast-enhanced chest CT showed resolution of right middle lobe atelectasis, and positron emission tomography-CT demonstrated decreased metabolic activity, with maximum standardized uptake value declining from 8.0 to 6.0 at lymph node station 11R.
Juan Ni Gong, MD, of the Department of Respiratory and Critical Care Medicine at Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China, and colleagues used endoscopic-ultrasound guidance to inject 100 mg of high-concentration rituximab (2 mg/mL) into hypermetabolic lymph nodes identified by PET-CT imaging. Four months later, researchers administered a second 100 mg injection using higher-concentration rituximab (5 mg/mL) to minimize technical challenges.
Pulmonary function tests showed FEV₁ improved from 40.3% to 60.9% and FEV₁/FVC ratio increased from 39.8% to 60.9% compared with initial presentation. Following balloon angioplasty in the RA10 and RA8 pulmonary arteries, mean pulmonary artery pressure decreased from 35 mm Hg to 26 mm Hg measured by right heart catheterization.
The patient developed influenza between treatments, accompanied by lymphocytopenia, which was managed successfully with thymalfasin. Researchers noted this was the only adverse effect observed during the treatment course.
Fibrosing mediastinitis is a rare condition characterized by abnormal proliferation of fibrous tissue within the mediastinum that can compress or displace mediastinal structures. Traditional vascular interventions provide temporary relief but have limited long-term benefits, with restenosis occurring in up to 45.5% of cases due to ongoing fibrosis driven by abnormal immune activity. Intravenous rituximab has been shown to reduce fibrosis volume but has been associated with upper respiratory infections, pleural space infections, and opportunistic infections.
Researchers hypothesized that lymph node-targeted drug administration reduced the volume of mediastinal lymph nodes, alleviating airway compression and improving both airway patency and pulmonary function while avoiding the systemic effects of intravenous administration.
The study was supported by the Beijing Research Ward Excellence Program; several authors reported no disclosures.
Source: Annals of Internal Medicine
