Rituximab Effectively Reverses Papilledema Associated with Cerebral Venous Sinus Thrombosis in Antiphospholipid Antibody Syndrome

Abstract

A case of bilateral papilledema secondary to cerebral venous sinus thrombosis treated with Rituximab, an anti-CD20 monoclonal antibody. A 23 year old obese female with a one week history of blurred vision, headaches and vomiting presented with bilateral papilledema. Her BCVA was 20/50 in right eye and 20/200 in the left eye with severe reduction of visual fields. Laboratory investigations revealed thrombocytopenia, prolonged prothrombin time (not reversed when mixed with normal plasma) and anticardiolipin antibodies. Besides, cerebral angiogram showed presence of cerebral venous thrombosis. The patient to have anti phospholipid antibody syndrome and treated with rituximab I.V. 375 mg/m 2 weekly x 4 doses, acetazolamide 500 mg BID, methyl prednisolone I. V. QID x 4. At 1-month, her headaches and vision improved to 20/30 in both eyes with partial resolution of papilledema and complete restoration of visual fields. Nine months later, patient had 20/25 vision in right eye and 20/30 in left eye with complete resolution of papilledema and cerebral sinus thrombosis. Rituximab was effective in reversing papilledema and cerebral sinus thrombosis, while preserving the vision in patient with antiphospholipid antibody syndrome. It is efficacious in treating papilledema in patients refractory to treatment with systemic steroids and immunoglobulin, with better clinical compliance and no side effects.