Cytomegalovirus infection in patients with rheumatic disorders under rituximab treatment: a scoping review.

Abstract

BACKGROUND: Cytomegalovirus (CMV), a DNA virus known for asymptomatic infections in immunocompetent individuals, can lead to fatal complications in the setting of immunosuppression. Rituximab (RTX) is an anti-CD20 monoclonal antibody with immunosuppressive properties, used as a first-line treatment choice for various rheumatic disorders. Although multiple reviews have analyzed the effects of RTX on CMV infection incidence in the population with a history of transplantation and malignancies, limited data are available on CMV incidence in those with rheumatic disorders under RTX treatment. METHODS: In August 2025, a thorough search in PubMed, EMBASE, Web of Science, MEDLINE (Ovid), and Scopus was conducted according to the framework proposed by Arksey and O’Malley, and the PRISMA-ScR guidelines were employed for reporting and structuring the research question (Population: individuals with rheumatic disorders, Concept: association between RTX administration and CMV infection, Context: RTX exposure) Tricco (Ann Intern Med 169(7):467-73, 2018). Original English studies on human subjects with rheumatic disorders infected with CMV infection or disease were included. The RTX dosage range was defined as low (doses < 500 mg per infusion), moderate (doses ranging from 500 to 1000 mg per infusion), and high (doses ≥ 1000 mg per infusion). Following abstract and full-text screening, relevant data were compiled into an Excel spreadsheet. RESULTS: A total of 13 studies, involving 459 patients, were recorded, among which 23 (5.01%) CMV infectious episodes were identified, most commonly reported as reactivation (39.13%, n = 9). The majority of CMV episodes occurred in individuals with anti-neutrophil cytoplasmic antibody-associated vasculitis and dermatomyositis, accounting for six cases. Six (2.57%), 10 (83.33%), and one (1.31%) infectious episode were reported among those with a history of low-, moderate-, and high-dose infusions, respectively. One fatal episode of CMV pneumonia occurred in a female patient diagnosed with MPA who was previously treated with four low-dose infusions of RTX. CONCLUSION: This review’s findings illustrated a 5% prevalence of CMV infection following RTX infusion in patients with rheumatic disorders. Accurately estimating the infection burden of this population requires more extensive and precise studies.