Cytokine release syndrome

Background

  • Systemic inflammatory response syndrome that can be adverse effect of certain immunotherapies, such as monoclonal antibodies and CAR-T therapies (e.g. CART19 for leukemia)
  • Pathophysiology and presentation similar to sepsis
  • Severity ranges from mild flu-like illness to severe sepsis-like inflammatory response with shock, vascular leakage, DIC, and multi-organ system failure[1]

Clinical Features

  • Mild: flu-like illness
  • Severe: mimics septic shock
    • Fever, tachycardia, hypotension, dyspnea, hypoxia
    • Organ-specific dysfunction: encephalopathy, coagulopathy, renal failure, CHF

Differential Diagnosis

  • Sepsis!
  • Hemophagocytic lymphohistiocytosis

Shock

Oncologic Emergencies

Evaluation

Hospitals administering CAR-T therapies will often have very specific guidelines for initial workup

Management

  • Strongly consider discussion with CAR-T treatment team
  • Empiric antibiotics (assume sepsis until proven otherwise)
  • Treat shock
  • Corticosteroids for severe cases
  • Consider Tocilizumab (IL-6 receptor antagonist) in consultation with oncology

Disposition

  • Admit or consider transfer to hospital with oncology

See Also


https://www.mdcalc.com/cytokine-release-syndrome-crs-grading#evidence

References

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6003181/

  1. Shimabukuro-vornhagen A, Gödel P, Subklewe M, et al. Cytokine release syndrome. J Immunother Cancer. 2018;6(1):56.
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