This patient is at risk of infections, cytokine release syndrome (CRS) and neurologic toxicities (ICANS).
The information provided here may help guide you in their management.
Evaluate for infection
Tests to consider: physical exam (looking for infection), CBC, CMP, urinalysis, viral respiratory panel, quantitative immunoglobulins, blood and urine cultures, consider reactivation of CMV, HSV, VZV, EBV, adenovirus, and HHV6. Evaluate for fungal infections such as candida and PJP. Consider endemic infections from the area (tuberculosis, dengue, chagas, etc). Imaging studies as appropriate.
Intervention: start empiric antibiotics if concerned for possible infection until studies have resulted. Give IVIG if septic or IgG levels are below 400. Patient should be on VZV and PJP prophylaxis.
Evaluate for CRS
Tests to consider: physical exam (looking for fever, hypotension, hypoxia), CBC, CMP, CRP, ferritin, blood and urine cultures, viral respiratory panel.
Intervention: for any grade of CRS give antipyretic, tocilizumab 8 mg/kg (max 800 mg) or equivalent generic form. If no resolution of fever after 1 hr or if patient is hemodynamically unstable, consider giving dexamethasone 10 mg. Antipyretics may be continued every 6-8 hrs to control fever and an additional dose of tocilizumab may be given 6-8 hrs later if symptoms persist. Dexamethasone use should be minimized, but can be continued every 6-8 hrs if tocilizumab and antipyretics do not resolve symptoms.
ALERT: if grade 3 CRS or higher, give both tocilizumab and dexamethasone every 6-8 hrs until hemodynamically stable and CRS is down to grade 1. May continue antipyretics for fever.
Evaluate for neurotoxicity
Tests to consider: perform a full neurologic assessment, evaluate for ICANS using the ICE scoring system (see below), CBC, CMP, electrolytes, blood and urine cultures, urynalysis. A CT or MRI of the head is recommended to evaluate for bleeding, changes related to CAR-T therapy, infections, and other pathologies.
Intervention: if neurotoxicity is suspected, start anakinra 200 mg IV q 6-8 hrs until resolution of symptoms. May use dexamethasone 10 mg IV q 8 hrs if ICANS score of 2 or greater. Anti-seizure medication is recommended as prophylaxis if ICANS 3 or greater. Repeat neurologic exam every hour until symptoms have resolved or improved to Grade 1.
CRS grading system
Cytokine release syndrome (CRS)
Grade 1
Temperature > 38°C
Grade 2
Temperature > 38°C
• Hypotension responsive to fluids
• Oշ requirement using low-flow nasal cannula
Grade 3
Temperature > 38°C
• Hypotension requiring one vasopressor
• Oշ requirement of high-flow nasal canula, facemask, non-rebreather mask, or CPAP
Grade 4
Temperature > 38°C
• Hypotension requiring multiple vasopressor
• Oշ requirement of positive pressure (eg-CPAP, BiPAP, intubation and ventilation)
CRS: Cytokine Release Syndrome
ICE score and ICANS grading system
Neurotoxicity tools
Orientation: oriented to year, month, city, hospital: 1 point each
4 points total
Naming: ability to name 3 objects: 1 point each
3 points total
Follow commands: able to follow simple command
1 point total
Writing: able to write a standard sentence
1 point total
Attention: able to count backwards form 100 by 10's
1 point total
10 = no impairment
7-9 = ICANS 1
3-6 = ICANS 2
0-2 = ICANS 3
0 = ICANS 4
ICE: Immune Effector Cell-Associated Encephalopathy
ICANS: Immune Effector Cell-Associated Neurotoxicity Syndrome
This platform is intended to guide healthcare providers in the initial management of patients receiving immunotherapies such as bispecific T-cell engagers and CAR-T.
It does not replace clinical judgment, medical decision-making, or institutional policies.
Please contact the treating physician to establish a personalized plan of care.
