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, hepatitis, or zoster. 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.
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. May repeat 6-8 hrs later if no resolution of fever or patient remains hemodynamically unstable). Dexamethasone 10mg q 6-8 hrs can be given if tocilizumab is not available or symptoms did not resolve within an hour of initial tocilizumab administration. Assess and cover for infections if they cannot be ruled out.
ALERT: if hypotensive or hypoxic: give both tocilizumab and dexamethasone every 6-8 hrs until hemodynamically stable and afebrile. May give hydration, pressors, and oxygen as needed. Methylprednisolone 1mg/kg IV BID or 1000 mg daily can be used if no improvement.
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. Consider CT of the head if concerned for bleeding or other pathology.
Intervention: anakinra 200 mg IV q 8 hrs or dexamethasone 10 mg IV q 6-8 hrs until resolution of symptoms. May use both agents if ICANS score of 2 or greater. Anti-seizure medication is recommended if ICANS 3 or greater. Repeat neurologic exam every hour until symptoms have improved or resolved.
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.
