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I. Yakoub-Agha et al.
ASTCT consensus panel and has been replaced by the Immune Effector Cell-Associated Encephalopathy (ICE) score shown in Table 8.38 A different assessment tool for screening delirium in children, adapted from Traube et al., is shown in Table 9.61
Laboratory monitoring of cytokine release syndrome and neurotoxicity
In addition to routine daily hematology and chemistry laboratory tests, C-reactive protein and ferritin levels are of use in the monitoring of patients developing CRS and neurotoxicity. Although assaying IL-6 or other cytokine levels is theoretically interesting, cytokine testing is not routinely performed in most centers at present.
Atypical lymphocytes that can mimic blasts are not uncommon at the peak of CAR T-cell expansion and can be found in the peripheral blood, bone marrow, and even the cerebrospinal fluid of patients treated with these ther- apies. Flow cytometry can be used to exclude relapse. Repeating microbiological testing and imaging to rule out infection is recommended in febrile patients.
Antibiotic prophylaxis
The combined effect of prior treatments (immunochemotherapy and/or autologous or allogeneic HCT, bridging chemotherapy administered after leuk- apheresis and LD conditioning) all increase the risk of opportunistic infections in patients receiving CAR T-cell therapy. Approximately one-third of patients have pro- longed neutropenia (beyond day +30) and up to 20% of patients have neutropenia lasting more than 90 days. B- cell depletion and hypogammaglobulinemia are additional risk factors for infections.15,16,63,64
After CRS and ICANS, infections are one of the most common side effects of CAR T-cell therapy. Most infec- tions are seen within the first 30 days and are bacterial, and to a lesser extent, respiratory viral infections. Invasive fungal infections are rare and are mostly observed in ALL patients who have undergone prior allogeneic stem cell transplantation.65
CAR T-cell recipients, like patients undergoing allogene- ic HCT, are at increased risk of a range of infections at the
Figure 1. Management of cytokine release syndrome. Adapted from Yakoub-Agha et al.56 CPAP: continuous positive airway pressure: BiPAP: biphasic positive airway pressure; ICU: intensive care unit; CRS: cytokine release syndrome.
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haematologica | 2020; 105(2)