Journal of Hematology, ISSN 1927-1212 print, 1927-1220 online, Open Access
Article copyright, the authors; Journal compilation copyright, J Hematol and Elmer Press Inc
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Case Report

Volume 13, Number 6, December 2024, pages 295-299

A Case of Fulminant Cerebral Edema Leading to Death After Chimeric Antigen Receptor T-Cell Therapy

Figures

Figure 1.
Figure 1. (a) Normal head CT performed at 13:08 on day +4 with arrow indicating intact gray-white matter differentiation. (b) Head CT showing diffuse cerebral edema at 17:18 on day +4 with arrow indicating comparative loss of gray-white matter differentiation. (c) CT showing worsening of cerebral edema at 21:50 on day +4 with arrow demonstrating ventricle compression due to severe edema. CT: computed tomography.
Figure 2.
Figure 2. Inflammatory markers including (a) CRP and (b) ferritin for patient from day of CAR T-cell infusion until death. Baseline CRP 1.0 and ferritin 186. CAR: chimeric antigen receptor; CRP: C-reactive protein.

Table

Table 1. Cases of FCE and Their Characteristics
 
PaperAge at diagnosisAge at CAR TSexDiagnosisPrior treatmentLymphodepletionCAR TPeak CRS gradeCRS treatmentTime to FCESymptomsICANS treatmentNeuro HxPrevious neuro examFatal?
ALL: acute lymphoblastic leukemia; CAR: chimeric antigen receptor; CRS: cytokine release syndrome; FCE: fulminant cerebral edema; FLAG: fludarabine/arabinofuranosyl cytidine/granulocyte-colony stimulating factor; FluCy: fludarabine/cytarabine; ICANS: immune effector cell-associated neurotoxicity syndrome; LBCL: large B-cell lymphoma; MCL: mantle cell lymphoma; MRI: magnetic resonance imaging; UNK: unknown.
Hickmann et al3541MMCLR-CHOP, ibrutinibFluCyBrexucabtagene autoleucel2 (day +2)TocilizumabDay +4Lethargy, decreased responsiveness, seizureMethylprednisolone, levetiracetam, hypertonic saline, mannitol, lorazepamNoneBenignYes
Torre et al [4]1121MB-ALLChildren’s Oncology Group RegimenFLAGTrial CAR T2 (day +2)Tocilizumab, dexamethasoneDay +4Trouble word finding, lethargy, unresponsiveDexamethasone, levetiracetam, ventriculostomy, mannitol hyperventilationNone knownBenignYes
Pensato et al [1]UNK35FPrimary mediastinal LBCLUNKFluCyAxicabtagene ciloleucel1 (day 0)TocilizumabDay +4Expressive aphasia, postural tremors, lethargyDexamethasone, methylprednisolone, hypertonic saline, mannitol, hyperventilationNone knownBenignYes
Santomasso et al [6]66FALLUNKUNKTisagenlecleucel3 (day +4)Tocilizumab, dexamethasoneDay +6Confusion, seizure, comaMethylprednisolone, anakinra, hypertonic saline, phenobarbitalSeizures w/sepsisBenign, MRI chronic injuryNo