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
Journal website https://jh.elmerpub.com

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. (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 1.
↓  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.
Figure 2.

Table

↓  Table 1. Cases of FCE and Their Characteristics
 
Paper Age at diagnosis Age at CAR T Sex Diagnosis Prior treatment Lymphodepletion CAR T Peak CRS grade CRS treatment Time to FCE Symptoms ICANS treatment Neuro Hx Previous neuro exam Fatal?
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 al 35 41 M MCL R-CHOP, ibrutinib FluCy Brexucabtagene autoleucel 2 (day +2) Tocilizumab Day +4 Lethargy, decreased responsiveness, seizure Methylprednisolone, levetiracetam, hypertonic saline, mannitol, lorazepam None Benign Yes
Torre et al [4] 11 21 M B-ALL Children’s Oncology Group Regimen FLAG Trial CAR T 2 (day +2) Tocilizumab, dexamethasone Day +4 Trouble word finding, lethargy, unresponsive Dexamethasone, levetiracetam, ventriculostomy, mannitol hyperventilation None known Benign Yes
Pensato et al [1] UNK 35 F Primary mediastinal LBCL UNK FluCy Axicabtagene ciloleucel 1 (day 0) Tocilizumab Day +4 Expressive aphasia, postural tremors, lethargy Dexamethasone, methylprednisolone, hypertonic saline, mannitol, hyperventilation None known Benign Yes
Santomasso et al [6] 6 6 F ALL UNK UNK Tisagenlecleucel 3 (day +4) Tocilizumab, dexamethasone Day +6 Confusion, seizure, coma Methylprednisolone, anakinra, hypertonic saline, phenobarbital Seizures w/sepsis Benign, MRI chronic injury No