SCT Question 14
Publication/Presentation Date
10-2023
Published In/Presented At
Question 14
A 64-year-old patient with recurrent multiple myeloma (lambda light chain disease) was infused with idecabtagene vicleucel, 5x10^6 BCMA CAR + T cells 12 hours ago, lymphodepleting chemotherapy pre CAR T cell infusion was with fludarabine and cyclophosphamide. He is now c/o myalgias and chills; is febrile (102 F) and tachycardic (115), with preserved blood pressure (115/75) normal oxygenation. Pre therapy he had panhypogammaglobulinemia, 50% PC infiltration of a 50% cellular bone marrow; e now has an ANC of 700. CRP is 3xULN
The next step in management of is
- Acetaminophen, blood cultures and broad spectrum abx
- Dexamethasone
- Tocilizumab
- Acetaminophen, IV fluids and telemetry
- Anakinra
Answer
Option 1, this is a neutropenic and panhypogammaglobulinemic patient, who has undergone lymphodepleting therapy so with a new onset fever with hemodynamic consequence, while CRS is the most likely cause, infection has to be covered, surveillance alone is not adequate. If fever persists despite supportive measures or if the symptoms progress to grade 2 CRS (hypotension, hypoxia) then tocilizumab should be administered. Steroids are generally avoided unless tocilizumab/anakinra refractory CRS is encountered or ICANS develops.
Option 1, this is a neutropenic and panhypogammaglobulinemic patient, who has undergone lymphodepleting therapy so with a new onset fever with hemodynamic consequence, while CRS is the most likely cause, infection has to be covered, surveillance alone is not adequate. If fever persists despite supportive measures or if the symptoms progress to grade 2 CRS (hypotension, hypoxia) then tocilizumab should be administered. Steroids are generally avoided unless tocilizumab/anakinra refractory CRS is encountered or ICANS develops.
Disciplines
Medicine and Health Sciences
Department(s)
Department of Medicine
Document Type
Research