SCT Question 15
Publication/Presentation Date
10-2023
Published In/Presented At
Question 15
You are asked to evaluate a patient at 5 PM for increasing lethargy and confusion. This patient is 7 days out from an infusion of 2x10^6 CD19 CAR T cells (axicabtagene ciloleucel) for DLBCL. The patient is easily arousable, able to follow simple commands and name 2 of 3 objects, but is only oriented to name and does not recall date or location, nor is able to count. A handwriting sample is incomprehensible. There are no focal neurological deficits. In the days prior there was no CRS. Now the hear rate is 110 bpm, temp 100, and he is normotensive and not hypoxic. ANC is 1.8, PL are 52k. What are the next most effective management steps
- Get MRI of the head
- Administer keppra and dexamethasone and obtain a CT scan of the head
- Administer tocilizumab
- Administer broad spectrum antibiotics after an LP
- Give dexamethasone and get a MRI of the head
Answer
Option 2. This patient has grade 2 ICANS (ASTCT criteria) and with declining mental status should get dexamethasone, there is also risk for seizures, therefore along with dexamethasone keppra should be given as well until complete resolution of ICANS. CT of the head will be important to r/o alternative contributing etiologies. There is likely concomitant grade 1 CRS, which if it gets worse may require tocilizumab. LP and abx may be considered subsequently, if there is no improvement with initial ICANS management.
Disciplines
Medicine and Health Sciences
Department(s)
Department of Medicine
Document Type
Research