Cytokine release syndrome: Difference between revisions
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==Background== | ==Background== | ||
* | *Systemic inflammatory response syndrome that can be adverse effect of certain immunotherapies, such as monoclonal antibodies and CAR-T therapies (e.g. CART19 for [[leukemia]]) | ||
*Pathophysiology and presentation similar to [[sepsis]] | |||
*Severity ranges from mild flu-like illness to severe sepsis-like inflammatory response with shock, vascular leakage, DIC, and multi-organ system failure<ref>Shimabukuro-vornhagen A, Gödel P, Subklewe M, et al. Cytokine release syndrome. J Immunother Cancer. 2018;6(1):56.</ref> | |||
==Clinical Features== | ==Clinical Features== | ||
*septic shock | *Mild: [[flu-like illness]] | ||
* | **[[Fever]], [[headache]], and/or [[myalgia]] | ||
*Severe: mimics [[septic shock]] | |||
**[[Fever]], [[tachycardia]], [[hypotension]], [[dyspnea]], [[hypoxia]] | |||
**Organ-specific dysfunction: [[encephalopathy]], [[coagulopathy]], [[renal failure]], [[CHF]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*[[Sepsis]]! | |||
*Hemophagocytic lymphohistiocytosis | |||
{{Shock DDX}} | |||
{{Oncologic emergencies DDX}} | |||
==Evaluation== | ==Evaluation== | ||
''Hospitals administering CAR-T therapies will often have very specific guidelines for initial workup'' | |||
*Immunocompromised infection workup: see [[neutropenic fever]] | |||
*Evaluate for [[tumor lysis syndrome]] | |||
*Labs to screen for organ dysfunction: CBC, BMP, [[LFTs]], [[DIC]] labs | |||
==Management== | ==Management== | ||
* | *Strongly consider discussion with CAR-T treatment team | ||
* | *Empiric [[antibiotics]] (assume sepsis until proven otherwise) | ||
**See [[immunocompromised antibiotics]], [[sepsis]] | |||
*Treat [[shock]] | |||
*[[Corticosteroids]] for severe cases | |||
*Consider Tocilizumab (IL-6 receptor antagonist) in consultation with oncology | |||
==Disposition== | ==Disposition== | ||
* | *Admit or consider transfer to hospital with oncology | ||
==See Also== | ==See Also== | ||
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==External Links== | ==External Links== | ||
https://www.mdcalc.com/cytokine-release-syndrome-crs-grading#evidence | |||
==References== | ==References== | ||
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6003181/ | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6003181/ | ||
<references/> | <references/> | ||
[[Category:Heme/Onc]] |
Revision as of 20:25, 21 August 2019
Background
- Systemic inflammatory response syndrome that can be adverse effect of certain immunotherapies, such as monoclonal antibodies and CAR-T therapies (e.g. CART19 for leukemia)
- Pathophysiology and presentation similar to sepsis
- Severity ranges from mild flu-like illness to severe sepsis-like inflammatory response with shock, vascular leakage, DIC, and multi-organ system failure[1]
Clinical Features
- Mild: flu-like illness
- Severe: mimics septic shock
- Fever, tachycardia, hypotension, dyspnea, hypoxia
- Organ-specific dysfunction: encephalopathy, coagulopathy, renal failure, CHF
Differential Diagnosis
- Sepsis!
- Hemophagocytic lymphohistiocytosis
Shock
- Cardiogenic
- Acute valvular Regurgitation/VSD
- CHF
- Dysrhythmia
- ACS
- Myocardial Contusion
- Myocarditis
- Drug toxicity (e.g. beta blocker, CCB, or bupropion OD)
- Obstructive
- Distributive
- Hypovolemic
- Severe dehydration
- Hemorrhagic shock (traumatic and non-traumatic)
Oncologic Emergencies
Related to Local Tumor Effects
- Malignant airway obstruction
- Bone metastases and pathologic fractures
- Malignant spinal cord compression
- Malignant Pericardial Effusion and Tamponade
- Superior vena cava syndrome
Related to Biochemical Derangement
- Hypercalcemia of malignancy
- Hyponatremia due to SIADH
- Adrenal insufficiency
- Tumor lysis syndrome
- Carcinoid syndrome
Related to Hematologic Derangement
Related to Therapy
- Chemotherapy-induced nausea and vomiting
- Cytokine release syndrome
- Chemotherapeutic drug extravasation
- Differentiation syndrome (retinoic acid syndrome) in APML
- Stem cell transplant complications
- Catheter-related complications
- Tunnel infection
- Exit site infection
- CVC obstruction (intraluminal or catheter tip thrombosis)
- Catheter-related venous thrombosis
- Fracture of catheter lumen
- Oncologic therapy related adverse events
Evaluation
Hospitals administering CAR-T therapies will often have very specific guidelines for initial workup
- Immunocompromised infection workup: see neutropenic fever
- Evaluate for tumor lysis syndrome
- Labs to screen for organ dysfunction: CBC, BMP, LFTs, DIC labs
Management
- Strongly consider discussion with CAR-T treatment team
- Empiric antibiotics (assume sepsis until proven otherwise)
- Treat shock
- Corticosteroids for severe cases
- Consider Tocilizumab (IL-6 receptor antagonist) in consultation with oncology
Disposition
- Admit or consider transfer to hospital with oncology
See Also
External Links
https://www.mdcalc.com/cytokine-release-syndrome-crs-grading#evidence
References
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6003181/
- ↑ Shimabukuro-vornhagen A, Gödel P, Subklewe M, et al. Cytokine release syndrome. J Immunother Cancer. 2018;6(1):56.