Cytokine release syndrome: Difference between revisions

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==Background==
==Background==
*Cytokine release syndrome form of systemic inflammatory response syndrome from adverse effect of some monoclonal antibody drugs, as well as adoptive T-cell therapies
*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: hypotension, hypoxia, dyspnea, fever, tachycardia
*Mild: [[flu-like illness]]
*organ specific dysfunction: encephalopathy, coagulopathy, renal failure, CHF
**[[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==
*treat for sepsis
*Strongly consider discussion with CAR-T treatment team
*consider Tocilizumab (IL-6 receptor antagonist)
*Empiric [[antibiotics]] (assume sepsis until proven otherwise)
*corticosteroids for severe cases
**See [[immunocompromised antibiotics]], [[sepsis]]
*Treat [[shock]]
*[[Corticosteroids]] for severe cases
*Consider Tocilizumab (IL-6 receptor antagonist) in consultation with oncology


==Disposition==
==Disposition==
*admit
*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

Differential Diagnosis

  • Sepsis!
  • Hemophagocytic lymphohistiocytosis

Shock

Oncologic Emergencies

Related to Local Tumor Effects

Related to Biochemical Derangement

Related to Hematologic Derangement

Related to Therapy

Evaluation

Hospitals administering CAR-T therapies will often have very specific guidelines for initial workup

Management

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/

  1. Shimabukuro-vornhagen A, Gödel P, Subklewe M, et al. Cytokine release syndrome. J Immunother Cancer. 2018;6(1):56.