Cytokine release syndrome (CRS) typically presents with fever, then hypotension and hypoxia, within days of starting a bispecific T-cell engager or CAR-T. Immune effector cell-associated neurotoxicity (ICANS) shows as confusion, word-finding difficulty, tremor or handwriting change, and can progress to seizures.
Both are graded and treated by protocol, with tocilizumab for CRS and corticosteroids for ICANS. Infection must be treated in parallel, since it cannot be excluded at presentation.
- Treat fever after immune effector therapy as both possible CRS and infection: cultures and antibiotics without delay.
- Check a simple handwriting sample or ICE score daily to detect early neurotoxicity.
- Contact the treating haematology team immediately; grading decides tocilizumab or steroids.
- Patients should carry a card stating their therapy and the treating centre's number.
Why it matters
These patients increasingly present to general emergency departments far from the centre that treated them.
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