PMID- 34950390
OWN - NLM
STAT- PubMed-not-MEDLINE
LR  - 20230102
IS  - 1941-8744 (Print)
IS  - 1941-8752 (Electronic)
IS  - 1941-8744 (Linking)
VI  - 12
IP  - 1
DP  - 2022 Jan
TI  - Recurrent Status Epilepticus in the Setting of Chimeric Antigen Receptor (CAR)-T 
      Cell Therapy.
PG  - 74-79
LID - 10.1177/19418744211000980 [doi]
AB  - Axicabtagene ciloleucel (AC) is an FDA-approved anti-CD19 autologous chimeric 
      antigen receptor T-cell (CAR-T) therapy for refractory diffuse large B cell 
      lymphoma (DLBCL). While its efficacy in DLBCL has been promising, neurotoxicity 
      remains a significant concern. We present a case of a 22-year-old woman with 
      chemotherapy-refractory DLBCL who exhibited Grade IV neurotoxicity in the setting 
      of sepsis, after undergoing AC infusion. Despite prophylactic levetiracetam given 
      per guidelines,(1,2) she experienced a precipitous mental status decline on 
      post-infusion day 8 (D8) followed by hypoxic respiratory failure in the setting 
      of clinical status epilepticus on D11 and nonconvulsive status epilepticus (NCSE) 
      on D18. While neuroimaging was unremarkable, EEG demonstrated diffuse slowing and 
      2.5-3 Hz generalized periodic discharges consistent with NCSE. Seizures were 
      initially refractory to lorazepam, increasing doses of levetiracetam, and 
      phenobarbital, requiring a midazolam drip titrated to 50-70% burst suppression 
      for resolution. Methylprednisolone and tocilizumab were used to treat 
      neurotoxicity and cytokine release syndrome, respectively. Empiric antibiotics 
      were used for sepsis. After cessation of sedatives on D19, mental status improved 
      to near baseline. PET/CT just prior to discharge showed a complete response of 
      the DLBCL (Deauville 3). She was discharged on D37 with no further seizure 
      activity. Unfortunately, a 3-month interval PET/CT demonstrated disease 
      progression which continued through salvage pembrolizumab eventually leading to 
      death 1.2 years post-CAR-T infusion. This case illustrates the clinical 
      management challenges of a complex and rare neurotoxic side effect of CAR-T cell 
      therapy, namely NCSE following status epilepticus.
CI  - (c) The Author(s) 2021.
FAU - Reveron-Thornton, Rosyli
AU  - Reveron-Thornton R
AUID- ORCID: 0000-0002-4943-581X
AD  - School of Medicine, Stanford University, Stanford, CA, USA.
FAU - Scott, Brian J
AU  - Scott BJ
AD  - Department of Neurology and Neurological Sciences, School of Medicine, Stanford 
      University, Stanford, CA, USA.
FAU - Post, David
AU  - Post D
AD  - Department of Neurology and Neurological Sciences, School of Medicine, Stanford 
      University, Stanford, CA, USA.
FAU - Caulfield, Anna Finley
AU  - Caulfield AF
AD  - Department of Neurology and Neurological Sciences, School of Medicine, Stanford 
      University, Stanford, CA, USA.
FAU - Werbaneth, Katherine
AU  - Werbaneth K
AD  - Department of Neurology and Neurological Sciences, School of Medicine, Stanford 
      University, Stanford, CA, USA.
FAU - Hovsepian, Dominic A
AU  - Hovsepian DA
AD  - Department of Neurology and Neurological Sciences, School of Medicine, Stanford 
      University, Stanford, CA, USA.
FAU - Spiegel, Jay
AU  - Spiegel J
AD  - Department of Medicine, School of Medicine, Stanford University, Stanford, CA, 
      USA.
FAU - Miklos, David
AU  - Miklos D
AD  - Department of Medicine, School of Medicine, Stanford University, Stanford, CA, 
      USA.
FAU - Thomas, Reena P
AU  - Thomas RP
AD  - Department of Neurology and Neurological Sciences, School of Medicine, Stanford 
      University, Stanford, CA, USA.
FAU - Patel, Chirag B
AU  - Patel CB
AD  - Department of Neurology and Neurological Sciences, School of Medicine, Stanford 
      University, Stanford, CA, USA.
AD  - Department of Radiology, School of Medicine, Stanford, University, Stanford, CA, 
      USA.
LA  - eng
PT  - Case Reports
DEP - 20210311
PL  - United States
TA  - Neurohospitalist
JT  - The Neurohospitalist
JID - 101558199
PMC - PMC8689529
OTO - NOTNLM
OT  - clinical specialty
OT  - epilepsy
OT  - neurohospitalist
OT  - neuroimmunology
OT  - neurotoxicity
OT  - seizures
OT  - status epilepticus
OT  - syndromes
COIS- Declaration of Conflicting Interests: The author(s) declared no potential 
      conflicts of interest with respect to the research, authorship, and/or 
      publication of this article.
EDAT- 2021/12/25 06:00
MHDA- 2021/12/25 06:01
PMCR- 2023/01/01
CRDT- 2021/12/24 05:49
PHST- 2021/12/24 05:49 [entrez]
PHST- 2021/12/25 06:00 [pubmed]
PHST- 2021/12/25 06:01 [medline]
PHST- 2023/01/01 00:00 [pmc-release]
AID - 10.1177_19418744211000980 [pii]
AID - 10.1177/19418744211000980 [doi]
PST - ppublish
SO  - Neurohospitalist. 2022 Jan;12(1):74-79. doi: 10.1177/19418744211000980. Epub 2021 
      Mar 11.