Recurrent Status Epilepticus in the Setting of Chimeric Antigen Receptor (CAR)-T Cell Therapy

Area of Science:

• Hematology
• Neuroscience
• Oncology

Background:

• Axicabtagene ciloleucel (CAR-T) therapy offers a promising treatment for refractory diffuse large B cell lymphoma (DLBCL).
• Neurotoxicity is a significant, albeit less common, adverse event associated with CAR-T therapy.
• Standard prophylactic measures may not always prevent severe neurological complications.

Observation:

• A 22-year-old female with chemotherapy-refractory DLBCL developed Grade IV neurotoxicity, sepsis, and status epilepticus post-axicabtagene ciloleucel infusion.
• Despite prophylactic levetiracetam, she experienced mental status decline, hypoxic respiratory failure, and nonconvulsive status epilepticus (NCSE).
• Electroencephalography (EEG) confirmed NCSE, requiring refractory seizure management with a midazolam drip and other agents.

Findings:

• The patient's NCSE was refractory to initial treatments, necessitating intensive care management including mechanical ventilation and high-dose sedation.
• Neuroimaging was unremarkable, highlighting the diagnostic challenge of CAR-T-related neurotoxicity.
• Complete DLBCL response was achieved post-treatment, but disease progression occurred later, leading to death 1.2 years post-infusion.

Implications:

• This case underscores the complex management of severe neurotoxicity, specifically NCSE, following CAR-T therapy.
• It highlights the need for vigilant monitoring and adaptable treatment strategies for CAR-T-related adverse events.
• Understanding and managing these rare but serious complications is crucial for optimizing CAR-T therapy outcomes in DLBCL patients.