Riding the storm: managing cytokine-related toxicities in CAR-T cell therapy

Recognizing and Managing Secondary Hemophagocytic Lymphohistiocytosis in Adults: A Practical Clinical Guide

Secondary hemophagocytic lymphohistiocytosis (sHLH) is a life-threatening hyperinflammatory syndrome triggered by infections, malignancies, or rheumatologic conditions. Effective management requires identifying and treating the acute trigger while addressing underlying factors and calming the inflammatory response. Like sepsis, sHLH represents a cytokine storm resulting from diverse triggering events rather than a standalone diagnosis. This review synthesizes current literature and the authors' clinical experience to provide a comprehensive framework for diagnosing and managing sHLH, emphasizing the importance of tailored, trigger-specific interventions. Emerging diagnostic tools and therapeutic strategies and improved mechanistic understanding of sHLH hold promise for improving outcomes in this challenging condition.

Cardiovascular toxicities associated with chimeric antigen receptor T-cell therapy

Chimeric antigen receptor (CAR) T-cell therapy has emerged as a groundbreaking immunotherapeutic approach, particularly for oncohematological patients who are refractory to conventional treatments. As clinical trials expand the applications of CAR T-cell therapy beyond hematologic malignancies, a critical understanding of its associated toxicities, particularly cardiovascular complications, becomes imperative. This review synthesizes current literature on the interplay between cytokine release syndrome (CRS) and cardiotoxicity related to CAR T-cell therapy, emphasizing the potential severity of these adverse events. While significant progress has been made in managing CRS, the cardiac manifestations-ranging from mild events to life-threatening complications-remain underreported in pivotal studies. We explore the incidence and nature of cardiotoxicity in real-world and clinical trial settings, identify risk factors contributing to cardiovascular events, and propose guidelines for pre-therapy evaluations, post-infusion monitoring, and management strategies. By highlighting the urgent need for heightened awareness and proactive care, this review aims to enhance patient safety and optimize outcomes in the evolving landscape of CAR T-cell therapy.

Classic Hodgkin lymphoma: Pathobiological features that impact emerging therapies

Classic Hodgkin lymphoma (cHL) is defined by distinctive Hodgkin Reed-Sternberg (HRS) cells, which are CD30+/CD15+ multinucleated tumor cells lacking typical B-cell markers. These cells comprise <5 % of tumor mass but orchestrate an extensive immunosuppressive tumor microenvironment (TME). Classic HL was curable with radiation therapy and multi-agent chemotherapy. Despite high cure rates, treatment-related toxicities remain significant. The goals of multimodality therapy are to achieve a cure while minimizing treatment-associated toxicity. Advances in molecular insights into HRS cells have led to transformative therapies, including checkpoint inhibitors, antibody-drug conjugates like brentuximab vedotin, which have shown remarkable efficacy, especially in relapsed or refractory disease. However, challenges persist due to the heterogeneity of cHL, driven by the complex biology of HRS cells and their surrounding tumor microenvironment. Novel approaches such as single-cell RNA sequencing and circulating tumor DNA profiling provide promising strategies to address these challenges. This review examines the origin, morphology, phenotype, and genetic profiles of HRS cells, highlighting key pathobiological features, including biomarkers and Epstein-Barr Virus involvement. It also explores the biological mechanisms underlying HRS cell survival and evaluates standard and emerging therapies, offering insights into the rationale for novel treatment strategies.

Deep insight into cytokine storm: from pathogenesis to treatment

Cytokine storm (CS) is a severe systemic inflammatory syndrome characterized by the excessive activation of immune cells and a significant increase in circulating levels of cytokines. This pathological process is implicated in the development of life-threatening conditions such as fulminant myocarditis (FM), acute respiratory distress syndrome (ARDS), primary or secondary hemophagocytic lymphohistiocytosis (HLH), cytokine release syndrome (CRS) associated with chimeric antigen receptor-modified T (CAR-T) therapy, and grade III to IV acute graft-versus-host disease following allogeneic hematopoietic stem cell transplantation. The significant involvement of the JAK-STAT pathway, Toll-like receptors, neutrophil extracellular traps, NLRP3 inflammasome, and other signaling pathways has been recognized in the pathogenesis of CS. Therapies targeting these pathways have been developed or are currently being investigated. While novel drugs have demonstrated promising therapeutic efficacy in mitigating CS, the overall mortality rate of CS resulting from underlying diseases remains high. In the clinical setting, the management of CS typically necessitates a multidisciplinary team strategy encompassing the removal of abnormal inflammatory or immune system activation, the preservation of vital organ function, the treatment of the underlying disease, and the provision of life supportive therapy. This review provides a comprehensive overview of the key signaling pathways and associated cytokines implicated in CS, elucidates the impact of dysregulated immune cell activation, and delineates the resultant organ injury associated with CS. In addition, we offer insights and current literature on the management of CS in cases of FM, ARDS, systemic inflammatory response syndrome, treatment-induced CRS, HLH, and other related conditions.

Pathogenesis, Diagnosis, and Management of Cytokine Release Syndrome in Patients with Cancer: Focus on Infectious Disease Considerations

Background: Cytokine Release Syndrome (CRS) is a hyperinflammatory state triggered by immune therapies like CAR T-cell therapy and bispecific T-cell engagers (BiTEs). Characterized by excessive cytokine release, CRS often mimics infectious and inflammatory conditions, complicating diagnosis and treatment. Immunosuppressive therapies used for CRS further elevate the risk of secondary infections. Methods: A systematic search of PubMed and EMBASE was conducted using terms related to "cytokine release syndrome", "cytokine storm", "infections", and "management". Studies were included if they described infectious complications, diagnostic mimics, or therapeutic approaches related to CRS. Results: Of 19,634 studies, 2572 abstracts were reviewed. Infections occurred in up to 23% of patients post-CAR T therapy and 24% post-BiTE therapy. Pathogens included gram-positive and gram-negative bacteria, herpesviruses (e.g., CMV, HSV), fungi (e.g., Candida, Aspergillus), and parasites (e.g., Toxoplasma gondii). CRS mimics also included non-infectious inflammatory syndromes. Differentiation remains challenging, but cytokine profiling and biomarkers (e.g., ferritin, CRP, sIL-2Rα) may aid in diagnosis. Treatments included tocilizumab, corticosteroids, and empiric antimicrobials. Prophylactic strategies were inconsistently reported. Conclusions: Effective CRS management requires early recognition, differentiation from infectious mimics, and collaboration between oncology and infectious disease (ID) specialists. A multidisciplinary, collaborative, and structured approach, including dedicated ID input and pre-treatment evaluation, is essential for optimizing CRS management and patient outcomes.

Immune Effector Cell-Associated Neurotoxicity Syndrome After CAR T-Cell Therapy and Other Psychiatric Manifestations: A Review and Case Series

Background/Objectives: Chimeric antigen receptor (CAR) T-cell therapy has transformed the treatment of hematologic malignancies, achieving durable remissions in cases refractory to standard therapies. A potentially life-threatening complication is immune effector cell-associated neurotoxicity syndrome (ICANS), which poses significant challenges to clinical management. ICANS encompasses a range of neuropsychiatric symptoms, including delirium, mood disorders, psychosis, seizures, and cerebral edema. The psychiatric dimensions of ICANS remain underreported, and their interplay with neurologic manifestations is poorly understood. This study reviews the psychiatric manifestations of ICANS and presents a case series illustrating its clinical complexity. Methods: A systematic literature search was conducted using PubMed and Google Scholar for studies published between 2020 and 2024. Search terms included "ICANS", "delirium", "CAR T-cell", "neurotoxicity", and "psychiatric". The inclusion criteria included studies published in English that focused on adult patients experiencing neuropsychiatric symptoms of ICANS. Two clinical cases of ICANS with prominent psychiatric features are presented. Results: The literature review found three relevant studies, which emphasized agitation, hypoactivity, and mood disturbances as often-overlooked psychiatric symptoms linked to ICANS. The case series highlights psychiatric manifestations, including delirium, irritability, and cognitive impairment. Recovery was supported through interventions such as corticosteroid tapering, antipsychotic treatment, and multidisciplinary care. Conclusions: ICANS is a multifaceted syndrome with significant neuropsychiatric sequelae that complicate its diagnosis and management. An enhanced recognition of its psychiatric dimensions and interdisciplinary approaches are critical to improving outcomes.

Efficacy of emapalumab in the management of anti‑CD19 chimeric antigen receptor T‑cell therapy‑associated cytokine release syndrome: A report of two cases

Chimeric antigen receptor (CAR) T-cell therapy is an effective treatment for diffuse large B-cell lymphoma (DLBCL). However, it may activate the systemic immune system of the patient, resulting in cytokine release syndrome (CRS). Emapalumab is a human monoclonal antibody targeting interferon-γ, inhibiting its interaction with cell surface receptors and the subsequent activation of inflammatory pathways. The present report describes the cases of 2 patients with relapsed DLBCL treated with CAR T-cell therapy, in which the severe CRS associated with CAR T-cell therapy was attenuated without compromising antitumor efficacy after receiving emapalumab. Further prospective clinical trials are warranted to determine the role of emapalumab in CAR T-cell therapy.

Neuropsychiatric manifestations following chimeric antigen receptor T cell therapy for cancer: a systematic review of clinical outcomes and management strategies

BACKGROUND

Chimeric antigen receptor (CAR)-T cell therapy has emerged as a transformative modality in the treatment of patients with cancer. However, it is increasingly evident that this therapeutic approach is not without its challenges. The unique nature of CAR-T cells as living drugs introduces a distinct set of side effects. As the application of CAR-T cell therapy expands to treat a broader range of diseases, it becomes increasingly important to devise effective strategies for handling the associated toxicities. Challenges in treating patients with CAR-T cells include addressing complications such as cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, and cytopenias. This comprehensive review seeks to systematically identify, categorize and elucidate all previously described neurological and psychological side effects associated with CAR-T cell therapy, shedding light on the pertinent laboratory findings that underscore these phenomena.

METHODS

PubMed, Springer Link, and ScienceDirect were systematically searched for empirical studies on adult patients with cancer receiving CAR-T cell therapy for hemato-oncological malignancies. Quality assessment was conducted using Version 2 of the Cochrane risk-of-bias tool (RoB 2) for randomized trials and adherence to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist for observational studies. The synthesis of findings was conducted via a narrative approach, consolidating the diverse array of data into a coherent framework.

RESULTS

From an initial pool of 2,276 citations, 546 studies met the inclusion criteria, exhibiting a rich tapestry of heterogeneity in terms of study characteristics and patient samples. The incidence of neuropsychological symptoms varied notably across different CAR-T cell products and hematological malignancies. Among the most frequently reported neuropsychological symptoms were aphasia, attention deficits, impaired consciousness, and disorientation, alongside a constellation of other symptoms including confusion, cognitive impairment, memory loss, writing difficulties, fatigue, headache, agitation, tremor, seizures, and psychomotor retardation. Early intervention strategies, including corticosteroids and tocilizumab, have shown the potential to reduce the intensity of neuropsychological symptoms and prevent their progression to critical complications.

CONCLUSION

These insights underscore the imperative of extending neuropsychological assessments beyond the conventional Immune Effector Cell-Associated Encephalopathy score framework.

Systemic capillary leak syndrome

The vascular endothelial barrier maintains intravascular volume and metabolic homeostasis. Although plasma fluids and proteins extravasate continuously from tissue microvasculature (capillaries, post-capillary venules), systemic vascular leakage increases in critical illness associated with sepsis, burns and trauma, among others, or in association with certain drugs or toxin exposures. Systemically dysregulated fluid homeostasis, which can lead to hypovolaemia, hypotensive shock and widespread tissue oedema, has been termed systemic capillary leak syndrome (SCLS) when overt secondary causes (for example, heart or liver failure) are excluded. In severe forms, SCLS is complicated by compartment syndrome in the extremities and multi-organ dysfunction syndrome due to shock and systemic hypoperfusion. The different forms of SCLS include idiopathic SCLS (ISCLS) and secondary SCLS (SSCLS), which can be triggered by several conditions, including certain infections and haematological malignancies. A subgroup of patients with ISCLS have monoclonal gammopathy-associated SCLS (also known as Clarkson disease), which is an ultra-rare and extreme form of ISCLS. ISCLS can be managed effectively with monthly prophylactic immunoglobulin therapy whereas SSCLS frequently does not recur once the underlying condition resolves or the offending agent is discontinued. Thus, differentiation between ISCLS, SSCLS and other causes of oedema is crucial for quick diagnosis and positive patient outcomes.

Cytokine Storm in COVID-19: Exploring IL-6 Signaling and Cytokine-Microbiome Interactions as Emerging Therapeutic Approaches

IL-6 remains a key molecule of the cytokine storms characterizing COVID-19, exerting both proinflammatory and anti-inflammatory effects. Emerging research underscores the significance of IL-6 trans-signaling over classical signaling pathways, which has shifted the focus of therapeutic strategies. Additionally, the synergistic action of TNF-α and IFN-γ has been found to induce inflammatory cell death through PANoptosis, further amplifying the severity of cytokine storms. Long COVID-19 patients, as well as those with cytokine storms triggered by other conditions, exhibit distinct laboratory profiles, indicating the need for targeted approaches to diagnosis and management. Growing evidence also highlights the gut microbiota's crucial role in modulating the immune response during COVID-19 by affecting cytokine production, adding further complexity to the disease's immunological landscape. Targeted intervention strategies should focus on specific cytokine cutoffs, though accurate cytokine quantification remains a clinical challenge. Current treatment strategies are increasingly focused on inhibiting IL-6 trans-signaling, which offers promise for more precise therapeutic approaches to manage hyperinflammatory responses in COVID-19. In light of recent discoveries, this review summarizes key research findings on cytokine storms, particularly their role in COVID-19 and other inflammatory conditions. It explores emerging therapeutic strategies targeting cytokines like IL-6, TNF-α, and IFN-γ, while also addressing open questions, such as the need for better biomarkers to detect and manage cytokine storms. Additionally, the review highlights ongoing challenges in developing targeted treatments that mitigate hyperinflammation without compromising immune function, emphasizing the importance of continued research in this field.

Molecular profiling and therapeutic tailoring to address disease heterogeneity in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic, heterogeneous, systemic autoimmune disease characterized by autoantibody production, complement activation, and immune complex deposition. SLE predominantly affects young, middle-aged, and child-bearing women with episodes of flare-up and remission, although it affects males at a much lower frequency (female: male; 7:1 to 15:1). Technological and molecular advancements have helped in patient stratification and improved patient prognosis, morbidity, and treatment regimens overall, impacting quality of life. Despite several attempts to comprehend the pathogenesis of SLE, knowledge about the precise molecular mechanisms underlying this disease is still lacking. The current treatment options for SLE are pragmatic and aim to develop composite biomarkers for daily practice, which necessitates the robust development of novel treatment strategies and drugs targeting specific responsive pathways. In this communication, we review and aim to explore emerging therapeutic modalities, including multiomics-based approaches, rational drug design, and CAR-T-cell-based immunotherapy, for the management of SLE.