Delayed cytokine release syndrome after neoadjuvant nivolumab: a case report and literature review

Abstract

Aim: Cytokine release syndrome (CRS) is an infrequently described immune-related adverse event of checkpoint inhibitors (CPI). CPI-induced CRS typically presents with fevers, hemodynamic instability and organ dysfunction within 2 weeks of the last treatment cycle. Case study: We report an unusual case of delayed and severe CRS occurring postoperatively in a patient with hepatic-limited metastatic colorectal cancer who received neoadjuvant immunotherapy. After a negative workup for alternative causes, he received prolonged corticosteroid treatment with symptom resolution. Conclusion: CPI-induced CRS can mimic sepsis and clinicians should maintain a high-index of suspicion to diagnose this immune-related adverse event early and initiate appropriate treatment. As use of perioperative immunotherapy increases, the potential role of surgery to trigger CRS in this case warrants further investigation.

Keywords: colorectal cancer; cytokine release syndrome; immunotherapy; neoadjuvant treatment; surgical-induced inflammation.

Figure 1.. Patient clinical course.

Day 0 = day of surgery – 4 months after initiation of neoadjuvant nivolumab and CV301 and 6 weeks since last dose. (+): Positive result T2 PCR; (b): Blood; (h): Heptic fluid collection; X: Negative bacterial culture; Y: Negative fungal blood culture.