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Case Reports
. 2024;16(12):791-801.
doi: 10.1080/1750743X.2024.2370180. Epub 2024 Jul 17.

Tocilizumab and CytoSorb for delayed severe cytokine release syndrome after ipilimumab plus nivolumab immunotherapy

Marko Kurnik  1 , Fazarinc Peter  2 , Podbregar Matej  1   3
Affiliations
Case Reports

Tocilizumab and CytoSorb for delayed severe cytokine release syndrome after ipilimumab plus nivolumab immunotherapy

Marko Kurnik et al. Immunotherapy. 2024.

Abstract

Cytokine release syndrome (CRS) is immune dysregulation phenomenon that is associated with immune checkpoint inhibitors. It is still difficult to distinguish CRS from other dangerous, acute and life-threatening medical disorders.We present a case of delayed grade 4 CRS following treatment of lung adenocarcinoma with ipilimumab plus nivolumab that warranted intensive care level treatment with abundant fluid resuscitation, two-tire vasopressor support, high-flow nasal oxygenation, corticosteroids in high dosages, as well as sustained low-efficiency daily diafiltration with CytoSorb hemadsorption and tocilizumab. Initial treatment of presumed septic shock of unknown origin did not yield results.After initiation of corticosteroids and particularly CytoSorb hemadsorption and tocilizumab, prompt clinical and laboratory improvement was observed.

Keywords: CytoSorb; critically ill; cytokine release syndrome; immune checkpoint inhibitors; intensive care unit; interleukin-6; tocilizumab.

Plain language summary

This case report describes a 62-year-old woman who experienced a life-threatening immune system reaction, 2 weeks after receiving immunotherapy for lung cancer. This reaction, called cytokine release syndrome (CRS), caused her organs to malfunction. The patient was treated with high-dose steroids, a blood purification technique (SLEDD with CytoSorb), and the medication tocilizumab. Her condition stabilized after initiation of SLEDD with CytoSorb and dramatically improved after receiving tocilizumab. This case highlights the importance of considering CRS in patients who experience severe illness after receiving immunotherapy.

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Conflict of interest statement

The authors have no competing interests or relevant affiliations with any organization or entity with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, stock ownership or options and expert testimony.

Figures

Figure 1.
Figure 1.
The graph represents the timeline of the first 48 h in the intensive care unit with main therapeutic approaches, vasopressor infusion dosages and main vital parameters. The graph clearly depicts the rapidly decreasing necessary doses of vasopressor support after initiating CytoSorb hemadsorption and especially after tocilizumab infusion. The scale for mean blood pressure (mmHg) and heart rate (bpm) is on the left, and on the right for noradrenaline (mcg/kg/min) and vasopressin (U/min) dose. Main therapeutic modalities are also marked according to the timeline.
Figure 2.
Figure 2.
The chest x-ray at intensive care unit admission shows diffuse pulmonary edema consistent with prominent capillary leak, bilateral pleural effusions and the need for high-flow nasal cannula oxygenation.
Figure 3.
Figure 3.
Graphic timeline representation of main events before treatment of CRS in our hospital and a more detailed representation of the treatment of CRS. The left half represents events before admission to our hospital, and the right half represents the timeline in our hospital. Note the change in the time axis. CRS: Cytokine release syndrome.
See this image and copyright information in PMC

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