Cytokine Release Syndrome After CAR T-Cell Therapy in a 35-Year-Old Patient With Pneumonia and Cytomegalovirus Viremia

The risk of cytokine release syndrome (CRS) in patients with infections prior to chimeric antigen receptor T-cell (CAR T-cell) therapy represents an important and underreported event. Patients with active infections needing prompt CAR T-cell therapy to treat aggressive hematologic malignancies remain a clinical challenge. This case describes the clinical course of a 35-year-old male patient with relapsed/refractory T-cell/histiocyte-rich large B-cell lymphoma who received axicabtagene ciloleucel. The patient developed ASTCT Grade II CRS on day +5, necessitating hospital admission and intravenous antibiotics, dexamethasone and tocilizumab. The patient was found to have a pneumonia (PJP) infection 3 days prior to CAR T-cell infusion and cytomegalovirus (CMV) viremia 3 days after CAR T-cell infusion. He received TMP-SMX for 21 days to treat PJP and valganciclovir to treat CMV viremia. PET/CT on day +26 demonstrated near resolution of pulmonary nodules and significant partial response of disease according to Deauville criteria. This case highlights the risk of CRS in immunocompromised patients with infections, and presents a unique case of CRS associated with PJP and CMV infections. Although the patient's clinical course was fraught with complications, he achieved a significant partial response to CAR T-cell therapy with the help of a multidisciplinary medical team.