Use of long-term corticosteroids in patients treated with CAR T-cell therapy.

INTRODUCTION: Cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) are common toxicities associated with chimeric antigen receptor (CAR) T-cell therapy. Severe grade 3 or higher ICANS is less common and requires the use of corticosteroids with or without an Interleukin (IL)-6 receptor antagonist. Although corticosteroids are effective in the management of CRS and ICANS, their impact on CAR T efficacy remains unknown. CASE REPORT: We present the case of a 65-year-old male who received CAR T-cell therapy with brexucabtagene autoleucel for stage I/II Mantle Cell Lymphoma (MCL) and achieved complete remission despite receiving a prolonged course of corticosteroids for severe ICANS. MANAGEMENT AND OUTCOME: The patient received treatment with high-dose corticosteroids, tocilizumab, and anakinra, in addition to multiple antiepileptic agents. Despite a remitting relapsing pattern of ICANS, the patient not only recovered from the life-threatening complication but also achieved a complete remission at three months post CAR T. CONCLUSION: This case describes the successful use of corticosteroids for the management of ICANS in a patient treated with CAR T-cell therapy for MCL.

Risk factors and epidemiology of Clostridium difficile infection in hematopoietic stem cell transplant recipients during the peritransplant period.

BACKGROUND: Hematopoietic stem cell transplant (HSCT) recipients represent a high-risk group for developing Clostridium difficile (CD) infection (CDI). We aimed to identify specific risk factors for CDI in an HSCT patient population during the peritransplant period. METHODS: We performed a case-control study within a cohort of HSCT patients who received a transplant from November 2010 to March 2013. Cases had a clinical presentation compatible with CDI and a positive stool sample Xpert® C. difficile test. Controls were CDI negative and matched on age, gender, and transplant type. Peritransplant period was defined as -30 days or time of stem cell mobilization maneuver to 30 days post transplant in autologous SCT or 90 days post transplant in allogeneic SCT. RESULTS: Of 781 HSCTs performed during the study period, 650 (83.2%) had a stool sample submitted for CD testing. Eight-six (13.2%) cases with CDI were identified. Most of the cases were diagnosed within a week after transplantation (median of 5 days). In adjusted analysis, prior hospitalization (odds ratio [OR]: 2.01, 95% confidence interval [CI] 1.2-3.36), prior cephalosporin administration (OR 2.72, 95% CI: 1.54-4.83), and prior chemotherapy (OR: 3.26, 95% CI: 1.92-5.5) were significantly associated with CDI. CONCLUSIONS: Hospitalization, and prior antibiotic and chemotherapy use are risk factors that are not easily modifiable, which emphasizes the need to start investigating preventive or prophylactic strategies in this high-risk population.