Triaging Post-CAR T Complications in Two Practical Scenarios

Surbhi Sidana, MD, presents 2 practical scenarios: a patient 6 to 7 weeks post-infusion who develops a fever at a local emergency department 4 hours from the treating center, and a patient around 7 to 8 weeks post-infusion who develops facial droop, drooling, and behavioral changes noticed by a spouse. Prerna Mewawalla, MD, says any suspected delayed neurotoxicity, including parkinsonian symptoms, warrants immediate transfer to the treating center given how difficult these toxicities are to manage, distinguishing them from more reversible findings such as isolated cranial nerve palsies. For a delayed fever, Dr. Mewawalla says management depends on the patient’s earlier course, including whether cytokine release syndrome or rising inflammatory markers occurred previously, to help distinguish infection, which becomes more likely as time passes, from a recurrence of treatment-related inflammation. Dr. Sidana adds that cytokine release syndrome beyond the first 2 to 3 weeks is uncommon in her experience, that fever at this stage is most often infectious, and that keeping communication channels open allows the team to triage which patients can be managed locally and which need to be brought in urgently.