Exacerbations of Persistent Neurotoxicity following Axicabtagene Ciloleucel in a Patient with Relapsed/Refractory Diffuse Large B-Cell Lymphoma: A Case Report

Introduction: Neurological toxicity following chimeric antigen receptor T-cell infusion, termed immune cell-associated neurotoxicity syndrome (ICANS), is a common and limiting factor in the expansion of this promising treatment modality. While refractory cases of ICANS have been reported in clinical trials, there is limited description of these presentations and their associated treatment. The use of predictive biomarkers and risk stratification tools offer a means of identifying patients with higher likelihood of developing ICANS; however, their discriminatory sensitivity has been shown to vary depending on disease type. Case Presentation: In this case report, we present the clinical course of a patient with diffuse large B-cell lymphoma treated with axicabtagene ciloleucel who developed a nonsinusoidal pattern of severe neurotoxicity refractory to steroid treatment, and we evaluate the predictive value of commonly used biomarkers and risk scores in assessing the likelihood of her presentation. Conclusion: In assessing the efficacy of these scores in the context of our patient's pattern of severe neurotoxicity exacerbations, we aim to provide valuable clinical insight to better manage refractory ICANS and ultimately improve patient outcomes.