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

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. 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.