Cytokine storms during alemtuzumab infusion: a case series

Address for correspondence: Thiago Santillan (email: [e-mail]).

Abstract

Case Presentation: Alemtuzumab, a high efficacy therapy (HET) for multiple sclerosis (MS) patients in Brazil's public healthcare system, is reserved for cases where natalizumab has failed or is contraindicated due to its effectiveness. Despite being relatively common, infusion-associated reactions (IAR) with alemtuzumab are mostly mild and manageable with pre-infusion protocols involving corticosteroids, antihistamines, and analgesics. However, severe IARs can occur, posing risks to patients, yet data on clinical presentation and management remain limited. The objective of this study is to report three cases of serious adverse reactions linked to alemtuzumab infusion in MS patients. These patients were treated at two neuroimmunology clinics in São Paulo. Inclusion criteria encompassed MS patients treated with alemtuzumab infusion without contraindications. All received 12 mg of intravenous alemtuzumab, premedicated with methylprednisolone, diphenhydramine, and acetaminophen. Nursing and medical staff were trained to manage adverse effects promptly. Case 1 involved a 45-year-old female experiencing acute generalized pain, somnolence, dyspnea, and hypertensive crisis during her second infusion. Treatment was paused, and a new cycle of steroids and symptomatic drugs was initiated. Case 2, a 35-year-old male, developed acute ataxia, hypertension, and fever within two hours of infusion on the third day. The infusion was paused, and a stroke protocol was enacted to rule out vascular complications. Case 3, a 44-year-old female, presented with bilateral leg weakness and fever within two hours of infusion. Similar symptoms d during previous MS relapses were reported, yet both patients underwent a stroke protocol due to acute onset. Symptoms resolved with antipyretics.

Discussion: Suggests these IARs correspond to cytokine storm syndrome, involving release of TNF-alpha, IFN-Gamma, and IL-6, leading to fever, rash, dyspnea, and blood pressure fluctuations.

Final Comments: Infusion-associated reactions, exceeding 90%, highlight the importance of healthcare providers being vigilant regarding potential side effects associated with alemtuzumab infusion in MS treatment.

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Publikationsverlauf

Artikel online veröffentlicht:
02. Oktober 2024