We read with great interest the recent meta-analysis by Rao et al. [...].
Introduction CAR T-cell therapy is transformative for relapsed/refractory B-cell malignancies but may cause prolonged cytopenias with multifactorial etiologies. We report a complex case of persistent post-CAR-T pancytopenia and its management. Objectives To describe diagnostic evaluation and sequential management of prolonged cytopenia after CD19/CD22 CAR-T and to review contributing factors. Methods We performed a detailed retrospective case review of a 52-year-old female with R/R DLBCL treated with CD19/CD22 CAR-T. Persistent cytopenia was defined as cytopenia beyond Day +30. Extracted data included serial CBCs, peripheral smear, bone marrow aspirate/biopsy with flow cytometry, peripheral-blood immunophenotyping, quantitative viral PCRs (Parvovirus B19, CMV, EBV), and whole-exome sequencing for clonal mutations. Interventions (G-CSF, high-dose IVIG, antivirals, CD34+ stem-cell boost, mesenchymal stromal cell infusion, and low-dose methotrexate) were documented; hematologic response required sustained transfusion-independent counts as predefined. Results The patient developed persistent pancytopenia beyond Day +30. Parvovirus B19 PCR was positive. Sequential therapies included G-CSF, high-dose IVIG, antiviral therapy (foscarnet/cidofovir), CD34+ stem-cell boost and mesenchymal stromal cell infusion; Peripheral blood immunophenotyping and subset analysis done showed NK-cell predominance. Clinical exome sequencing from peripheral blood identified a pathogenic TET2 mutation consistent with clonal hematopoiesis. Finally patient responsed to low-dose methotrexate, with WBC rising to 2.4 × 10^9/L. Conclusion Prolonged post-CAR-T cytopenia may reflect overlapping infectious, immune-mediated and clonal mechanisms. A systematic diagnostic approach and multimodal, stepwise management can achieve hematologic recovery in selected patients. This case highlights the complex issue of immunological cause of post CART cytopenia and its dramatic response after Methotrexate.
High dose radio iodine administration has passed through the conventional open suction method, with its drawbacks and dangers of spillage and excessive exposure to radiation personnel. This was followed by the closed system vacuum-assisted technique. The latest innovation is the gravity augmented administration, which further reduces exposure to radiation personnel by faster consumption by the patient. This technique is easy using simple and easily available materials.
