In the clinic, chimeric antigen receptor–modified T (CAR T) cell therapy is frequently associated with life-threatening cytokine-release syndrome (CRS) and neurotoxicity. Understanding the nature of these pathologies and developing treatments for them are hampered by the lack of appropriate animal models. Herein, we describe a mouse model recapitulating key features of CRS and neurotoxicity. In humanized mice with high leukemia burden, CAR T cell–mediated clearance of cancer triggered high fever and elevated IL-6 levels, which are hallmarks of CRS. Human monocytes were the major source of IL-1 and IL-6 during CRS. Accordingly, the syndrome was prevented by monocyte depletion or by blocking IL-6 receptor with tocilizumab. Nonetheless, tocilizumab failed to protect mice from delayed lethal neurotoxicity, characterized by meningeal inflammation. Instead, the IL-1 receptor antagonist anakinra abolished both CRS and neurotoxicity, resulting in substantially extended leukemia-free survival. These findings offer a therapeutic strategy to tackle neurotoxicity and open new avenues to safer CAR T cell therapies.

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We thank G. Dotti (University of North Carolina) and H. Abken (University of Cologne) for providing the original CAR constructs, F. Falkenburg (Leiden University Medical Center) for providing ALL-CM leukemic cells and L. Naldini (San Raffaele-Telethon Institute for Gene Therapy) for providing lentiviral vectors. We thank R. Norato (San Raffaele Scientific Institute) for histology technical support. This work was supported by the Italian Association for Cancer Research (AIRC) (MFAG grant no. 13390 and Investigator grant no. 17706 to B.A.; MFAG grant no. 20247 to O.R.).

Author information


  1. Innovative Immunotherapies Unit, San Raffaele Hospital Scientific Institute, Milano, Italy

    • Margherita Norelli
    • , Barbara Camisa
    • , Laura Falcone
    • , Ayurzana Purevdorj
    • , Monica Casucci
    •  & Attilio Bondanza
  2. Vita-Salute San Raffaele University, Milano, Italy

    • Margherita Norelli
    • , Claudio Bordignon
    • , Fabio Ciceri
    • , Chiara Bonini
    •  & Attilio Bondanza
  3. Genomics of the Innate Immune System Unit, San Raffaele-Telethon Institute for Gene Therapy (SR-Tiget), Milano, Italy

    • Giulia Barbiera
    • , Marco Genua
    •  & Renato Ostuni
  4. Pathology Unit, San Raffaele Hospital Scientific Institute, Milano, Italy

    • Francesca Sanvito
    • , Maurilio Ponzoni
    •  & Claudio Doglioni
  5. San-Raffaele-Telethon Institute for Gene Therapy (SR-Tiget), Milano, Italy

    • Patrizia Cristofori
  6. Molmed Spa, Milano, Italy

    • Catia Traversari
    •  & Claudio Bordignon
  7. Hematology and Bone Marrow Transplantation Unit, San Raffaele Hospital Scientific Institute, Milano, Italy

    • Fabio Ciceri
  8. Experimental Hematology Unit, San Raffaele Hospital Scientific Institute, Milano, Italy

    • Chiara Bonini


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M.N. and B.C. designed and performed experiments and interpreted results. M.C. and L.F. assisted in experimental design and provided constructs and vectors. A.P. performed experiments and interpreted results. F.S., M.P., P.C. and C.D. performed histopathological analysis. G.B. and M.G. performed and analyzed scRNA-seq experiments. C.T., C. Bordignon, F.C. and C. Bonini interpreted results. R.O. supervised G.M. and B.G., interpreted results and wrote the manuscript. A.B. designed experiments and interpreted results. M.N. and A.B. wrote the manuscript and prepared the figures. All authors approved the final version of the manuscript.

Competing interests

C.T. and C. Bordignon are employees of Molmed Spa, whose potential product is studied in this work. F.C. and C. Bonini are consultants of Molmed Spa.

Corresponding author

Correspondence to Attilio Bondanza.

Supplementary information

  1. Supplementary Text and Figures

    Supplementary Figures 1–19

  2. Reporting Summary

  3. Supplementary Table 1

    Datasets generated in this study and sequencing information

  4. Supplementary Table 2

    List of differentially expressed genes for each scRNA-seq

  5. Supplementary Table 3

    List of differentially expressed genes in scRNA-seq clusters 5, 7, 11, 12 (monocyte and DC populations)

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