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.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.

from $8.99

All prices are NET prices.

Additional information

Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


  1. 1.

    Brentjens, R. J. et al. Safety and persistence of adoptively transferred autologous CD19-targeted T cells in patients with relapsed or chemotherapy refractory B-cell leukemias. Blood 118, 4817–4828 (2011).

  2. 2.

    Savoldo, B. et al. CD28 costimulation improves expansion and persistence of chimeric antigen receptor-modified T cells in lymphoma patients. J. Clin. Invest. 121, 1822–1826 (2011).

  3. 3.

    Kochenderfer, J. N. et al. B-cell depletion and remissions of malignancy along with cytokine-associated toxicity in a clinical trial of anti-CD19 chimeric-antigen-receptor-transduced T cells. Blood 119, 2709–2720 (2012).

  4. 4.

    Porter, D. L., Levine, B. L., Kalos, M., Bagg, A. & June, C. H. Chimeric antigen receptor-modified T cells in chronic lymphoid leukemia. N. Engl. J. Med. 365, 725–733 (2011).

  5. 5.

    Grupp, S. A. et al. Chimeric antigen receptor-modified T cells for acute lymphoid leukemia. N. Engl. J. Med. 368, 1509–1518 (2013).

  6. 6.

    Neelapu, S. S. et al. Axicabtagene ciloleucel CAR T-cell therapy in refractory large B-Cell lymphoma. N. Engl. J. Med. 377, 2531–2544 (2017).

  7. 7.

    Maude, S. L. et al. Tisagenlecleucel in children and young adults with B-cell lymphoblastic leukemia. N. Engl. J. Med. 378, 439–448 (2018).

  8. 8.

    Davila, M. L. et al. Efficacy and toxicity management of 19-28z CAR T cell therapy in B cell acute lymphoblastic leukemia. Sci. Transl. Med. 6, 224ra25 (2014).

  9. 9.

    Turtle, C. J. et al. CD19 CAR-T cells of defined CD4+:CD8+ composition in adult B cell ALL patients. J. Clin. Invest. 126, 2123–2138 (2016).

  10. 10.

    Turtle, C. J. et al. Durable molecular remissions in chronic lymphocytic leukemia treated with CD19-specific chimeric antigen receptor-modified T cells after failure of ibrutinib. J. Clin. Oncol. 35, 3010–3020 (2017).

  11. 11.

    Teachey, D. T. et al. Identification of predictive biomarkers for cytokine release syndrome after chimeric antigen receptor T-cell therapy for acute lymphoblastic leukemia. Cancer Discov. 6, 664–679 (2016).

  12. 12.

    Lee, D. W. et al. Current concepts in the diagnosis and management of cytokine release syndrome. Blood 124, 188–195 (2014).

  13. 13.

    Park, J. H. et al. Long-term follow-up of CD19 CAR therapy in acute lymphoblastic leukemia. N. Engl. J. Med. 378, 449–459 (2018).

  14. 14.

    Topp, M. S. et al. Safety and activity of blinatumomab for adult patients with relapsed or refractory B-precursor acute lymphoblastic leukaemia: a multicentre, single-arm, phase 2 study. Lancet Oncol. 16, 57–66 (2015).

  15. 15.

    Bondanza, A. et al. Suicide gene therapy of graft-versus-host disease induced by central memory human T lymphocytes. Blood 107, 1828–1836 (2006).

  16. 16.

    Mastaglio, S. et al. NY-ESO-1 TCR single edited central memory and memory stem T cells to treat multiple myeloma without inducing GvHD. Blood 130, 606–618 (2017).

  17. 17.

    Casucci, M. et al. CD44v6-targeted T cells mediate potent antitumor effects against acute myeloid leukemia and multiple myeloma. Blood 122, 3461–3472 (2013).

  18. 18.

    Gattinoni, L., Speiser, D. E., Lichterfeld, M. & Bonini, C. T memory stem cells in health and disease. Nat. Med. 23, 18–27 (2017).

  19. 19.

    Nijmeijer, B. A., Willemze, R. & Falkenburg, J. H. An animal model for human cellular immunotherapy: specific eradication of human acute lymphoblastic leukemia by cytotoxic T lymphocytes in NOD/scid mice. Blood 100, 654–660 (2002).

  20. 20.

    Rongvaux, A. et al. Human hemato-lymphoid system mice: current use and future potential for medicine. Annu. Rev. Immunol. 31, 635–674 (2013).

  21. 21.

    Shultz, L. D. et al. Multiple defects in innate and adaptive immunologic function in NOD/LtSz-scid mice. J. Immunol. 154, 180–191 (1995).

  22. 22.

    Takenaka, K. et al. Polymorphism in Sirpa modulates engraftment of human hematopoietic stem cells. Nat. Immunol. 8, 1313–1323 (2007).

  23. 23.

    Billerbeck, E. et al. Development of human CD4+FoxP3+ regulatory T cells in human stem cell factor-, granulocyte-macrophage colony-stimulating factor-, and interleukin-3-expressing NOD-SCID IL2Rγ(null) humanized mice. Blood 117, 3076–3086 (2011).

  24. 24.

    Wils, E. J. et al. Stem cell factor consistently improves thymopoiesis after experimental transplantation of murine or human hematopoietic stem cells in immunodeficient mice. J. Immunol. 187, 2974–2981 (2011).

  25. 25.

    Koo, G. C., Hasan, A. & O’Reilly, R. J. Use of humanized severe combined immunodeficient mice for human vaccine development. Expert Rev. Vaccines 8, 113–120 (2009).

  26. 26.

    Strowig, T. et al. Priming of protective T cell responses against virus-induced tumors in mice with human immune system components. J. Exp. Med. 206, 1423–1434 (2009).

  27. 27.

    Lan, P., Tonomura, N., Shimizu, A., Wang, S. & Yang, Y. G. Reconstitution of a functional human immune system in immunodeficient mice through combined human fetal thymus/liver and CD34+ cell transplantation. Blood 108, 487–492 (2006).

  28. 28.

    Bouma, G. et al. NOD mice have a severely impaired ability to recruit leukocytes into sites of inflammation. Eur. J. Immunol. 35, 225–235 (2005).

  29. 29.

    Patel, A. A. et al. The fate and lifespan of human monocyte subsets in steady state and systemic inflammation. J. Exp. Med. 214, 1913–1923 (2017).

  30. 30.

    Bondanza, A. et al. IL-7 receptor expression identifies suicide gene-modified allospecific CD8+ T cells capable of self-renewal and differentiation into antileukemia effectors. Blood 117, 6469–6478 (2011).

  31. 31.

    Kochenderfer, J. N. et al. Chemotherapy-refractory diffuse large B-cell lymphoma and indolent B-cell malignancies can be effectively treated with autologous T cells expressing an anti-CD19 chimeric antigen receptor. J. Clin. Oncol. 33, 540–549 (2015).

  32. 32.

    Turtle, C. J. et al. Immunotherapy of non-Hodgkin’s lymphoma with a defined ratio of CD8+ and CD4+ CD19-specific chimeric antigen receptor-modified T cells. Sci. Transl. Med. 8, 355ra116 (2016).

  33. 33.

    Schuster, S. J. et al. Chimeric antigen receptor T cells in refractory B-cell lymphomas. N. Engl. J. Med. 377, 2545–2554 (2017).

  34. 34.

    Hunter, C. A. & Jones, S. A. IL-6 as a keystone cytokine in health and disease. Nat. Immunol. 16, 448–457 (2015).

  35. 35.

    Singh, N. et al. Monocyte lineage-derived IL-6 does not affect chimeric antigen receptor T-cell function. Cytotherapy 19, 867–880 (2017).

  36. 36.

    Gust, J. et al. Endothelial activation and blood-brain barrier disruption in neurotoxicity after adoptive immunotherapy with CD19 CAR-T cells. Cancer Discov. 7, 1404–1419 (2017).

  37. 37.

    Goldbach-Mansky, R. et al. Neonatal-onset multisystem inflammatory disease responsive to interleukin-1β inhibition. N. Engl. J. Med. 355, 581–592 (2006).

  38. 38.

    Fox, E. et al. The serum and cerebrospinal fluid pharmacokinetics of anakinra after intravenous administration to non-human primates. J. Neuroimmunol. 223, 138–140 (2010).

  39. 39.

    Kaneko, S. et al. IL-7 and IL-15 allow the generation of suicide gene-modified alloreactive self-renewing central memory human T lymphocytes. Blood 113, 1006–1015 (2009).

  40. 40.

    Zheng, G. X. et al. Massively parallel digital transcriptional profiling of single cells. Nat. Commun. 8, 14049 (2017).

  41. 41.

    Levine, J. H. et al. Data-driven phenotypic dissection of AML reveals progenitor-like cells that correlate with prognosis. Cell 162, 184–197 (2015).

  42. 42.

    Villani, A. C. et al. Single-cell RNA-seq reveals new types of human blood dendritic cells, monocytes, and progenitors. Science 356, eaah4573 (2017).

Download references


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


  1. Search for Margherita Norelli in:

  2. Search for Barbara Camisa in:

  3. Search for Giulia Barbiera in:

  4. Search for Laura Falcone in:

  5. Search for Ayurzana Purevdorj in:

  6. Search for Marco Genua in:

  7. Search for Francesca Sanvito in:

  8. Search for Maurilio Ponzoni in:

  9. Search for Claudio Doglioni in:

  10. Search for Patrizia Cristofori in:

  11. Search for Catia Traversari in:

  12. Search for Claudio Bordignon in:

  13. Search for Fabio Ciceri in:

  14. Search for Renato Ostuni in:

  15. Search for Chiara Bonini in:

  16. Search for Monica Casucci in:

  17. Search for Attilio Bondanza in:


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)

About this article

Publication history