Table 4.

Management recommendations for suspected neurotoxicity during immunotherapy with DB.

Stop DB infusion/immunotherapy

Start antibacterial and antiviral therapy for potential infectious cause

Examine for VZV and HSV infection (PCR of blood and CSF) Rule out other cause for neurological symptoms by cMRI, MRI of spinal cord and evaluate metabolic conditions

EEG if clinically indicated

Carry out CSF examination

Urgently start immunosuppression with dexamethasone or prednisolone and IVIG

In case of no improvement of symptoms, consider plasmapheresis

DB, dinutuximab beta; cMRI, cardiac magnetic resonance imaging; CSF, cerebrospinal fluid; EEG, electroencephalogram; HSV, herpes simplex virus; IVIG, intravenous immunoglobulins; MRI, magnetic resonance imaging; PCR, polymerase chain reaction; VZV, varicella zoster virus.