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Background: CD19-targeting chimeric antigen receptor (CAR) T-cell therapy has shown remarkable outcomes in patients with systemic lupus erythematosus. The effects of CD19-targeting CAR T cells on organ manifestations in patients with systemic sclerosis have yet to be characterised. B cells have a central role in the pathogenesis of systemic sclerosis. We present a detailed analysis of the effects of CD19-targeting CAR T-cell therapy in patients with systemic sclerosis., Methods: Six patients with severe diffuse systemic sclerosis with an insufficient response to at least two treatments were consecutively recruited at the Department of Internal Medicine 3, University Hospital Erlangen (Erlangen, Germany) to receive CD19-targeting CAR T-cell treatment (1 × 10 6 CAR T cells per kg bodyweight). Events were predefined by progression of interstitial lung disease, onset of congestive heart failure, onset of renal failure, onset of arterial hypertension, or initiation of new immunosuppressive or antifibrotic therapy. Event-free time or treatment intensification after study entry was the primary outcome. Key secondary outcomes included changes in the modified Rodnan Skin Score (mRSS), imaging (a component of the assessment of lung fibrosis), laboratory assessments, patient-reported outcomes, and a modified version of the American College of Rheumatology Composite Response Index in Systemic Sclerosis (ACR-CRISS), assessed at baseline, 3 months, 6 months, 9 months, and 12 months., Findings: Between April 20, 2022, and Nov 8, 2023, six patients with severe diffuse systemic sclerosis (median age 42 years [IQR 36-53]; four men and two women; all White European) were recruited and received CD19-targeted CAR T-cell therapy. The median follow-up time was 487 days (IQR 342-585). No events occurred within the observational period. Probability of improvement in the ACR-CRISS score increased to a median of 100% (IQR 100-100) at 6 months. Median mRSS decreased by 31% (IQR 29-38), corresponding to a median of 8 points (IQR 7-13) within 100 days. The extent of disease on CT scan decreased by a median of 4% (IQR 3-4) due to reduction of ground-glass opacities while the reticular pattern remained stable. Forced vital capacity improved by a median of 195 mL (IQR 18-275) at the latest observational timepoint., Interpretation: We provide the first evidence that CD19-targeting CAR T-cell therapy might intercept with the progression of fibrotic organ manifestations in patients with systemic sclerosis., Funding: Deutsche Forschungsgemeinschaft, Deutsche Krebshilfe, ELAN-Foundation Erlangen, IZKF Erlangen, and Bundesministerium für Bildung und Forschung., Competing Interests: Declaration of interests JA and ChB received a travel grant from Kyverna therapeutics. ChB received a research grant from Boehringer Ingelheim and speaker fees from Novartis. CaB received consulting fees from Almirall, Delcath, BMS, Immunocore, Pierre Fabre, MSD, Novartis, Regeneron, and Sanofi; honoraria from Almirall, Leo Pharma, BMS, Pierre Fabre, and MSD; travel support from Pierre Fabre; and participates on the data safety monitoring or advisory board of Miltenyi Biotech and InflaRx. FM received a research grant from Kite/Gilead and consulting fees from AbbVie, ArgoBio, AstraZeneca, BMS, Crispr Therapeutics, Janssen, Kite, and Novartis; honoraria from AbbVie, ArgoBio, AstraZeneca, BMS, Crispr Therapeutics, Janssen, Kite, Kyverna, Miltenyi, Novartis, and Sobi; and participates on the BMS and Biontech data safety monitoring or advisory board. TKr received grants, consulting fees, honoraria, and travel support from Novartis and Pfizer, as well as consulting fees and honoraria from Kiowa Kirin, payment for expert testimony from Novartis, and travel support from AbbVie. GS received honoraria from Cabaletta, Novartis, Janssen, and Kyverna. SoK received honoraria from BMS and Sobi, as well as travel support from Janssen, BMS, Sobi, Novartis, and Kite/Gilead. JHWD has consultancy relationships with and is part of the speaker or advisory board of AbbVie, Active Biotech, Anamar, ARXX, AstraZeneca, Bayer Pharma, Boehringer Ingelheim, Calliditas Therapeutics, Celgene, Galapagos, Genentech, GSK, Inventiva, Janssen, Novartis, Pfizer, Roche, and UCB; has received research funding from Anamar, Argenx, ARXX, BMS, Bayer Pharma, Boehringer Ingelheim, Cantargia, Celgene, CSL Behring, Galapagos, GSK, Inventiva, Kiniksa, Lassen, Sanofi-Aventis, RedX, and UCB; travel support from AbbVie and SOBI; and is Chief Executive Officer of 4D Science and Scientific Lead of FibroCure. AM received grants from Miltenyi Biomedicine and Kyverna, and consulting fees from BMS/Celgene, KITE/Gilead, Novartis, BioNTech, Miltenyi Biomedicine, and Century Therapeutics. AM received honoraria from BMS/Celgene, KITE/Gilead, Novartis, BioNTech, Miltenyi Biomedicine, and Century Therapeutics, and travel support from AbbVie and Janssen. RGB received grants from Kyverna and travel support from BMS and Novartis. MA received grants, honoraria, payment for expert testimony, travel support and equipment from Miltenyi Biotec; and received consulting fees, honoraria and travel support from Miltenyi Biomedicine. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)