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800 - A case of acute inpatient rehabilitation in the setting of refractory ICANS and cerebellar neurotoxicity in a patient with multiple myeloma

Friday, February 28, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

GM

Grace Meehan, DO

Resident Physician
UT Southwestern Physical Medicine & Rehabilitation
Dallas, Texas, United States

Co-Author(s)

JL

Jeremiah Ling, MD

Resident Physician
UT Southwestern Physical Medicine & Rehabilitation
Dallas, Texas, United States
Michael Fediw, MD (he/him/his)

Medical Director
UT Southwestern Cancer Rehabilitation Program
Dallas, Texas, United States
AP

Amar Patel, MD

Assistant Professor
UT Southwestern Physical Medicine & Rehabilitation
Dallas, Texas, United States

Case Diagnosis: Immune effector cell-associated neurotoxicity syndrome (ICANS) is a toxicity that can present in patients following chimeric antigen receptor CAR-T cell therapy (CAR-T). CAR-T cell therapy is targeted immunotherapy using hybrid cytotoxic T-cells to attack cancer cells. ICANS typically presents within 3 weeks of therapy, and is usually reversible with supportive care, corticosteroids, antiepileptics, and tocilizumab. Common symptoms include tremor, altered mental status, speech involvement, and seizures. Ataxia and cerebellar symptoms are not commonly described with CAR-T although the neurotoxicity syndrome can vary highly in neurologic manifestations and severity. Rarely, long term or permanent neurotoxicity despite treatment has been reported.

Case Description: This case reports a 74 year old female patient with refractory multiple myeloma treated with multiple, distinct lines of CAR-T cell therapy including BCMA CAR-T, clinical trial with GPRC5D CAR-T and bispecific CAR-T targeting CD3 and BCMA. This patient had symptoms of severe, non-positional dizziness and gait instability on day 29 after her 2nd CAR-T treatment, outside of the typical window of ICANS presentation. Symptoms persisted despite treatment with corticosteroids, Tociluzimab, meclizine, benzodiazepines and physical therapy. After unrevealing neurologic workup, she was diagnosed with permanent cerebellar toxicity, considered neurotoxicity related to CAR-T. Her multiple myeloma relapsed and she was started on Teclistamab which caused further deterioration functionally and neurologically with dysarthria and fine motor impairment.

Discussions: The patient was admitted to inpatient rehabilitation (IPR) for comprehensive rehabilitation after failing to experience significant functional improvement with outpatient occupational, physical, and speech therapy. She demonstrated subjective and objective functional gains in all domains of self care and mobility, achieving a higher level of independence after a comprehensive rehabilitation stay in IPR.

Conclusions: In this case, we highlight a unique and potentially emerging neurologic sequelae of newer CAR-T cell therapy as well as the benefit of comprehensive rehabilitation in a patient with relapsed refractory multiple myeloma.