Multiple Sclerosis and other Neurological Conditions
Matthew Chen, BA
Medical Student
Case Western Reserve University School of Medicine
Cleveland Heights, Ohio, United States
Kristen de vries, DO, MS
Assistant Professor
Weill Cornell Medicine
New York, New York, United States
Raisa Masood, MD, MS
Resident Physician
NYP- Cornell/Columbia
New York, New York, United States
Matthew Chen, BA
Case Western Reserve University School of Medicine
Cleveland heights, Ohio, United States
Non-immune effector cell-associated neurotoxicity syndrome
Case Description: 62-year-old male admitted to acute inpatient rehabilitation after experiencing delayed left lower motor neuron facial droop, dysphagia, and parkinsonian-like features including left hand tremor, bradykinesia, and word-finding difficulty after chimeric antigen receptor (CAR) T-cell therapy for multiple myeloma. Patient received two courses of steroids and intrathecal methotrexate/cytarabine and thiotepa, with worsening progression of speech and swallow. Patient was treated with Anakinra, IV Cytoxan, and IVIG. Neurology was consulted and patient started on carbidopa-levodopa, ropinirole, and amantadine. Brain MRI revealed left cranial nerve VII neuritis with no other parenchymal or spinal cord lesions. While working with physical and occupational therapy, he progressed from a minimum assistance level of supervision for mobility, gait, and ADLs to a supervision level. He also made improvements with speech therapy specifically during structured tasks, however his carryover to spontaneous speech remained reduced at discharge. He was provided with scripts to continue therapy outpatient.
Discussions:
CAR-T therapy has revolutionized the treatment of hematologic malignancies but is associated with significant toxicities, such as cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome (ICANS). While ICANS has been well described, non-ICANS neurologic syndromes are not as well understood and underreported. This case highlights a presentation of parkinsonian-like features and language dysfunction. The mechanism of non-ICANS remains unclear. Management of this condition includes supportive care with physical, occupational, speech therapy, and utilizing medications that may alleviate parkinsonism and help with cognition.
Conclusions:
This case illustrates a rare but debilitating complication following CAR-T therapy. Non-immune effector cell-associated neurotoxicity syndrome appears to have a prolonged recovery course. Multidisciplinary rehabilitation is essential to optimize recovery and quality of life in these patients.
