Disclosures: Aruba Ahmed, DO:

Case Description: The patient presents with altered mental status a few days after completion of his second infusion of CAR T-cell Therapy. Per wife, patient had seemed “off” for several days, stating that he was wandering around the house, seemed markedly confused, and answering questions slowly. Wife additionally noted new jerking movements of the patient’s left arm and face over a 2 day period. After presenting to the Emergency Department, patient was admitted for Acute Encephalopathy work up.

Setting: Tertiary Care Hospital

Patient: 59 year old male with Multiple Myeloma. Assessment/

Results: Lumbar puncture and cultures were negative for acute infection. CT head revealed a subacute hematoma, but unlikely consistent with acute mental status changes. Continuous EEG negative for seizure like activity. On day 3 of admission, patient’s symptoms were resolving, and on exam patient was awake, alert, and oriented x3. Differential diagnosis included ICANS due to CAR T toxicity versus progression of underlying Multiple Myeloma.

Discussion: ICANS (immune cell-associated neurologic syndrome) is a recognized potential side effect of CAR T-cell therapy. Clinical manifestations are varied in the literature – encephalopathy, aphasia, weakness, headache, seizures, tremor, change in level of consciousness, rarely diffuse cerebral edema including more mild symptoms such as impairments of attention and cognitive processing. In a series of patients treated with CAR T-cell Therapy, 60-62% developed at least one neurologic adverse event, median of 4-5 days after infusion, lasting between 5-11 days. While ICANS features can usually be managed with supportive measures, some advocate for immunosuppressive treatment (tocilizumab, steroids), but this is less favored due to concerns that it can make ICANS worse.

Conclusion: When working up acute mental status changes in a Rehabilitation patient with known history of hematologic malignancy being treated with CAR T-cell Therapy, ICANS should be considered as part of the differential.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/mental-status-changes-secondary-to-icans-immune-cell-associated-neurologic-syndrome-from-car-t-cell-therapy-toxicity-case-report/