Disclosures: Eric W. Villanueva, MD: No financial relationships or conflicts of interest

Case Diagnosis: Two men ages 73 and 76 who presented to an Inpatient Rehabilitation Facility (IRF) after Chimeric Antigen Receptor (CAR) T-cell therapy for Diffuse Large B Cell Lymphoma and Mantle Cell Lymphoma, respectively.

Case Description or Program Description: During their acute hospitalization, both developed sequelae of CAR T-cell therapy: cytokine release syndrome, a systemic inflammatory response with fever and hypotension, and its encephalopathic counterpart, immune effector cell-associated neurotoxicity syndrome, requiring intensive care unit level of care, monoclonal antibodies, and steroids. On admission to IRF, they presented with dizziness and disorientation and were found to have symptomatic orthostatic hypotension during therapies. These orthostatic symptoms limited participation in physical and occupational therapy.

Setting: IRF.

Assessment/Results: For initial management of orthostasis at the IRF, both patients donned abdominal binders and TED hose stockings when out of bed. Both required the use of Midodrine for management of orthostatic symptoms: one patient was started on Midodrine in acute care whereas the second patient was prescribed Midodrine at the IRF. Both required ongoing dose titration to manage symptoms and allow for maximum participation in therapy. Due to ongoing severe orthostatic symptoms despite the use of Midodrine, the second patient also required the addition of Florinef to manage his orthostasis. With management of orthostasis, both patients were able to participate in therapy and ultimately discharge to the community with improved function as evidenced by comparison of admission and discharge Quality Indicators (QI) scores.

Discussion (relevance): CAR T-cell therapy is a relatively new but expanding immunotherapy modality for a growing list of cancers. CAR T-cell therapy can lead to debilitating side effects necessitating acute inpatient rehabilitation. One possible side effect, orthostasis, may have significant effects on the acute inpatient rehabilitation course.

Conclusions: As indications for CAR T-cell therapy expand, Physiatrists will need to recognize and manage potential side effects of this therapy, including orthostasis, during acute inpatient rehabilitation.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/symptomatic-orthostasis-in-car-t-cell-patients-undergoing-inpatient-rehabilitation-a-case-series/