Clinical Report: Acute Myelopathy After CAR T-Cell Therapy

Background

CAR-T cell therapy can be associated with ICANS and other neurologic toxicities. Acute myelitis is among the non-ICANS neurologic complications described after CAR-T, although spinal cord involvement within ICANS remains inadequately characterized. In profoundly immunocompromised patients, infectious myelitis—including viral causes—requires systematic exclusion. Severe encephalopathy can also limit neurological examination and make the timing of spinal cord involvement difficult to establish.

Data Highlights

The source describes a single case and provides no numerical trial or cohort data. Cerebrospinal fluid cultures and multiplex PCR testing were negative; spinal MRI showed a longitudinally extensive lesion without contrast enhancement. The patient was treated for grade IV ICANS with high-dose corticosteroids and anakinra.

Key Findings

• The authors describe a rare case of acute, extensive myelopathy after CAR-T cell therapy, considered likely to represent spinal cord involvement within ICANS.
• The authors emphasize excluding infectious myelitis in profoundly immunocompromised patients, including viral causes such as cytomegalovirus, herpes simplex virus, varicella-zoster virus, enteroviruses, and human herpesvirus-6.
• In the reported patient, cerebrospinal fluid cultures and multiplex PCR testing were negative, making an infectious etiology unlikely.
• Spinal MRI showed a longitudinally extensive lesion without contrast enhancement. The authors note that this finding is nonspecific and has been reported in infectious, autoimmune, and vascular myelopathies.
• Concurrent brain lesions suggestive of ICANS and exclusion of infection supported ICANS-associated myelopathy as the most likely diagnosis, consistent with limited published cases reporting comparable non-enhancing findings.
• Severe encephalopathy limited neurological examination and obscured the onset of spinal cord symptoms. The authors considered cerebral and spinal cord involvement probably concurrent. The patient was treated for grade IV ICANS with high-dose corticosteroids and anakinra; the authors state that definitive evidence does not support a particular treatment for ICANS-associated myelopathy, including immunoglobulins or plasmapheresis.

Clinical Implications

The authors emphasize that infectious myelitis, particularly viral infection, must be excluded in profoundly immunocompromised patients with acute myelopathy after CAR-T. In this case, the patient was treated for grade IV ICANS with high-dose corticosteroids and anakinra. The authors state that evidence does not establish a specific treatment for ICANS-associated myelopathy and that larger series are needed to determine optimal management and prognosis.

Conclusion

Acute myelopathy after CAR-T may represent spinal cord involvement within ICANS, but diagnosis depends on clinical context and exclusion of infection because MRI findings are nonspecific. The source identifies optimal management and prognosis as unresolved.

Related Resources & Content

1. EBMT Practice Harmonisation and Guidelines Committee, PubMed, 2025 -- Non-ICANS neurological complications after CAR T-cell therapies: recommendations from the EBMT Practice Harmonisation and Guidelines Committee
2. ASTCT, PubMed, 2026 -- ASTCT Consensus Grading for Toxicities after Immune Effector Cell Therapy
3. Case report source, publication details not provided -- Acute Myelopathy After CAR T-Cell Therapy: A Rare Diagnostic Dilemma
4. Frontiers in Medicine — Acute Myeloid Leukemia Induced by Therapy with a 24-Month Latency Following CD19 CAR-T Cell Treatment for Relapsed/Refractory Diffuse Large B-Cell Lymphoma: A Case Study
5. Frontiers in Oncology — Therapy-related myelodysplastic syndrome rapidly evolving to acute myeloid leukemia following CAR-T cell therapy in a patient with refractory diffuse large B-cell lymphoma: a case report
6. Blood Cancer Journal — Development of chronic inflammatory demyelinating polyneuropathy (CIDP) following cilta-cel treatment
7. ASCO Publications — Extreme persistence of polyclonal CD8⁺ CAR T cells as a driver of marrow failure, neurotoxicity, and fatal immune collapse after ciltacabtagene autoleucel.
8. Non-ICANS neurological complications after CAR T-cell therapies: recommendations from the EBMT Practice Harmonisation and Guidelines Committee
9. ASTCT Consensus Grading for Toxicities after Immune Effector Cell Therapy
10. Non-ICANS neurological complications after CAR T-cell therapies: recommendations from the EBMT Practice Harmonisation and Guidelines Committee.
11. Table 19, Summary of Harms Results From CARTITUDE-4 Trial (Safety Analysis Set; Data Cut-Off: November 1, 2022) - Ciltacabtagene Autoleucel (Carvykti) - NCBI Bookshelf
12. Non-ICANS neurologic toxicity after BCMA CAR-T therapy: a systematic review and meta-analysis of 4630 patients with multiple myeloma.
13. Incidence of immune effector cell-associated neurotoxicity among patients treated with CAR T-cell therapy for hematologic malignancies: systematic review and meta-analysis - PMC
14. Case Report: Transverse myelitis following CAR-T cell therapy for post-transplant lymphoproliferative disorder - PMC
15. Transient imaging changes accompany ‘spinal ICANS’ following CAR T‐cell therapy for large B‐cell lymphoma in adults - PMC
16. Immune effector cell-associated neurotoxicity syndrome (ICANS) and other neurologic toxicities of CAR-T cell and related therapies - UpToDate