Clinical Scorecard: Acute Myelopathy After CAR T-Cell Therapy: A Rare Diagnostic Dilemma

At a Glance

Key Highlights

• Infectious myelitis should be systematically excluded, particularly viral causes in profoundly immunocompromised patients.
• The reported spinal MRI showed a longitudinally extensive lesion without contrast enhancement; this finding is nonspecific and is reported in infectious, autoimmune, and vascular myelopathies.
• The article notes that acute autoimmune inflammation or ischemia-induced disruption of the blood-spinal cord barrier generally produces enhancement; concurrent brain lesions suggestive of ICANS and exclusion of infection supported ICANS-associated myelopathy as the most likely diagnosis in this case.
• Severe encephalopathy can prevent a comprehensive neurological examination and obscure when spinal cord involvement begins.
• The article states that no definitive evidence supports a particular treatment approach for ICANS-associated myelopathy, including immunoglobulins or plasmapheresis.

Guideline-Based Recommendations

Diagnosis

• The article advises systematically excluding infectious myelitis, including cytomegalovirus, herpes simplex virus, varicella-zoster virus, enteroviruses, and human herpesvirus-6.
• The article describes longitudinally extensive, non-enhancing spinal lesions as nonspecific; they are reported in infectious, autoimmune, and vascular myelopathies.
• In the reported case, concurrent brain lesions suggestive of ICANS and exclusion of infection supported ICANS-associated myelopathy as the most likely diagnosis.

Management

• The reported patient was treated for grade IV ICANS with high-dose corticosteroids and anakinra.
• The article states that definitive evidence does not support a particular treatment approach, including immunoglobulins or plasmapheresis, for ICANS-associated myelopathy.

Monitoring & Follow-up

• The article notes that severe encephalopathy may limit neurological examination and obscure the onset of spinal cord symptoms.
• In the reported patient, cerebral and spinal cord involvement probably arose concurrently.

Risks

• The article emphasizes that infectious myelitis must be excluded in profoundly immunocompromised patients.
• A non-enhancing spinal cord lesion is nonspecific and is reported in infectious, autoimmune, and vascular myelopathies.
• The article states that larger series are required to determine optimal management and prognosis of ICANS-associated myelopathy.

Patient & Prescribing Data

The reported case involved a patient with acute extensive myelopathy after CAR-T cell therapy and severe ICANS.

The patient received high-dose corticosteroids and anakinra for grade IV ICANS. The article states that definitive evidence does not support immunoglobulins, plasmapheresis, or another particular treatment approach for ICANS-associated myelopathy.

Clinical Best Practices

• The article advises systematically excluding infectious causes of myelitis in profoundly immunocompromised patients after CAR-T cell therapy.
• Interpret spinal MRI alongside brain imaging, infectious testing, and clinical context; non-enhancement is not diagnostic.
• Account for the limitations of neurological examination when severe encephalopathy is present.
• The article states that larger series are needed to determine optimal management and prognosis of ICANS-associated myelopathy.

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