Abstract
Chimeric antigen receptor (CAR) T-cell therapy has transformed the management of relapsed/refractory multiple myeloma (MM), particularly with the advent of ciltacabtagene autoleucel (cilta-cel). As its clinical use expands, novel and delayed toxicities are increasingly recognized. We report the first documented case of bilateral phrenic nerve palsy following cilta-cel infusion, presenting with acute dyspnea and profound orthopnea. Diagnostic evaluation was challenged by the patient’s inability to tolerate the supine position, delaying definitive imaging. Ultimately, diaphragmatic ultrasound and phrenic nerve conduction studies confirmed isolated bilateral phrenic neuropathy without evidence of myopathy or cervical radiculopathy. The patient was treated with intravenous immunoglobulin (IVIG), high-dose corticosteroids, and prolonged bilevel positive airway pressure (BiPAP) support. Despite this neurologic complication, he achieved minimal residual disease (MRD)–negative complete remission. This case highlights an emerging neurotoxicity of cilta-cel, underscores the importance of early recognition of diaphragmatic dysfunction, and outlines diagnostic and management considerations for advanced practice providers (APPs).
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