DOI: https://doi.org/10.36347/sjmcr.2026.v14i10.003

Pages: 2126-2128

Background: Nelarabine is a purine nucleoside analogue used in relapsed or refractory T-cell acute lymphoblastic leukemia and T-cell lymphoblastic lymphoma. Although effective, it may cause severe, dose-dependent neurotoxicity, ranging from paresthesias to irreversible paralysis. Case presentation: We report the case of a 34-year-old woman with relapsed T-cell lymphoblastic lymphoma who developed rapidly progressive neurological toxicity four days after initiating a nelarabine based regimen. Symptoms began with symmetrical paresthesias in the lower limbs and progressed within days to ascending sensorimotor weakness, areflexia, quadriplegia, and respiratory muscle paralysis. Cerebrospinal fluid analysis revealed albuminocytologic dissociation, while infectious and lymphomatous involvement were excluded. Electrophysiological studies demonstrated a severe demyelinating sensorimotor polyneuropathy compatible with a Guillain–Barré–like syndrome. Despite corticosteroid therapy, plasma exchange, and intensive respiratory support, the patient experienced progressive neurological deterioration and ultimately died from respiratory failure. Discussion: Nelarabine based combination regimens have been associated with improved survival and higher rates of transplantation in broader relapsed/refractory T ALL/LBL populations. This case illustrates an unusually early onset of severe nelarabine-associated neurotoxicity, occurring only four days after treatment initiation, compared with the more typical latency of several weeks. Prior intrathecal chemotherapy was the only identified potential risk factor. The absence of response to plasma exchange suggests that established neurological injury may be irreversible or poorly responsive to standard immunomodulatory treatment. Conclusion: Nelarabine-associated neurotoxicity can occur early and progress rapidly to fatal respiratory failure. Close neurological monitoring, patient counseling, prompt treatment adaptation, and further research