Immunology · Year 2 · from Immunology

Case 2: Graft-Versus-Host Disease After Stem Cell Transplant

Patient Demographics

  • Age: 28 years old
  • Sex: Female
  • Ethnicity: Caucasian

Chief Complaint

Rash, diarrhea, and jaundice 35 days after bone marrow transplant

History of Present Illness

A 28-year-old woman who underwent allogeneic hematopoietic stem cell transplant (HSCT) 35 days ago for acute myeloid leukemia presents with a progressive rash, profuse watery diarrhea, and yellowing of her skin. The rash began 5 days ago as erythema on her palms and soles, then spread to her trunk and extremities. Over the past 3 days, she has developed watery diarrhea (10-12 episodes daily, approximately 2 liters/day) with crampy abdominal pain. She also notes decreased appetite, nausea, and dark urine.

Transplant Details

  • Indication: AML in first complete remission
  • Donor: Matched unrelated donor (10/10 HLA match)
  • Conditioning: Myeloablative (busulfan/cyclophosphamide)
  • GVHD prophylaxis: Tacrolimus and methotrexate
  • Engraftment: Day +16 (neutrophils), Day +22 (platelets)

Physical Examination

  • General: Ill-appearing woman with obvious jaundice
  • Vital Signs: T 38.2C, HR 105, RR 18, BP 100/65
  • Skin: Diffuse maculopapular erythematous rash involving >50% BSA; palms and soles affected; no bullae or desquamation
  • HEENT: Icteric sclerae; dry mucous membranes; no oral lesions
  • Abdomen: Mildly distended; diffuse tenderness; hyperactive bowel sounds
  • Extremities: No edema

Laboratory Workup

TestResultReference Range
WBC4,200/uL4,500-11,000/uL
ANC2,100/uL1,500-8,000/uL
Hemoglobin9.8 g/dL12-16 g/dL
Platelets65,000/uL150,000-400,000/uL
Total bilirubin8.5 mg/dL0.1-1.2 mg/dL
Direct bilirubin6.2 mg/dL0-0.3 mg/dL
AST185 U/L10-40 U/L
ALT210 U/L7-56 U/L
Alkaline phosphatase520 U/L44-147 U/L
Albumin2.8 g/dL3.5-5.0 g/dL
Stool studiesC. diff negative; cultures negativeNegative

Skin Biopsy

Interface dermatitis with scattered apoptotic keratinocytes; lymphocytic infiltrate at dermoepidermal junction

Diagnosis

Acute Graft-Versus-Host Disease (Grade III) involving skin, liver, and gastrointestinal tract

Discussion

GVHD occurs when donor T cells attack recipient tissues. Three requirements (Billingham criteria):

  1. Graft contains immunocompetent cells (donor T cells)
  2. Recipient expresses antigens foreign to donor (histocompatibility differences)
  3. Recipient cannot reject donor cells (immunocompromised)

Acute GVHD target organs and staging:

StageSkinLiver (Bilirubin)GI (Diarrhea)
1<25% BSA2-3 mg/dL500-1000 mL/day
225-50% BSA3.1-6 mg/dL1000-1500 mL/day
3>50% BSA6.1-15 mg/dL>1500 mL/day
4Bullae, desquamation>15 mg/dLSevere pain, ileus

Overall grade:

GradeStaging
ISkin 1-2, no liver/GI
IISkin 1-3, liver/GI 1
IIISkin 2-3, liver/GI 2-3
IVSkin/liver/GI 2-4 with severe organ involvement

This patient's staging:

  • Skin: Stage 3 (>50% BSA)
  • Liver: Stage 3 (bilirubin 8.5 mg/dL)
  • GI: Stage 3 (~2L/day diarrhea)
  • Overall: Grade III acute GVHD

Pathology findings:

  • Skin: Interface dermatitis, satellite cell necrosis (apoptotic keratinocytes)
  • Liver: Bile duct destruction, cholestasis
  • GI: Crypt cell apoptosis, mucosal denudation

Treatment

  1. First-line: High-dose corticosteroids (methylprednisolone 2 mg/kg/day)
  2. Supportive care:
  • IV fluids and electrolyte replacement (for diarrhea)
  • Nutritional support (may need TPN)
  • Ursodiol for cholestasis
  • Infection prophylaxis
  1. If steroid-refractory (no response by day 7):
  • Ruxolitinib (JAK inhibitor) - FDA approved for steroid-refractory acute GVHD
  • Other options: ATG, extracorporeal photopheresis
  1. Continue tacrolimus prophylaxis
  2. Monitor for infections: Severely immunocompromised

Prognosis: Grade III acute GVHD has significant mortality (50-70%); early treatment improves outcomes

Graft-versus-leukemia effect: Donor T cells also target residual leukemia cells, reducing relapse risk. Complete GVHD suppression may increase leukemia relapse.


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