3. An enigmatic case of undiagnosed severe diarrhoea post living donor liver transplant

Abstract

Background and Aims: Graft versus Host Disease (GVHD) after orthotopic liver transplant (OLT), although rare, carries >80% mortality. Early diagnosis, prompt treatment, and aggressive supportive care are imperative to potentially reverse this otherwise fatal ailment. We describe a case of recurrent severe diarrhoea post living donor OLT who was diagnosed with acute GVHD. Case Summary: A 56 year old lady underwent an uneventful (swap) living donor OLT for Hepatitis C related chronic liver disease with multifocal hepatocellular carcinoma. Initial immunosuppression consisted of tacrolimus, mycophenolate mofetil and prednisolone. At ten weeks post- transplantation, sirolimus was introduced and Tacrolimus tapered gradually. At 78 and 84 weeks post-transplantation she had two episodes of acute cellular rejection treated with pulse methylprednisolone therapy. She developed profuse watery painless diarrhoea with significant nocturnal symptoms at 90 weeks post-transplantation, for which she was admitted on several occasions. Multiple stool examinations were bland (no pus cells, red blood cells, mucus, ova and cysts), negative for cryptosporidium and clostridium difficile (antigen + toxin) and there was no Cytomegalovirus viremia. Laboratory parameters revealed mild anemia, thrombocytopenia, hypoalbuminemia and transaminitis. Celiac serology was negative. Every time her symptoms settled with intravenous fluids and antibiotics, only to recur within few days. An upper gastrointestinal endoscopy and duodenal biopsy was normal. Random normal appearing terminal ileum and colonic mucosal biopsies revealed mild active GVHD. Lamina propria showed mild chronic inflammatory cell infiltrate along with lymphoid aggregates. Few crypts demonstrated apoptosis (Fig. 1). There were no crypt dropouts, cryptitis or crypt abscesses (GVHD grade I). She was started on oral budesonide therapy. Her symptoms responded briskly and diarrhoea subsided. At six months follow-up, she was completely asymptomatic. Conclusions: This is the first case of GVHD with isolated gastrointestinal manifestations post OLT to be reported from India and treated successfully with oral budesonide. The authors have none to declare.