Graft Versus Host Disease after Liver Transplant

Abstract

Purpose: Graft versus host disease (GVHD) is most commonly seen after allogenic bone marrow transplantation. We present a rare case of GVHD occurring after liver transplantation. Methods: A 66-year-old man with non-alcoholic fatty liver disease presented with fever and dysuria one month after undergoing an orthotopic liver transplant (OLT). He was treated with levofloxacin for a presumed urinary tract infection, but continued to have fevers. Subsequently, the patient developed pancytopenia, with a WBC of 1.24 × 103/mcL, hemoglobin of 8.3 g/dL, and platelet count of 19 × 103/mcL. Two days after admission, he developed a generalized erythematous to violaceous macular skin eruption on his back and lower extremities. Punch biopsy of the skin lesions demonstrated lymphocytic infiltrates and basal epidermal cell vacuolization consistent with GVHD. He received high-dose steroids followed by three doses of basiliximab (20 mg) and one dose of daclizumab (16.5 mg). Antimicrobial prophylaxis was initiated with voriconazole, acyclovir, aztreonam, and daptomycin. G-CSF was administered for neutropenia. Results: The patient's fever, rash, and diarrhea transiently improved, though he remained pancytopenic. Despite antimicrobial prophylaxis, the patient developed an influenza pneumonia requiring intubation. Oseltamivir was initiated but he subsequently suffered a cardiopulmonary arrest and expired. Conclusion: The incidence of GVHD after OLT is estimated to be 1–2% based on case series, but the mortality is quite high at 85%. GVHD in this population is thought to occur when 109–10 donor lymphocytes within the liver graft successfully mount an attack before the recipient is able to reject the organ. Diagnosis of GVHD can often be made on biopsy of affected organs (skin, GI tract, bone marrow), but if biopsy is non-specific, HLA typing can be performed for confirmation. Risk factors for the development of GVHD after OLT are not well elucidated, but may include closely matched HLA status, older age of the recipient, and relative immunodeficiency of the recipient. Treatment protocols have not been standardized, but have included modification of immunosuppression, corticosteroids, anti-lymphocyte agents, and interleukin-2 antibodies. As most patients succumb to death from sepsis, prevention of infection with antimicrobial prophylaxis is of the utmost importance. Clinicians should be aware that GVHD is a rare but serious complication of OLT. Every attempt should be made to diagnose and treat promptly when symptoms arise.