LATE ONSET, FATAL GRAFT VS. HOST DISEASE IN A LIVER TRANSPLANT RECIPIENT

Abstract

A178 Case Report: A 52 year old Hispanic male received a liver transplant for end stage liver disease due to alcoholic cirrhosis. His post transplant course was unremarkable until about eight months after transplant when he presented with severe neutropenia, infections and diarrhea. He was diagnosed to have several infections secondary to bone marrow aplasia. The possible differential diagnosis of graft vs. host disease (GvHD) was not initially considered because that had not been reported to occur so long after transplant. However, he did not respond to therapy and subsequent testing of his peripheral blood and bone marrow revealed that graft vs. host disease was certainly the cause of his aplasia. Using PCR analysis of 11 Single Tandem Repeat (STR) locus alleles present in stored samples collected from the patient and donor prior to transplant, the patient’s then current peripheral blood mononuclear cells were (only) approximately 4% of recipient origin. His bone marrow sample could not be separated into cell fractions because it was so acellular but the total nucleated cell population was 30% of donor origin. The high proportion of recipient cells in the bone marrow sample could reflect the inclusion of non-hematopoietic cells in the sample tested. The patient was treated with OKT3 to try to eliminate the donor lymphocytes and was quickly scheduled to receive a stem cell transplant from an HLA identical brother but he succumbed to his overwhelming fungemia. Comments: This patient did not have any of the risk factors for GvHD that have previously been described. He was relatively young and shared only a single major HLA antigen with his liver donor: HLA-B35. He was mismatched not only for both HLA-A types but also for one HLA-B type, one HLA-C type, both DRB1 types, DR52 (vs. the patient’s DR53) and one DQ type. This case should serve to remind clinicians to consider the possibility of GvHD for any post-transplant patient who presents with aplasia at any time after transplant. The long-term survival of donor stem cells has been well documented in many solid organ transplant recipients, and the factors that can initiate a GvHD response are certainly not well known. A more timely allogeneic stem cell transplant could then be considered. Storage of patient and donor samples collected at the time of transplant to facilitate making this diagnosis post transplant is highly recommended.