Mild Rejection Episode Evoked by Modification of Immunosuppressive Protocol Observed in a Patient With Forearm Transplantation: Case Report

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Skin is the most immunogenic component of a composite tissue allograft (CTA). Clinicopathologic monitoring of the skin seems to be the most reliable method to detect rejection in CTA patients. The symptoms in cases demonstrating full-blown rejection are clear, contrary to those of just mild rejection. The aim of the study was to present the symptoms of mild rejection observed in a midforearm transplant patient at 20 months postoperative. The 32-year-old man underwent right dominant forearm transplantation at 12 years after a traumatic amputation. During the first 20 months, the course was uneventful, with no signs of impaired function. Immunotherapy at 20 months consisted of: Cellcept (2 g/d), prednisolone (10 mg/d), tacrolimus (7 mg/d; level C 0 of 13 ng/mL), An attempt was made to modify therapy by diminishing the tacrolimus dose to 4 mg/d (C 0-8 ng/mL). After 10 days postimplementation of the new regimen, are hardly visible macullopapular erythematous rash appeared on the palmar and dorsal sides of the hand as well as the skin of the forearm. There was a slight red swelling of the nail bed margins. No deterioration of hand function was observed. The patient was immediately admitted to the hospital; despite unclear clinical and pathomorphological symptoms, we diagnosed a mild rejection (grade I). The therapy consisted of methylprednisolone (500 mg three times daily for 3 consecutive days) and 5 days of topical application of immunosuppressant ointments (tacrolimus and Protopic) with maintenance of the previously applied oral tacrolimus doses. After 5 days of treatment, the symptoms subsided. This approach utilized the advantage of the unique possibility to treat rejection locally, consistent with current awareness that skin is the primary target of hand rejection. However, topical application of immunosuppressants has not been extensively investigated. The manifestations of rejection in CTA patients may be heterogeneous and difficult to diagnose.