S2765 Autologous Graft vs Host Disease: An Unusual and Unexpected Cause of Bowel Obstruction

Abstract

INTRODUCTION: Autologous-graft versus host disease (auto-GVHD) is an extremely rare entity comprising only 0.9% of cases of lymphoma patients undergoing autologous hematopoietic stem cell transplantation (HSCT). Although very uncommon, it can lead to serious complications including abdominal pain, rectal bleeding, and profuse diarrhea. We present a very rare case of auto-GVHD leading to small bowel obstruction. CASE DESCRIPTION/METHODS: A 39 year-old man with history of large B cell lymphoma underwent autologous-HSCT after treatment with R-CHOP and cyclophosphamide plus dexamethasone following a relapse. Days later developed fever, nausea, vomiting, abdominal pain and diarrhea. Laboratories showed leukopenia, thrombocytopenia, elevated liver enzymes and bilirubin. Tests for infectious diarrhea were negative. Colonoscopy showed elevated whitish lesions and diffuse loss of vascular pattern up to mid transverse and biopsies revealed marked crypt loss, regenerative atypia with rare apoptotic bodies. A diagnosis of auto-GVHD was entertained. Steroids were started and tapered off after clinical improvement. Months later there was worsening of symptoms associated with distended and tender abdomen with diminished bowel sounds. Abdominal CT scan showed ileal inflammation associated with small bowel dilatation. Colonoscopy showed a stricture at ileum with associated friable mucosa. Biopsy revealed chronic active ileitis and necrotic purulent material with associated ulcer, negative for CMV. Resection of ileal segment was performed and steroids given for 6 weeks. DISCUSSION: The differential diagnosis included auto-GVHD, lymphoma recurrence and Crohn's disease (CD). Lymphoma was unlikely given negative immunohistochemistry and PET scan. No classic endoscopic or histologic features of CD were observed. This led to a diagnosis of GVHD, a multisystem disorder that commonly complicates allogeneic-HSCT but is exceedingly rare in autologous-HSCT. The pathophysiology is unknown and establishing the diagnosis is a challenging task. The clinical presentation of Auto-GVHD is similar to allogeneic GVHD, with the skin, gastrointestinal tract and liver the principal target organs. It commonly begins with a maculopapular rash, diarrhea, hematochezia, abdominal pain, vomiting, and elevated liver tests. The diagnosis of auto-GVHD can be made on the basis of ongoing GI symptoms, endoscopic evidence of mucosal abnormalities, and histological findings of apoptotic epithelial cells or crypt cell dropout with lymphocytic infiltrate.Figure 1.: Elevated whitish lesions, loss of vascular pattern diffusely.Figure 2.: Glandular apoptosis and crypt cell drop out.