SHM Converge Scientific Abstract ePoster Gallery-Once in a Blue...liver? A Rare Case of Delayed Graft Versus Host Disease After Liver Transplant

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This case describes a rare, fatal episode of graft-versus-host disease (GVHD) occurring three years after orthotopic liver transplantation for cirrhosis due to nonalcoholic fatty liver disease. The 41-year-old woman initially presented with three months of diarrhea and odynophagia, followed by one week of fevers. Her evaluation showed new leukopenia, but extensive infectious testing, CT imaging, and liver Doppler studies were unrevealing.<br /><br />During hospitalization, she developed classic GVHD features including glossitis, mucositis, and a painful erythematous rash involving the trunk and palms. Skin biopsy showed vacuolar interface changes and keratinocyte degeneration, while sigmoid colon biopsy demonstrated crypt apoptotic activity and immune cell depletion. Viral stains were negative, and the pathology was consistent with GVHD. Despite high-dose steroids and broad-spectrum antimicrobials, she worsened and died of multiorgan failure and sepsis.<br /><br />The report emphasizes that GVHD is a rare but highly lethal complication of solid organ transplantation, with mortality greater than 80%. It most commonly presents with fever, pancytopenia or leukopenia, maculopapular rash, mucositis, and diarrhea. Although symptoms usually occur within 2 to 8 weeks after transplant, late-onset cases can occur years later, as in this patient.<br /><br />Diagnosis is based on clinical suspicion supported by histopathology, which typically shows epidermal vacuolar change and keratinocyte apoptosis in skin, and crypt epithelial apoptosis in the intestine. Chimerism testing demonstrating donor lymphocytes in recipient tissues is diagnostic when available. There is no standard treatment; reported approaches include either reducing immunosuppression to encourage recipient immunity or increasing immunosuppression with corticosteroids and other agents to suppress donor immune cells.<br /><br />The key lesson is to consider GVHD in any solid organ transplant recipient with fever, rash, and diarrhea, since early recognition may improve outcomes.

Asset Subtitle

Courtney Mullins

Meta Tag

Author List Alina Iuga, Courtney Mullins, Darryl Kalil, Evan Raff, Sam Wu

Category Clinical Vignettes

Concept Graft-versus-Host Disease

Concept Liver Transplantation

Concept Crypt Epithelial Apoptosis

Concept Organ transplantation

Concept Pancytopenia

Distinguished Non-Finalist

Presenter Organization UNC Hospitals

Presenting Author Courtney Mullins

Track Adult

Keywords

graft-versus-host disease

liver transplantation

solid organ transplant

late-onset GVHD

diarrhea

mucositis

skin biopsy

crypt apoptosis

leukopenia

multiorgan failure

Graft-versus-Host Disease

Liver Transplantation

Crypt Epithelial Apoptosis

Organ transplantation

Pancytopenia