title: Graft-versus-host disease presenting with pancytopenia after en bloc multiorgan transplantation: case report and literature review.
abstract: Graft-versus-host disease (GVHD) is a dreaded complication of bone marrow and solid organ transplantation. Commonly affected organs include skin, liver, and the gastrointestinal tract, with bone marrow and renal involvement occurring more rarely. GVHD is less commonly seen with solid organ transplants. Fewer than 100 cases of GVHD have been reported in the literature following liver transplantation. We report a case of a 53-year-old woman who required a multiorgan transplant after a complicated postoperative course following paraduodenal hernia repair. She developed isolated pancytopenia approximately 4 months after receiving an en bloc transplant involving the liver, kidney, small bowel, and pancreas. No evidence of skin, gastrointestinal, or hepatic involvement was discovered. HLA typing of the peripheral blood revealed that 28% of patient peripheral blood was composed of donor lymphocytes. Bone marrow biopsy showed a markedly hypocellular marrow with 23% donor lymphocytes and 80% of the T-cell population from the donor as well. The patient began treatment for GVHD, including high-dose steroids, basiliximab, and rituximab. Unfortunately, she developed overwhelming sepsis and subsequently died. This case describes an instance of GVHD manifested by isolated pancytopenia after en bloc transplantation of multiple solid organs. GVHD is a rare, but serious complication of solid organ transplantation that can result in death. Although isolated bone marrow involvement is uncommon, it must be considered early to avoid a delay in diagnosis. This case also highlights an association of GVHD with multiorgan transplants, although this is incompletely characterized in the current literature.
authors.affiliation: Department of Internal Medicine, UCSF Medical Center, 505 Parnassus, M987, San Francisco, CA 94143, USA. rayamawad@gmail.com
authors.forename: R
authors.initials: R
authors.lastname: Mawad
authors.forename: A
authors.initials: A
authors.lastname: Hsieh
authors.forename: L
authors.initials: L
authors.lastname: Damon
mesh_terms: D004617:Embolism / Q000473:pathology; D005260:Female; D006086:Graft vs Host Disease / Q000175:diagnosis* / Q000453:epidemiology; D006554:Hernia, Umbilical / Q000601:surgery*; D006650:Histocompatibility Testing; D006801:Humans; D007583:Jejunum / Q000473:pathology / Q000601:surgery; D016030:Kidney Transplantation / Q000009:adverse effects* / Q000276:immunology; D016031:Liver Transplantation / Q000009:adverse effects* / Q000276:immunology; D008875:Middle Aged; D010198:Pancytopenia / Q000209:etiology*; D019168:Portasystemic Shunt, Transjugular Intrahepatic; D011183:Postoperative Complications / Q000601:surgery; D012307:Risk Factors; D013601:T-Lymphocytes / Q000276:immunology / Q000473:pathology; D013921:Thrombocytopenia / Q000209:etiology; D014471:Umbilical Veins / Q000473:pathology