title: Clinicopathological Findings of Chronic Rejection in a Face Grafted Patient.
abstract: BACKGROUND
  Skin chronic rejection (CR) in vascularized composite allotransplantation has not been included in the Banff classification yet. We report a face-transplant patient who developed cutaneous clinicopathologic changes suggestive of CR.
  
  
  METHODS
  The recipient was a 27-year-old man with severe disfigurement of the lower face due to a pyrotechnic explosion. He received a facial allograft, including mandible, cheeks, lips, and chin, in November 2009. Immunosuppression included antithymocyte globulins and bone-marrow infusion then steroids, tacrolimus, and mycophenolate mofetil.
  
  
  RESULTS
  During the first posttransplant year the acute rejection episodes were characterized by reversible oedema and erythema of the graft. Subsequently, the patient developed primary asymptomatic Epstein-Barr virus (EBV) infection, followed by EBV+ B-cell lymphoma and hepatic EBV-associated posttransplant smooth muscle tumors; therefore, the immunosuppressive treatment was greatly reduced. Since the second posttransplant year, the allografted facial skin became progressively sclerotic and presented pigmented macules on a background of hypopigmentation and teleangiectasias, resulting in a poikilodermatous aspect. Skin biopsies showed epidermal atrophy, basal cell vacuolization, and diffuse dermal sclerosis in the absence of significant dermal cell infiltration. The dermal capillaries showed thickened walls and narrowed lumina, whereas the large vessels did not show significant alterations. Neither donor-specific antibodies nor vascular Cd4 deposits were detected.A dysfunction of the graft functions occurred. It was evidenced by a decrease in mouth opening and modification of some phonemes although lip closure was still possible allowing food intake.
  
  
  CONCLUSIONS
  This is the first report suggestive of CR in a face allotransplantation after immunosuppression minimization.
authors.affiliation: 1 Department of Transplantation, Hopital Edouard Herriot, HCL, Lyon, France. 2 Department of Surgery, University of Cagliari, Cagliari, Italy. 3 Department of Dermatology, Hopital Edouard Herriot, Lyon, France. 4 Service de Chirurgie Maxillofaciale et Stomatologie, CHU-Nord, Amiens, France. 5 Department of Radiology, Hopital Edouard Herriot, Lyon, France. 6 Université de Lyon, INSERM U1111, Lyon, France.
authors.forename: Palmina
authors.initials: P
authors.lastname: Petruzzo
authors.forename: Jean
authors.initials: J
authors.lastname: Kanitakis
authors.forename: Sylvie
authors.initials: S
authors.lastname: Testelin
authors.forename: Jean-Baptiste
authors.initials: JB
authors.lastname: Pialat
authors.forename: Fanny
authors.initials: F
authors.lastname: Buron
authors.forename: Lionel
authors.initials: L
authors.lastname: Badet
authors.forename: Olivier
authors.initials: O
authors.lastname: Thaunat
authors.forename: Bernard
authors.initials: B
authors.lastname: Devauchelle
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Morelon
mesh_terms: D000328:Adult; D064591:Allografts; D001706:Biopsy; D002908:Chronic Disease; D054445:Facial Transplantation / Q000379:methods*; D006084:Graft Rejection / Q000188:drug therapy / Q000473:pathology*; D006085:Graft Survival; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D008297:Male
chemical_list: D007166:Immunosuppressive Agents