Graft-versus-host disease

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Graft-versus-host disease, abbreviated as GVHD, is a rare thingy seen mostly in tertiary care centres. It is a complication of hematopoietic stem cell transplantation.

General

  • Complication of hematopoietic stem cell transplantation, i.e. bone marrow transplantation (BMT).
    • Affects skin, liver (bile ducts), gastrointestinal tract.[1][2]
  • The histology of GVHD in the intestine is the same as rejection in bowel transplantation.[3]

Clinical:

  • May present as diarrhea.
  • Main DDx (clinical): infection.

Microscopic (skin)

Features:[4]

  1. Keratinocyte apoptosis.
  2. Epidermotropic lymphocytic infiltrate = lymphocytes in the epidermis.
  3. Vacuolar degeneration of basal and suprabasal cells in the epidermis.

Grading[4]

  • Grade I: Only vacuolar changes, no apoptosis; not treated.
  • Grade II: Only scattered apoptotic cells.
  • Grade III: Focal separation/cleft formation at the dermal-epidermal junction.
  • Grade IV: Extensive necrosis with degeneration of epidermis.

Notes:

  • Same scheme applies to esophagus... it has the same structure.
  • Originally described in NEJM.[5]

Microscopic (intestine)

Features:[6]

  • Isolated epithelial cell apoptosis - key feature.
  • +/-Crypt destruction (focal or extensive).
  • +/-Loss of epithelium (denudation).

Notes:

  • Neutrophils should not be present.

Images:

Grading[6]

  • Grade 1 = isolated epithelial cell apoptosis.
    • No crypt loss/destruction.
  • Grade 2 = individual crypts are lost/scatter destruction of single crypts.
  • Grade 3 = foci several adjacent crypts lost.
  • Grade 4 = large number of adjacent crypts lost/loss of epithelium.

Notes:

  • Low-grade rejection is a diagnosis that requires a careful examination, i.e. it is subtle.

See also

References

  1. {{cite journal |author=Niino D, Nakashima M, Kondo H, et al. |title=Correlation of donor-derived keratinocytes and severity of graft-versus-host disease (GVHD) in epidermis |journal=Pathol. Res. Pract. |volume=200 |issue=11-12 |pages=775–81 |year=2005 |pmid=15792120 |doi= |url=}
  2. van Dijk AM, Kessler FL, Verdonck LF, et al. (December 2000). "Primary human keratinocytes as targets in predicting acute graft-versus-host disease following HLA-identical bone marrow transplantation". Br. J. Haematol. 111 (3): 791–6. PMID 11122139.
  3. GT. 14 January 2011.
  4. 4.0 4.1 "Acute Graft versus Host Disease of the Skin". http://surgpathcriteria.stanford.edu/transplant/skinacutegvhd/printable.html. Retrieved January 17, 2011.
  5. Thomas ED, Storb R, Clift RA, et al. (April 1975). "Bone-marrow transplantation (second of two parts)". N. Engl. J. Med. 292 (17): 895–902. doi:10.1056/NEJM197504242921706. PMID 235092.
  6. 6.0 6.1 Cogbill CH, Drobyski WR, Komorowski RA (January 2011). "Gastrointestinal pathology of autologous graft-versus-host disease following hematopoietic stem cell transplantation: a clinicopathological study of 17 cases". Mod. Pathol. 24 (1): 117–25. doi:10.1038/modpathol.2010.163. PMID 20953169. http://www.nature.com/modpathol/journal/v24/n1/full/modpathol2010163a.htm.