SESSION TYPE: Pleural Cases II
PRESENTED ON: Wednesday, October 24, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Chronic graft-versus-host disease (cGVHD) is a well-known complication following allogeneic hematopoietic stem cell transplantation (HSCT) that varies in time of onset, clinical course and organ involvement. The most commonly effected organ systems are the skin, mucous membranes, liver and eyes. We report a rare case of polyserositis secondary to cGVHD presenting with dyspnea on exertion, pericardial effusion and large bilateral pleural effusions that resolved following the institution of systemic steroids.
CASE PRESENTATION: A 30-year-old male with pre-B-cell acute lymphoblastic leukemia, status post allogeneic HSCT who had been doing well until 6 months after transplant when he developed an erythematous rash. Shortly thereafter, the patient presented with increasing dyspnea on exertion and peripheral edema, unresponsive to diuretic therapy. Computed tomography of the chest revealed large bilateral pleural effusions without parenchymal abnormalities, and a significant pericardial effusion. Transthoracic echocardiogram confirmed the pericardial effusion and noted mild hemodynamic compromise with preserved ejection fraction. The patient underwent thoracentesis, consistent with transudative effusion. Pleural fluid contained 48% lymphocytes and cytology was consistent with reactive T lymphocytes without evidence of malignancy by cytology and immunostaining. Viral infection and nephrotic syndrome were excluded as other etiologies of serositis. The patient was started on prednisone with gradual, almost complete resolution of pleural and pericaridal effusions.
DISCUSSION: Chronic GVHD is one of the most common problems affecting patients surviving allogeneic HSCT. It is the leading cause of non-relapse mortality in patients surviving more than 2 years after allogeneic HSCT. cGVHD can also impact functional status and quality of life. Development of serositis as a clinical manifestation of cGVHD has been reported but not well described. The pleural fluid is typically transudative as in this case. Pericardial involvement has been reported; however only one retrospective study has been done which showed the incidence of large pericardial effusion to be less than 1%.
CONCLUSIONS: Polyserositis as a complication of cGVHD should be considered in patients post-HSCT presenting with dyspnea on exertion. Presence of pleural effusions should prompt an evaluation for other locations of serositis particularly pericardial effusions which may be massive and result in hemodynamic compromise. Early recognition and treatment with immunosuppressive therapy may prevent further morbidity and mortality.
1) Lee, SJ et al. 2003; Chronic Graft-versus-Host Disease. Biology of Blood and Marrow Transplantation 9: 215-233.
2) Norkin, M et al. 2011; Large pericardial effusion as a complication in adults undergoing SCT. Bone Marrow Transplantation 46: 1353-1356
DISCLOSURE: The following authors have nothing to disclose: Jessica Boehmler, Kristin Miller, Harold Chung
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