Cardiothoracic Surgery: Student/Resident Case Report Poster - Cardiac and Thoracic Surgery II |

Chimerism Gone Awry: A Rare Case of Pulmonary Allograft vs Host Disease FREE TO VIEW

David Dai, MD; Bryan Garber, MD; Stephen Weigt, MD; Scott Worswick, MD; David Sayah, MD
Author and Funding Information

UCLA, Los Angeles, CA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):67A. doi:10.1016/j.chest.2016.08.074
Text Size: A A A
Published online

SESSION TITLE: Student/Resident Case Report Poster - Cardiac and Thoracic Surgery II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Graft versus host disease (GVHD) is an uncommon phenomenon among solid organ transplant recipients. GVHD after lung transplant is particularly rare and is associated with poor outcomes, with mortality rates in the literature nearing 100%.1

CASE PRESENTATION: A 52 year old woman with RA-ILD, post bilateral lung transplant 6 weeks prior to admission, presented with fever. Because of extensive pre-transplant allosensitization, including donor-specific anti-HLA antibodies and a positive pre-transplant flow cross-match, her immediate post-transplant treatment had included antithymocyte globulin, plasmapheresis, IVIG and rituximab. On admission, an extensive evaluation revealed no evidence of infection or allograft rejection. She developed an erythematous maculopapular rash, predominantly on the palms, soles, flanks and abdomen. Skin biopsy showed interface dermatitis with peri-vascular and interstitial inflammation and rare eosinophils. She developed a transaminitis and hyperbilirubinemia with total bilirubin peaking at 17 mg/dl. Liver biopsy revealed patchy non-zonal hepatocellular necrosis with focal bile duct injury, no cholestasis or portal inflammation. A peripheral blood chimerism study demonstrated that 58% of her circulating lymphocytes were donor-derived. She was diagnosed with acute GVHD with skin and liver involvement. High dose corticosteroid therapy was initiated with resolution of her symptoms and biochemical abnormalities.

DISCUSSION: The pathophysiology of GVHD involves allorecognition by passenger T-lymphocytes from the allograft, leading to activation of these cells which then injure recipient tissues, often with skin, marrow or GI involvement.2 A chimeric state between recipient and donor leukocytes has been postulated to maintain a delicate homeostatic balance; if donor cells dominate, then GVHD develops.3 In our patient, we hypothesize that aggressive immunosuppression around the time of transplantation allowed the persistence of passenger lymphocytes and subsequent development of GVHD. First line therapy for GVHD is immunosuppression with high dose corticosteroids.

CONCLUSIONS: GVHD is an extremely rare and often fatal complication of lung transplantation. Diagnosis is challenging given that the clinical findings often mimic those of more common infectious and pharmacologic complications in the post-transplant period. Palmoplantar involvement of rash can be suggestive of a diagnosis of GVHD, but is not pathognomonic. A chimerism study can aid in identifying a suspected case of GVHD by detecting an elevated percentage of donor lymphocytes.

Reference #1: Pavenski, K., et al. Lung transplantation complicated by GVHD and confounded by incidental transfusion-associated macrochimerism. Transfusion. 2008 Oct;48(10):2190-6.

Reference #2: Triulzi DJ1, et al. Microchimerism, GVHD, and tolerance in solid organ transplantation. Transfusion. 2001 Mar;41(3):419-26.

Reference #3: T.E Starzl et al. Cell migration, chimerism and graft acceptance. Lancet. 1992 Jun 27;339(8809):1579-82.

DISCLOSURE: The following authors have nothing to disclose: David Dai, Bryan Garber, Stephen Weigt, Scott Worswick, David Sayah

No Product/Research Disclosure Information




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543