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Sweat the Small Stuff: The Importance of Clinical-Pathologic Correlation in Cutaneous GVHD Following Orthotopic Liver Transplant

Megan N. Moody, MD, MPH; Natalia Kazakevich, MD; Jeffrey R. Smith, MD, MPH; Jennifer M. Landau, BS; Jaime A. Tschen, MD; Aton Holzer, MD; Leonard H. Goldberg, MD
Arch Dermatol. 2011;147(11):1345-1346. doi:10.1001/archdermatol.2011.331.
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Graft vs host disease (GVHD) is an immunologically mediated disorder. Donor lymphocytes (T cells) from transplanted tissues attack major histocompatibility complex (MHC) antigens on cells of the immunosuppressed recipient.1 Classic targets are rapidly dividing cells of the liver, gastrointestinal tract, skin and bone marrow, giving rise to clinical manifestations of jaundice, diarrhea, dermatitis, and pancytopenia.

Graft vs host disease is seen in only 1% to 2% of orthotopic liver transplant (OLT) cases and has a mortality rate of 85% to 90%, although there are rare reports of spontaneous regression.2 The transplanted liver itself is spared in OLT-associated GVHD because it lacks host antigens and is actually the source of attacking lymphocytes.3 Typical OLT-associated GVHD is acute ( <100 days postoperatively) and often involves the skin.1 The characteristic skin eruption begins on the palms and soles as a maculopapular, red to violaceous eruption that spreads centripetally; it may progress to blisters, resembling toxic epidermal necrolysis in severe cases.1 On the other hand, cutaneous manifestations of chronic GVHD (>100 days postoperatively) are more variable, including psoriasiform, papulosquamous, lichenoid, poikiloderma, or pityriasis-like lesions.1 We report herein a case of post-OLT GVHD.

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Figure 1. Clinical images of our patient. A, Multiple, well-circumscribed, erythematous, hyperkeratotic plaques with overlying scale. B, Confluent, erythematous, hyperkeratotic plaques on the dorsal aspect of the hand with nail involvement.

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Figure 2. Hematoxylin-eosin –stained biopsy specimens from the subject case. A, Epidermis is detached or absent; upper dermis has bandlike mononuclear infiltrate (original magnification ×4). B, Partially necrotic sweat duct with many dyskeratotic epithelial cells (original magnification ×40).

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