Clinical History:

A 15-year-old adolescent underwent bone marrow transplantation for acute lymphocytic leukemia. About a month after transplantation, his pancytopenia was resolving as the marrow showed engraftment, and there was no evidence for recurrent leukemia. However, he developed a fine scaling skin rash, increasing jaundice, and diarrhea.

Image 8.1:

This is a high power light microscopic view of the skin stained with H&E. What is wrong? There is apoptosis (single cell necrosis) of cells in the epidermis, along with a lymphocytic infiltrate in the upper dermis.

Image 8.2:

This is the gross appearance of the skin rash. Note the scaling of the epidermis as white flakes.

Image 8.3:

This is a high power light microscopic view of the liver stained with H&E. What is the yellow-green pigment? This is bile pigment. There is marked cholestasis.

Questions:

1. What is the name of this complication following transplantation?

Graft versus host disease (GVHD). The three major clinical manifestations of this disease are present in this patient.

2. How does this occur?

Donor lymphocytes are attacking host tissues.

3. In what types of transplants does this occur?

First of all, GVHD would NOT occur with autologous transplants (donor tissues come from the host). GVHD is primarily a complication of allogeneic bone marrow transplantation, because the stem cells give rise to lymphocytes that can also engraft. These donor lymphocytes recognize the new host as foreign.