Acute graft-versus-host disease following hematopoietic stem-cell transplantation

Hematopoietic stem-cell transplantation has become the standard of care for numerous malignant and nonmalignant conditions. As the number of stem-cell transplants performed worldwide rises, it is imperative that dermatologists taking care of these patients are able to understand the methods of transplantation, as well as to recognize and treat the cutaneous complications that commonly follow transplant, particularly acute graft-versus-host disease.     

皮肤移植物抗宿主病

移植物抗宿主病（graft-versus-host disease, GVHD）是异基因造血干细胞移植（allogeneic hemapoietic stem cell transplantation, allo-HSCT）包括骨髓移植、外周血移植、脐带血移植等的主要并发症。少数实质器官移植也可能产生GVHD,如肝移植、小肠移植等。皮肤是GVHD最易受累且最易发现的器官,对全身其他器官的排异反应有重要的预警作用……     

Cutaneous graft-versus-host disease

Although stem cell transplantation is a life-saving measure and the treatment of choice for many patients with various hematologic malignancies, a high incidence of complications and a transplantation associated mortality of about 30% are to be expected.Graft-versus-Host Disease (GvHD) is the major cause of morbidity and mortality after stem cell transplantation. GvHD can arise at various time points. Acute GvHD occurs during the first 100 days after transplantation in up to 50% of graft recipients, while chronic GvHD develops in about 30-50% usually within 100-500 days following allogeneic stem cell transplantation. It can involve the skin, liver, gastrointestinal tract, and less frequently the lungs, eyes and neuromuscular system. Early diagnosis of GvHD can be difficult, as drug reactions, viral infections and cutaneous reactions to radiation therapy may have clinical and histological similarities. In this review, the various cutaneous manifestations of GvHD, the histopathologic features, prophylaxis and therapy of acute and chronic GvHD are discussed in light of the recent literature.     

Acute follicular graft-vs-host reaction. A distinct clinicopathologic presentation

Human graft-vs-host disease (GVHD) is a life-threatening complication that may occur following allogeneic bone marrow transplantation. In acute GVHD, skin involvement is frequent, and the skin is often the initial organ involved. The rash typically is a blanchable, erythematous macular eruption. We present the first report of follicular cutaneous GVHD. Three patients developed follicular papules simulating bacterial or fungal folliculitis as a major clinical expression of cutaneous involvement in acute GVHD following allogeneic bone marrow transplantation. In each case, histopathologic examination demonstrated features of acute graft-vs-host reaction involving hair follicles. This suggests that follicular epithelium may be an early target in acute GVHD.     

Atypical acute graft-versus-host disease

Acute graft-versus-host disease (GVHD) is a life-threatening complication of allogeneic bone marrow transplantation. It is important to recognize the dermatologic manifestations of acute GVHD, as skin is often the initial organ of involvement. We present a case of acute GVHD characterized by rare clinical and histopathologic findings as only two erythematous nodules clinically and abrupt follicular wall necrosis histopathologically.     

Sclerodermatous chronic graft-versus-host disease. Analysis of seven cases.

BACKGROUND: Sclerodermatous chronic graft-versus-host disease is a disabling complication after allogeneic bone marrow transplantation from HLA-identical sibling donors. Only a few series of patients have been reported and the dermatologic features have never been extensively described. OBJECTIVE: The purpose of the study was to describe clinical and biologic features of chronic sclerodermatous graft-versus-host disease and to compare them with scleroderma. METHODS: We reviewed 196 patients grafted between April 1973 and July 1987 with survival times sufficient to be at risk of chronic graft-versus-host disease. Seven had the sclerodermatous form. RESULTS: Most patients had disseminated sclerosis of the trunk and the proximal portions of the limbs. In two cases, atrophy of the skin was predominant, corresponding with a severe clinical evolution. Periorbital pigmentation was observed as an initial manifestation in three cases. Visceral manifestations resembled those observed in scleroderma but histologic and immunologic studies demonstrated clear differences. Response to therapy was variable. CONCLUSION: Chronic sclerodermatous graft-versus-host disease may realize two different patterns. Major atrophy is associated with a more severe progression.     

Graft-versus-host disease: part II. Management of cutaneous graft-versus-host disease

Dermatologists are ideally suited to manage the various cutaneous sequelae of graft-versus-host disease (GVHD) outlined in part I of this review. However, the complexity of the patient with GVHD, including comorbidities, potential drug interactions related to polypharmacy, and the lack of evidence-based treatment guidelines, are significant challenges to optimizing patient care. In this section, we will provide an outline for the role of the dermatologist in a multispecialty approach to caring for patients with GVHD.     

Many faces of graft-versus-host disease

Allogeneic haematopoietic stem cell transplantation is increasingly used in the treatment of malignant and non-malignant disorders. Despite ongoing advances in the field, morbidity and mortality related to graft- versus -host disease remains a major barrier to its application. Graft- versus -host disease is a difficult-to-diagnose disease. Dermatologists are involved due to its diverse cutaneous expression. In order to appropriately diagnose, classify and treat this complex disease, knowledge of its expanding cutaneous expression is required. This review provides a synopsis of the clinical manifestations of acute, lichenoid and sclerodermatous phases of graft- versus -host disease with a look at the current evidence surrounding its differential diagnosis.     

Immunopathology of cutaneous graft-versus-host disease

Graft-versus-host disease (GVHD) occurs when lymphoid cells from an immunocompetent donor are introduced into a histoincompatible recipient that is incapable of rejecting them. GVHD is seen most commonly as a complication of therapeutic bone marrow transplantation, and the skin is a primary target organ. As GVHD mimics several important skin diseases both clinically and histologically, it provides a useful model for studying the immunopathologic features of epidermal cell-lymphocyte interactions.     

Graft-versus-host disease: part I. Pathogenesis and clinical manifestations of graft-versus-host disease

Approximately 25,000 allogeneic hematopoietic cell transplants are performed worldwide each year for a variety of malignant and non-malignant conditions. Graft-versus-host disease represents one of the most frequent complications and is a major source of long-term morbidity and mortality. Whereas acute graft-versus-host disease is induced by recognition of host tissues as foreign by immunocompetent donor cells, the pathogenesis of chronic graft-versus-host disease is not as well understood, and continues to be a major treatment challenge. Part I of this two-part series reviews the epidemiologic factors, classification, pathogenesis, and clinical manifestations of acute and chronic graft-versus-host disease. Part II discusses the topical, physical, and systemic treatment options available to patients with graft-versus-host disease.     

Cutaneous manifestations of chronic graft-versus-host disease

Graft-versus-host disease (GVHD) occurs in a number of clinical settings. It is well recognized after bone marrow transplantation, an increasingly used therapeutic option for haematologicl disorders. Chronic GVHD, occurring at an interval greater than 100 days post-transplant, has many systemic manifestations, but it is the cutaneous manifestations which are most frequent and often most troubling to the patient In this review article, the wide spectrum of cutaneous chronic GVHD (including involvement of hair, nails and mucosae), and its complications and associations are discussed. The clinical and histological features and management guidelines are presented to assist the dermatologist with diagnosis and treatment of this condition.     

The changing face of graft-versus-host disease

Despite advances in the procedure and posttransplantation immunosuppressive therapy, more than half of allogeneic hematopoietic stem cell transplant (HSCT) recipients develop graft-versus-host disease (GVHD), which remains a major cause of morbidity and mortality. Modern HSCT protocols have resulted in substantial alterations in the timing and relative incidences of acute and chronic GVHD, making traditional classification schemes obsolete. This article reviews major changes in HSCT during the past decade, evolving concepts of acute and chronic GVHD (including new diagnostic criteria) and the expanding spectrum of cutaneous GVHD. It focuses on observations that have led to a better delineation of the full constellation of skin findings in chronic cutaneous GVHD, including lichen sclerosus, morpheaform lesions, and eosinophilic fasciitis. Recent insights into pathogenesis of GVHD, lessons from GVHD arising in settings outside HSCT, and therapeutic advances also are highlighted.     

慢性移植物抗宿主病1例

1临床资料患者,女,26岁。1年半前因患"急性粒细胞性白血病"而接受其姐为供体的"同种异体骨髓造血干细胞移植术"。术后一直连续口服"环孢素A"和"泼尼松"抗排异治疗,未发生急性排斥反应。半年前于腰、腹、四肢、腋下及双腘窝出现红褐色丘疹,近2