A 53-Year-Old Man With Steroid-Refractory Acute Graft-Versus-Host Disease

Case: A 53-Year-Old Man With Steroid-Refractory Acute Graft-Versus-Host Disease

Initial presentation

• A 53-year-old man presents on day +40 for a routine follow-up visit after matched donor peripheral blood stem cell transplant. He complains of a new rash, abdominal pain and ‘countless’ loose stools every day for the last 4 days
• PMH: unremarkable
• PE: Rash noted on arms and upper trunk (~45% BSA); diarrhea was quantified to about 1100 cc/day
  
  

Clinical workup

• Labs: total bilirubin 2.6 mg/dl, AST 60 U/L, ALT 75 U/L, Hb 9.8 g/dl
• Negative for HBV, HBV, CMV, EBV, HHV-6
• Stool testing negative for bacterial/viral infection
• Skin biopsy of the rash showed exocytosed lymphocytes, and dyskeratotic epidermal keratinocytes with follicular involvement
• Colonoscopy with biopsy showed numerous apoptotic bodies in the crypt epithelium
• He was diagnosed with acute GVHD:
  • Skin stage 2
  • GI stage 2
  • Liver stage 1
  • Modified Glucksberg Criteria: grade II; MAGIC Criteria: grade II
• ECOG 1
  
  

Treatment

• Initiated methylprednisolone 1.0 mg/kg and topical steroids
• There was minimal response to treatment after 2 days, dose was increased to 2.0 mg/kg/day
• Continued on systemic steroids for 5 more days; rash subsided minimally
• He was started on ruxolitinib 5 mg PO BID, tolerated well; increased to 10 mg PO BID at day 3