A 61-Year-Old Man With Acute Graft-Versus-Host Disease

April 24, 2020
Usama Gergis, MD

Usama Gergis, MD, presents the case of a 61-year old man with GvHD, and provides an overview of available treatment options for similar patients, with consideration of the REACH1, REACH2, and GRAVITAS-301 trial regimens.


Case Overview:

Initial presentation

  • A 61-year old man presented with a generalized pruritic rash, abdominal pain and diarrhea (8-12 BMs/day)
  • PMH: he underwent haploidentical allogeneic hematopoietic-cell transplantation for AML 40 days ago
  • PE: maculopapular erythematous rash on bilateral palms, cheeks, ears and upper back (rash involvement >50% of skin); abdomen is tender to palpation diffusely

Clinical workup

  • Labs: ANC 0.7 x 109/L, plt 75 x 109/L, total bilirubin 8 mg/dl, AST 54 U/L, ALT 60 U/L
    • Negative for HBV, HBV, CMV, EBV, HHV-6
  • Negative stool tests
  • Flexible sigmoidoscopy with biopsy:
    • Lower GI biopsy showed moderate mixed inflammation in the lamina propria and scattered apoptotic bodies without crypt loss
  • Skin punch biopsy of the back shows hyperkeratosis, hypergranulosis associated with lichenoid inflammatory infiltrate
  • Modified Glucksberg criteria: grade 3; MAGIC criteria: grade III

Treatment

  • Systemic corticosteroids (prednisone 2 mg/kg/day) + topical steroids (triamcinolone)
    • No treatment response after day 5
  • He was started on ruxolitinib 5 mg PO BID, increased to 10 mg PO BID on day 6