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

April 24, 2020

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