Patient Case: A 48-Year-Old Man with Chronic GVHD


Dr Chen and Dr Cutler review a clinical case and discuss GVHD assessment for the patient.


Yi-Bin Chen, MD: I’ll move on to the first of our cases here. This was a 48-year-old man who underwent a myeloablative matched unrelated donor peripheral blood stem cell transplant for AML [acute myeloid leukemia]. At that time, he received the combination of tacrolimus and methotrexate for his GVHD [graft-versus-host disease] prevention. His donor was a CMV [cytomegalovirus]-positive, 50-year-old female who had had 3 children in the past. At day 22 in follow up, he presented the clinic with a skin rash diagnosed as acute graft-versus-host disease. He was treated with oral prednisone successfully and then a slow steroid taper afterwards, as we would all expect. A bone marrow biopsy was performed at about 3 months after transplant for restaging and showed continued complete remission and full donor chimerism. He’s seen for follow-up after that.

And then around 6 months post-transplant, he comes into clinic for follow-up. His counts appear normal, consistent with continued remission of AML. But on exam, you notice that he has skin changes with some hyperpigmentation. Approximately half of each arm is showing lichen planus changes. There are some superficial sclerotic features, meaning you can still pinch the skin and it's not high bound on the lower trunk as well as the lower extremities, and this involves about 18% of his body surface area [BSA]. You compute as you examine. You did order pulmonary function tests at that point, and this shows no decrease in his FEV1 [Forced expiratory volume], as well as his DLCO [diffusing capacity of the lungs for carbon monoxide]. So, Corey, you jogged us through the grading of chronic graft-versus-host disease. Can you review? If you’re in clinic and you actually have the time to do this grading for this patient, how would you grade?

Dr Corey S. Cutler. MD, MPH, FRCPC: I think it’s really important that we formally grade these patients and we try to incorporate the grading into our electronic medical record, and we will do that. So you mentioned on the last slide that he had about 18% BSA, so using the rule of 9s, and then this superficial sclerosis. You can still pinch the skin, but there are sclerotic features. That by definition gives him NIH [National Institutes of Health] moderate chronic GVHD because he now has a score of 2 in 1 organ. So that excludes him from being a stage I and automatically makes him a moderate NIH chronic GVHD. I would go through the eyes and the mouth and really probe for symptoms at that time. Make sure there’s nothing else going on. But in the absence of anything else, he meets the definition for NIH moderate chronic GVHD.

Yi-Bin Chen, MD: And just to clarify, you wouldn’t be surprised at all if he met the criteria for ocular and oral chronic at this point also, right?

Dr Corey Cutler, MD, MPH, FRCPC: Correct. Patients might not attribute their symptoms that they might be experiencing to GVHD. So it’s not uncommon for patients to present to their local ophthalmologist and say my eyes are itchy or dry, and not associate that as being a potential complication of transplant. Unless you ask them about their tolerance for spicy or acidic foods, they might not volunteer the information that they’re having trouble eating foods that they used to enjoy.

Transcript edited for clarity.

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Yi-Bin Chen, MD, an expert on GVHD
Yi-Bin Chen, MD, an expert on GVHD
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