Centering discussion on a patient scenario of acute graft-versus-host disease, participants discuss nuance in disease symptomology and patient education.
Nelson Chao, MD: I’ll start the first case. This is a 50-year-old woman who presented day 42 after matched donor peripheral blood stem cell transplant for AML [acute myeloid leukemia]. She has a new rash, abdominal pain, and loose stools for 3 days. A significant past of medical history. She has a rash in her trunk, which is approximately 35% of body surface area, diarrhea approximately at 800 cc per day. Labs show bilirubin 2.6, AST [aspartate aminotransferase] of 60, ALT [alanine transaminase] of 75, Hb [hemoglobin] at 9.5. She is negative for hepatitis, CMV [cytomegalovirus], EBV [Epstein-Barr virus], and HHV-6 [human herpesvirus 6]. Stool has tested for bacterial or viral infection, which was negative. Biopsy of the skin showed exocytosed lymphocytes and dyskeratotic epidermal keratinocytes with follicular involvement. She did have a colonoscopy as well which showed numerous apoptotic bodies in the crypt epithelium. She was diagnosed with skin stage II, GI [gastrointestinal] stage II, liver stage 1. The modified Glucksberg criteria was grade II. MAGIC criteria was also grade II with an ECOG [Eastern Cooperative Oncology Group] performance status of 1. First question is what do you think of this case, Dr Cutler?
Corey Cutler, MD, MPH, FRCPC: This is a pretty typical presentation of acute graft-versus-host disease [GVHD]. The timing is right. The clinical manifestations are right. Luckily, it is not a severe case just quite yet with early organ stage involvement of delivering the GI tract. This is the type of change that we would, I think, recognize rather clearly given that all 3 cardinal organs are involved. I don’t think we have much trouble making a firm diagnosis in this case.
Nelson Chao, MD: So you think these are pretty immerse practices, these are pretty typical?
Corey Cutler, MD, MPH, FRCPC: Right. The 3 organs that are involved in acute graft-versus-host disease are the skin, the GI tract, and the liver, which are all involved here. The patient has a typical erythematous rash, which is what we generally see in acute graft-versus-host disease. The liver is generally manifested by a rise in bilirubin. Here, the bilirubin is just a little bit above normal, but certainly does qualify as being involved with acute graft-versus-host disease. You didn’t mention that there were drugs that could cause the elevated bilirubin. Similarly, the diarrhea sets with the diarrhea that we see in acute GVHD. We sometimes go ahead and do colonoscopies in cases like this to exclude things like CMV collides or other causes of infection collides. But the triad here is the hallmark of acute graft-versus-host disease.
Nelson Chao, MD: I agree. Ms Minor, how do you counsel patients on these posttransplant issues? Could you give us a sense of the keratin involved before, during, and after transplant, and what each of those rules would be?
Kerry King Minor, MSN, ANP-BC: Yes. We try to start the education with these patients from the very first appointment. After they are deemed to be a transplant candidate, typically the health care provider, nurse practitioner, or PA [physician assistant], along with the nurse coordinator, meets with the patient and starts the conversation about what they could expect posttransplant. We hand them a transplant notebook that has a lot of information listed out and we try our best to go through to some extent, knowing good well that they would not absorb all of that in that appointment. In addition to that, we have a new patient class where our clinical nurse specialist plays a huge role in education and goes through that book in more detail. They counsel them on the potentials of what to expect for acute GVHD. To be monitoring their skin, to be monitoring their stool output, to notify their team with any changes. Again, we have our last appointment, or client appointment you may call it, prior to starting transplant. At that point again it’s drilled in their head, the possibilities of things that they may see and what to be on the lookout for. Then, during the transplant process, they meet with a whole other team of providers that we consider the acute care team that is also made up of a group of advanced practice providers and an attending along with daily care nurses who try to counsel them and assess them every day. They look for changes in skin, discuss the changes in their eating, their intake, their output, and check labs every day. Even when they are being prepared, at approximately day 90-100, and they are getting ready to get back to their community provider and their oncologist at home, they are required to go to a discharge class to again reemphasize all of these things and what to look for as far as the potential signs and symptoms of GVHD. It’s a lot of information to throw in just at once. So its strategically sprinkled throughout their transplant course from their first meetings all the way through to the time when they are discharged back home.
Transcript edited for clarity.