Korean J Hepatobiliary Pancreat Surg.  2016 Feb;20(1):38-43. 10.14701/kjhbps.2016.20.1.38.

Successful salvage treatment of acute graft-versus-host disease after liver transplantation by withdrawal of immunosuppression: a case report

• Qiu W
• Lv GY
• Jiang C
• Zhang P
• Sun XD
• Shi XJ
• Liu XY
• Wang GY

• KMID: 2243030
• DOI: http://doi.org/10.14701/kjhbps.2016.20.1.38

Abstract

Acute graft-versus-host disease (GVHD) following liver transplantation is a rare but fatal complication. The correct diagnosis and management of GVHD after liver transplantation are still major challenges. Herein, we reported successful salvage treatment of acute GVHD by withdrawal of immunosuppression in a patient who presented with fever, skin rashes, and decreased blood cell counts after liver transplantation. This case highlights the need for awareness of drug-induced liver injury if liver function tests are elevated during treatment, especially in patients taking multiple potentially hepatotoxic drugs, such as broad-spectrum antibiotics. When occurs, an artificial liver support system is a useful tool to provide temporary support of liver function for the patient in the event of drug-induced liver injury.

Keyword

Graft-versus-host disease; Liver transplantation; Drug-induced liver injury

MeSH Terms

Anti-Bacterial Agents
Blood Cell Count
Diagnosis
Drug-Induced Liver Injury
Exanthema
Fever
Graft vs Host Disease*
Humans
Immunosuppression*
Liver Function Tests
Liver Transplantation*
Liver*
Liver, Artificial
Anti-Bacterial Agents

Figure

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  Fig. 1 Maculopapular rashes on the palm (A), foot (B), and chest (C) of the patient at postoperative day (POD) 28; and ulcer lesions in the oral mucosa at POD 29 (D).

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  Fig. 2 Skin biopsy stained with hematoxylin-eosin (H&E at ×20), showing basal cell hydropic changes in epidermis, multiple apoptotic keratinocytes, and moderate lymphocytic infiltration in the dermis.

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  Fig. 3 Clinical course and laboratory changes following liver transplantation. (A) Serum AST and ALT concentrations during the postoperative period, (B) serum TBIL and DBIL concentrations during the postoperative period. ALSS, artificial liver support system; AST, aspartate aminotransferase; ALT, alanine aminotransferase; TBIL, total bilirubin; DBIL, direct bilirubin.

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  Fig. 4 Liver biopsy findings (H&E ×200). (A) Periportal infiltration of a few periportal neutrophils and lymphocytes at POD 50, (B) zone 3 cholestasis and lobular hepatocyte necrosis consistent with DILI at POD 50, (C) periportal infiltration of extremely few lymphocytes at POD 64, and (D) zone 3 cholestasis and lobular hepatocyte necrosis, eosinophilic bodies, and liver cell proliferation at POD 64.

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  Fig. 5 The patient recovered with satisfactory clinical outcomes. (A) The skin rashes on the hands healed at POD 50, (B) the jaundice was resolved at the leg at POD 50, (C) the skin rashes on the feet healed at POD 80, and (D) new fingernails grew to replace old ones at POD 80.

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