P037 Rare presentation of cutaneous graft-versus-host disease following liver transplantation

Abstract

Graft-versus-host disease (GvHD) following liver transplantation is reported in 0.1–2% of recipients. It has a 60–85% mortality rate, constituting a rare and fatal complication. The immune-mediated attack most frequently affects the skin; however, cutaneous ­manifestations of acute GvHD vary considerably. Its rarity creates multiple clinical challenges. Diagnosis of cutaneous GvHD may not be considered as its presentation is nonspecific, sharing features with more commonly seen diagnoses post-transplant such as drug eruptions. Histological examination may demonstrate characteristic changes such as superficial infiltrate, basal-layer vacuolar degeneration and interface dermatitis. However, these do not distinguish acute GvHD from other differentials like erythema multiforme. There are no universal standards of care in the treatment of GvHD following solid organ transplantation. We present a case and literature review of reported cases of cutaneous GvHD following liver transplant. A 50-year-old man presented with cervical lymphadenopathy and pyrexia 3 weeks after orthotropic transplantation for metabolic dysfunction-associated steatotic liver disease. He was receiving tacrolimus, prednisolone and mycophenolate post-transplant. Extensive investigations for infection were unremarkable, including lumbar puncture, imaging, respiratory polymerase chain reaction panels and blood cultures. Several days into admission he developed a blanching erythematous morbilliform rash affecting the groin, later becoming widespread with oral mucosal ulcerations and haemorrhagic bullae of the plantar aspects of the feet. Differentials included viral exanthem, drug reaction and acute GvHD. Histopathology showed satellite cell necrosis, florid interface damage and numerous apoptotic keratinocytes at various levels of the epidermis, along with subepidermal clefting, in keeping with acute GvHD given the clinical presentation. He was promptly commenced on methylprednisolone and recovered well without the need for ­second-line treatments. A limited evidence base and rarity means cutaneous GvHD following solid organ transplantation poses significant diagnostic difficulties. Our case highlights the importance of early recognition and prompt initiation of appropriate treatment to reduce morbidity and mortality.