Skill Checkup: A Man Who Had Autologous Hematopoietic Stem Cell Transplantation Developed Acute Graft-vs-Host Disease

James L. Harper, MD

Disclosures

February 10, 2022

The Skill Checkup series provides a quick, case-style interactive quiz highlighting key guidelines- and evidence-based information to inform clinical practice.

A 46-year-old man was diagnosed with acute myeloid leukemia 1 year ago. He was treated with idarubicin plus etoposide and cytarabine, with no hematologic response, and then underwent autologous hematopoietic stem cell transplantation. Neutrophil and platelet engraftment occurred on days 14 and 18 respectively. The patient had a transient rash suggestive of grade 1 acute graft-vs-host disease on day 19 and an episode of cytomegalovirus, successfully treated with preemptive valganciclovir and immunoglobulins.

The patient was readmitted to the hospital because of severe anemia and thrombocytopenia (hemoglobin level, 5.8 g/dL; platelet count, 5000 cells/µL) and right abdominal pain with melena on day 26. Significant weight gain (12 lb) along with abdominal distention and anasarca were observed on day 35. Laboratory examinations showed the following:

  • Total bilirubin level, 3.30 mg/dL

  • Aspartate aminotransferase level, 140 U/L

  • Alanine aminotransferase level, 164 U/L

  • Gamma-glutamyltransferase level, 725 U/L

  • International normalized ratio, 1.7

  • Activated partial thromboplastin time, 41.3 sec

  • Serum creatinine level, 2.0 mg/dL

  • Platelet count 20,000 cells/µL

Abdominal CT revealed ascites and hepatic vein compression. Transjugular measurement of the hepatic venous pressure gradient showed severe sinusoidal portal hypertension, with a significant transhepatic/caval gradient diagnostic of severe veno-occlusive disease (also known as sinusoidal obstruction syndrome). Histologic studies were consistent with severe veno-occlusive disease.

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