Diarrhea after allogeneic stem cell transplantation: beyond graft-versus-host disease

Abstract

Diarrhea constitutes a frequent and often debilitating complication of allogeneic hematopoietic cell transplantation (alloHCT). Especially when accompanied by jaundice, skin rash, and symptoms of the upper gastrointestinal tract, diarrhea strongly suggests emergence of acute graft-versus-host disease (GvHD), which is a serious immune complication of the procedure, with possible fatal consequences. However, especially when diarrhea occurs as an isolated symptom, the other causes must be excluded before initiation of GvHD treatment with immune-suppressive drugs. In this article, a broad overview of the literature of different causes of diarrhea in the setting of alloHCT is provided, revealing causes and presentations different from those observed in the general population. We discuss gastrointestinal GvHD with a special focus on biomarkers, but also uncover underlying infectious: viral, bacterial, and parasitic as well as toxic causes of diarrhea. Finally, we suggest a practical algorithm of approach to patients with diarrhea after alloHCT, which may help to establish a proper diagnosis and initiate a causative treatment.

Mesenchymal Stem Cell Therapy Overcomes Steroid Resistance in Severe Gastrointestinal Acute Graft-Versus-Host Disease

“…The diagnosis of causes leading to posttransplant diarrhea is a complex process. The differential diagnosis with infection including CMV, adenovirus, rotavirus, norovirus, and Clostridium difficile, is a critical point before conducting immunosuppression treatment for gastrointestinal GVHD [20]. The possibility of intestinal tract infection was excluded by analyzing stool specimen and culture, determining the presence of CMV DNA in serum, observation and biopsy under colonoscopy.…”

Make Sure You Have a Safety Net: Updates in the Prevention and Management of Infectious Complications in Stem Cell Transplant Recipients

“…Diagnostic and treatment recommendations with standard antimicrobials for CDI in HSCT recipients are expected to be the same as the general population; however, a few unique features and the concern of FMT safety in this population are worth mentioning. Asymptomatic C. difficile colonization in HSCT recipients has been noted to be as high as 29%; compare that to the up to 15% in healthy adults [124,125]; this high rate of colonization coupled with the high incidence of diarrhea overall (i.e., due to mucosal barrier injury with cytotoxic therapy, GVHD other infections such as CMV) may present diagnostic challenges in identifying true CDI [126,127]. Damage to the gut barrier may also have therapeutic implications; for instance, severe GI GVHD has been associated with systemic absorption to supra-therapeutic levels of oral vancomycin for concomitant CDI treatment, with potential effects on renal function [128].…”

Diarrhea in Transplant: Diagnosis and Management

“…Engraftment syndrome occurs within a week of engraftment and encompasses a constellation of symptoms, including diarrhea, fever, pulmonary edema, and rash [11]. Infections account for 6-40% of diarrheal illnesses in HSCT recipients [3,12].…”