Induction of Hyperacute Graft-vs-Host Disease After Donor Leukocyte Infusions

Abstract

Background: Infusions of leukocytes obtained from the original bone marrow donor is a new approach for treating patients who have a relapse of leukemia after allogeneic bone marrow transplantation. Up to 90% of patients who achieved remission developed graft-vs-host disease (GVHD). However, any description of the clinical and histologic features in these cases is lacking. Observations: We describe 2 patients in whom a severe, peculiar, hyperacute, fatal GVHD developed after treatment with donor leukocyte infusions and interferon alfa. The patients had not received any additional chemotherapy or GVHD prophylaxis. In both patients, the eruption started with the appearance of erythematous plaques at the interferon alfa injection sites, and a generalized maculopapular eruption subsequently developed. The clinical lesions evolved from acute to lichenoid within several days. The histologic examination also demonstrated unusual findings and showed features of both acute and chronic lichenoid GVHD. Conclusions: Donor leukocyte infusions without GVHD prophylaxis may provoke a severe fatal hyperacute GVHD. In the cases presented herein, we discuss the significance of the rapid clinical evolution from acute to lichenoid and the combination of histologic features of both acute and chronic GVHD in the biopsy specimens.

Many faces of graft‐versus‐host disease

“…Moreover, hyperacute GvHD is more resistant to treatment and non‐relapse mortality is higher. A similar clinical presentation has been found in patients after donor leukocyte infusion 9 …”

“…Dermatologists have traditionally used this classification, 4 but multiple findings suggest this may no longer be suitable. It is possible to find aGvHD lesions beyond day 100, 8 while cGvHD lesions sometimes appear before 4,9,10 . Histological findings of aGvHD can be found in biopsies performed beyond day 100 and lichenoid findings in biopsies performed before day 100 11 .…”

“…Cutaneous lesions of hyperacute GvHD rapidly evolved into a lichenoid clinical pattern within 10 days (Fig. 2) with histological features of both acute and lichenoid GvHD 9,47 . These patients had severe gastrointestinal and hepatic damage with frequent fatal outcome.…”

Clinical and immunologic outcomes following haplocompatible donor lymphocyte infusions

“…Clinicians administering haplocompatible DLI should monitor for the development of this uncommon potential complication, as hyperacute GVHD has been previously reported following even-matched related donor DLI. 24 The ability of this study to conclusively demonstrate the efficacy of haplocompatible DLI is limited by the small size and lack of untreated controls. Nevertheless, in the majority of patients, the administration of DLI may be associated with slow but definite clearance of life-threatening infections present at the time of DLI.…”

Late Appearance of Acute Graft-vs-Host Disease After Suspending orTapering Immunosuppressive Drugs

“…Hyperacute or explosive presentations of GVHD may be observed after allogeneic transplantations without or with insufficient GVHD prophylaxis, which are characterized by severe systemic involvement, high mortality, and an erythroderma that evolves from acute to lichenoid within several days of onset with histological features of both acute and chronic lichenoid GVHD. 11,17,18 Although the criterion of 100 days for separating acute from chronic GVHD has been challenged, the concept of acute cutaneous GVHD appearing after day 100 (without progression to lichenoid or sclerodermoid GVHD) is not well established. To our surprise, we found only 2 references in the hematologic literature dealing with this form.…”