Tissue eosinophils and the perils of using skin biopsy specimens to distinguish between drug hypersensitivity and cutaneous graft-versus-host disease

Clinical differentiation of acute cutaneous graft-versus-host disease from drug hypersensitivity reactions

“…3 In the early period after transplantation, allogeneic HCT recipients are usually on multiple medications, many of which are well known to induce cutaneous hypersensitivity. 4 Therefore, DHRs are frequently encountered and especially difficult to differentiate from GVHD. Differentiating GVHD from DHR has profound clinical implications, as the former requires intensive immunosuppressive treatment at the peril of an increased risk of infections, whereas the latter requires only discontinuation of the offending drugs.…”

Rash and pancytopenia as initial manifestations of acute graft-versus-host disease after liver transplantation

“…27 However, recent studies have shown that eosinophils in skin biopsy specimens do not help differentiate between these two conditions. 28,29 A recent study showed that important risk factors in liver transplant-associated GVHD included recipients older than 65 years, donor age greater than 40 years younger than the recipient, and closely matched HLA recipients. 19 In addition, the only preoperative diagnosis seen more commonly for patients with GVHD was cryptogenic cirrhosis, as was the case for this patient.…”

Graft-versus-host disease

“…Distinguishing between GVHD, drug reactions, or infectious exanthem is often difficult on clinical grounds alone, and although histologic confirmation is sometimes helpful, it is often nonspecific. 25 Initially, vacuolar changes are present at the basal cell layer, accompanied by a sparse lymphocytic infiltrate. The presence of scattered eosinophils, a hallmark feature of drug-induced and other hypersensitivity reactions, should not delay a diagnosis of acute GVHD if there is a strong clinical suspicion.…”

“…The presence of scattered eosinophils, a hallmark feature of drug-induced and other hypersensitivity reactions, should not delay a diagnosis of acute GVHD if there is a strong clinical suspicion. 25 A recent review found that a very high number of eosinophils (average 16 eosinophils/10 high power fields) was needed to rule out the possibility of GHVD with 100% specificity. 26 Dyskeratotic epidermal cells, which may be contiguous to a ''satellite lymphocyte,'' are characteristic of more advanced GVHD, but are also not specific to GVHD.…”