Graft versus Host Disease

The incidence of acute GVHD varies among different transplant centers and depends on the primary diagnosis. In patients with primary immunodeficiency

Table 25-15. Management of Infections during First 30 Days Post-HSCT

Gram-negative infections

Empiric combination therapy (Chapter 26) Gram-positive infections

Vancomycin Fungal infections Amphotericin B Liposomal amphotericin Voriconazole Itraconazole Removal of indwelling catheter Management of interstitial pneumonia

1. Bronchoalveolar lavage (BAL)

2. Open lung biopsy

3. Treatment depends on etiology a. Pneumocystis: Bactrim, pentamidine b. CMV: ganciclovir plus CMV high-titer gammaglobulin c. Idiopathic: supportive care, steroids d. Fungal: antifungals Management of herpes zoster

Acyclovir and aplastic anemia, the incidence of GVHD may vary from 10% to 35%, whereas in patients with acute leukemia, it may be approximately 50%. In unrelated matched donor transplantation, it may vary from 50 to 70%. Approximately 10-30% of all patients with sustained allogeneic engraftment die of acute GVHD or its complications.

GVHD is caused by donor alloreactivity in an immunocompromised host and results from T lymphocytes contained in the stem cell graft that proliferate and differentiate in the host. These T cells recognize host alloantigens as foreign and through both direct effector mechanisms and by inflammatory mediators released by T cells, monocytes and production of cytokines especially interleukin 1 (IL-1) and tumor necrosis factor in the host may cause tissue damage.

Graft versus host disease is divided into two stages:

• Acute GVHD, which manifests in the first 100 days post-transplantation, usually observed within 30-40 days

• Chronic GVHD, which manifests 100 days after stem cell transplantation.

Acute GVHD

The clinical manifestations of acute GVHD range from a mild maculopapular eruption to generalized erythroderma, hepatic dysfunction, gastroenteritis, stomatitis, and lymphocytic bronchitis. Thrombocytopenia and anemia have been reported in GVHD. Ocular symptoms, including photophobia, hemorrhagic conjunctivitis, and pseudomembrane formation, have also been observed. It is occasionally difficult to separate the clinical manifestations of GVHD from other disorders in the post-transplant patient and, in these cases, a biopsy of the skin or liver may be required. Table 25-16 lists the clinical manifestations and stages of acute GVHD, and Table 25-17 describes the histologic grades of acute GVHD. Table 25-18 presents a comparison between acute and chronic GVHD.

Table 25-16. Clinical Manifestations and Stages of Acute Graft versus Host Disease

Gut (diarrhea)'

Table 25-16. Clinical Manifestations and Stages of Acute Graft versus Host Disease

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