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#48
SEVERE GRAFT VERSUS HOST DISEASE MANIFESTING EIGHT MONTHS AFTER LIVER TRANSPLANTATION.
Marilyn S. Pollack, Ph.D., Kermit V. Speeg, M.D., Ph.D., Natalie S. Callander, M.D., Cesar O. Freytes, M.D. and Glenn A. Halff, M.D.. San Antonio TX, USA, University of Texas Health Science Center, 78229, Departments of Pathology, Medicine and Surgery.

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A 52 year old liver transplant recipient presented at eight months after transplant with diarrhea and infections secondary to severe bone marrow aplasia. All medications potentially causing his myelosuppression, notably Septra, were discontinued. Graft versus host disease was not initially suspected because it usually occurs 2 to 6 weeks after transplant. Also, he had no known risks for GvHD in that he was relatively young and shared only one major HLA antigen, HLA-B35, with his donor. However, when his cell counts failed to improve and it was noted that he also had a diffuse rash, chimerism tests were performed using stored pretransplant DNA from both the recipient and donor as controls. Tests for polymorphic alleles in eleven STR systems indicated that 96% of the blood mononuclear cells were of liver donor origin. Treatment with OKT3 was initiated to try to eliminate the donor T-cells but the relative proportion of peripheral blood donor mononuclear cells remained almost the same. Plans were made to provide the patient with a stem cell transplant from his HLA identical brother but he succumbed to his overwhelming fungemia. To our knowledge, the only other case of severe graft versus host disease reported to occur so late after transplant could not be documented to be caused by cells of liver donor origin since that patient also received several unirradiated blood transfusions and donor tissue was not available for comparison. Consideration should be given to GvHD as a cause of aplasia at any time after transplant and the storage of samples from all transplant recipients and donors is highly recommended to facilitate making this diagnosis.