A 55-year-old man with end-stage hepatitis C virus infection undergoes orthotopic liver transplantation from a deceased donor. The patient has no perioperative complications and is discharged from the hospital on appropriate immunosuppressant medications. One week after the surgery, he develops nausea, vomiting, abdominal pain, and bloody diarrhea. Physical examination shows a painful maculopapular rash over his neck, back, and extremities that extends to the palms and soles. Endoscopic evaluation reveals multiple ulcerations of the intestinal mucosa. Which of the following is the most likely cause of this patient's current condition?

Question

A 55-year-old man with end-stage hepatitis C virus infection undergoes orthotopic liver transplantation from a deceased donor.  The patient has no perioperative complications and is discharged from the hospital on appropriate immunosuppressant medications.  One week after the surgery, he develops nausea, vomiting, abdominal pain, and bloody diarrhea.  Physical examination shows a painful maculopapular rash over his neck, back, and extremities that extends to the palms and soles.  Endoscopic evaluation reveals multiple ulcerations of the intestinal mucosa.  Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

This patient most likely has graft-versus-host disease (GVHD), a condition that usually occurs after allogeneic bone marrow transplantation. However, GVHD can also occur following transplantation of organs rich in lymphocytes (eg, liver) or transfusion of non-irradiated blood. Patients affected by GVHD are generally severely immunodeficient due to the primary disease process or as a result of immunosuppressive medications. This allows immunocompetent donor T cells from the graft to survive and migrate into host tissues, where they recognize host MHC antigens as foreign and become sensitized. On activation, donor CD4⁺ and CD8⁺ T cells (not B cells) participate in host cell destruction (Choice A). Any organ may be a target of GVHD, but the skin, liver, and gastrointestinal (GI) tract are the most frequently affected. Early signs of GVHD include a diffuse maculopapular rash that has a predilection for the palms and soles and may desquamate in severe cases. GI tract involvement causes diarrhea, intestinal bleeding, and abdominal pain. Liver damage will manifest as abnormal liver function tests. In this case, the donated liver would not be significantly affected as the donor T cells perceive the liver as self. (Choices C and D) Acute and chronic graft rejections occur following host T and B cell sensitization against graft MHC antigens. The resulting immune response leads to graft failure without significant involvement of other organ systems. This patient's skin and GI findings make GVHD more likely. (Choice E) If the tissue recipient has antibodies against donor ABO antigens, hyperacute rejection will develop within minutes of transplantation. Spasm and occlusion of graft vessels occur, leading to ischemia and necrosis. Educational objective: Graft-versus-host disease can occur following transplantation of organs rich in lymphocytes (eg, liver). T lymphocytes found in the donor organ become sensitized against the MHC antigens of the recipient and subsequently attack the host's tissues. The skin, liver, and gastrointestinal tract are most frequently affected.

A 55-Year-Old Man with End-Stage Hepatitis C Virus Infection Undergoes