- Email: [email protected]
Acute graft-versus-host disease in the small intestine
ACUTE GRAFT-VERSUS-HOST DISEASE IN THE SMALL INTESTINE
A
B
C
D
E
F
A 50-year-old man received donor lymphocyte infusions for treatment of relapsing acute lymphocytic leukemia after allogenic bone marrow transplantation. On the twenty-third day after infusion, severe skin graft-versus-host disease (GVHD) developed but subsided with oral administration of prednisolone. On the thirty-fourth day after infusion during tapering of the corticosteroid dosage, cramping abdominal pain and watery diarrhea suddenly developed. The symptoms persisted despite treatment, and colonoscopy on day 49 revealed a pale mucosal surface with reticulated submucosal small vessels in the terminal ileum (A). Chromoscopy demonstrated extensive mucosal sloughing, specific for acute GVHD, except for occasional surviving islands of mucosa (B; indigo carmine dye). High-resolution magnifying endoscopy disclosed that the mucosal islands consisted of scattered erythematous villi (C). For comparison, endoscopic, chromoscopy, and high-
716
GASTROINTESTINAL ENDOSCOPY
magnification views of the ileum of a healthy patient of the same age are shown, respectively, in D, E, and F. Biopsy specimens revealed apoptotic bodies in crypts, consistent with acute GVHD, without viral inclusions. Stool cultures were negative for pathologic bacteria and viruses. The watery diarrhea improved with treatment. However, bone marrow aspiration on day 75 revealed leukemic relapse. The patient’s condition deteriorated and he died on day 89 because of fungal sepsis. Norihiko Watanabe, MD Kazuichi Okazaki, MD Shujiro Yazumi, MD Toshiki Nishi, MD Minoru Matsuura, MD Tsutomu Chiba, MD Kyoto University Kyoto, Japan doi:10.1067/mge.2002.121796
VOLUME 55, NO. 6, 2002
A
B
C
D
E
F
A 50-year-old man received donor lymphocyte infusions for treatment of relapsing acute lymphocytic leukemia after allogenic bone marrow transplantation. On the twenty-third day after infusion, severe skin graft-versus-host disease (GVHD) developed but subsided with oral administration of prednisolone. On the thirty-fourth day after infusion during tapering of the corticosteroid dosage, cramping abdominal pain and watery diarrhea suddenly developed. The symptoms persisted despite treatment, and colonoscopy on day 49 revealed a pale mucosal surface with reticulated submucosal small vessels in the terminal ileum (A). Chromoscopy demonstrated extensive mucosal sloughing, specific for acute GVHD, except for occasional surviving islands of mucosa (B; indigo carmine dye). High-resolution magnifying endoscopy disclosed that the mucosal islands consisted of scattered erythematous villi (C). For comparison, endoscopic, chromoscopy, and high-
716
GASTROINTESTINAL ENDOSCOPY
magnification views of the ileum of a healthy patient of the same age are shown, respectively, in D, E, and F. Biopsy specimens revealed apoptotic bodies in crypts, consistent with acute GVHD, without viral inclusions. Stool cultures were negative for pathologic bacteria and viruses. The watery diarrhea improved with treatment. However, bone marrow aspiration on day 75 revealed leukemic relapse. The patient’s condition deteriorated and he died on day 89 because of fungal sepsis. Norihiko Watanabe, MD Kazuichi Okazaki, MD Shujiro Yazumi, MD Toshiki Nishi, MD Minoru Matsuura, MD Tsutomu Chiba, MD Kyoto University Kyoto, Japan doi:10.1067/mge.2002.121796
VOLUME 55, NO. 6, 2002