A rare but life-threatening complication in liver transplant recipients

Graft versus host disease (GvHD) occurs in as little as 1–2% of cases after liver transplantation (LT), but is probably under-diagnosed and under-reported. Skin rash, diarrhoea, and/or fever are early symptoms of GvHD, and the most common causes of death are sepsis or gastrointestinal bleeding as a result of bone-marrow involvement. The delay in diagnosis as well as lack of standard treatment contributes to the high lethality of GvHD.
A 45-year-old patient, six weeks after liver transplantation because of primary sclerosing cholangitis (PSC), was admitted to the hospital due to watery diarrhoea. The patient presented dehydration with more than 20 watery, periodically bloody stools with spastic mid-abdominal pain, slight elevation of body temperature, and merging redness rush on feet and hands. C-reactive protein (CRP) was reached more than 300 mg/dl. All stool bacterial cultures were negative, including Clostridium difficile toxaemia, cytomegalovirus, and Epstein-Barr virus infections. Because of the patient’s history of ulcerative colitis, rectosigmoidoscopy was performed showing moderate exacerbation of the disease, confirmed by the result of a colonic biopsy. Unfortunately, the symptomatic treatment was ineffective, with a persistent high number of stools per day, with elevation of CRP, fibrinogen and dyselectrolytaemia, anaemia, and decreasing counts of leucocytes and platelets. His maculopapular rush developed occupying also the abdomen, chest, and back (Figures 1 A, B). Computer tomography revealed inflammation of both small and large intestines with ascites (Figure 2). The patient was treated with tacrolimus (drug blood levels of 8–12 ng/ml), basiliximab (20 mg i.v. in day 0 and 4), and methylprednisolone 500 mg IV q.d. for 3 days, subsequently with oral prednisolone and budesonide, antibiotics, and antifungal drugs as well as with intravenous colloids, crystalloids, human albumin, ions, and nutritional support. However, general vasculitis and multiorgan failure, secondary to fungal sepsis, developed and the patient died 30 days after onset.
A 54-year-old male patient, 1 month after liver transplantation due to HCV cirrhosis, was admitted to the hospital with a 3-day history of fever and dysuric symptoms. Chinolon was administered ambulatorily, but his fever grew growing, with very high CRP, procalcitonin, and pancytopaenia. His condition deteriorated in a short time, with skin rash on the chest and abdomen, and with...


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