Combined Solid Organ Transplant and Transfusion-Associated Graft-Versus-Host Disease in a Lung Transplant Recipient: An Uncertain Culprit With Lethal Complications

Abstract

Although graft-versus-host disease (GVHD) is a common complication of hematopoietic stem cell transplantation, it is rare after solid organ transplantation (SOT) or blood transfusion. We present a rare case of SOT-derived and/or transfusion-associated graft-versus-host disease (TA-GVHD) in a 66-year-old man with interstitial lung disease who underwent bilateral lung transplantation (LT) from a 12-year-old female donor and required three units of packed red blood cells intraoperatively. He presented with signs and symptoms consistent with GVHD, and a bone marrow biopsy revealed an XX karyotype. He died 3 months after bilateral LT, and postmortem chimerism testing using next-generation sequencing identified three sources of DNA within his bone marrow, including the recipient, the lung donor, and a third donor, thereby suggesting the presence of solid organ transplant graft-versus-host disease (SOT-GVHD), TA-GVHD, or a combination of both.

Keywords: bone marrow; chimerism; graft-versus-host disease; lung transplant; transfusion.

Figure 1

Widespread erythematous maculopapular rash seen 42 days after lung transplant. The rash initially developed on his upper back, 33 days after lung transplant, and spread to his entire back, chest, abdomen, and neck but was not associated with any mucosal involvement.

Figure 2

An anterior abdominal wall skin punch biopsy shows mild superficial perivascular dermatitis (hematoxylin and eosin stain; original magnification ×40). Sections reveal primarily lymphocytes, plasma cells, monocytes, and focal red blood cell extravasation with scattered dermal melanophages (iron stain negative).