Dr. Zuzana Kos
Resident PGY4
Case Three
Overview
Clinical history: This is a 63-year-old gentleman, who in August 2010 underwent a reduced intensity related donor allogenic stem cell transplant for myelodysplastic syndrome. Aside from severe mucositis his transplant course was fairly uneventful. He was discharged home for routine follow up. Initially, he did very well. Approximately 2 months post transplant he started tapering Tacrolimus as per protocol. Unfortunately, with discontinuing the Tacrolimus he developed diffuse skin rash and increasing problems with diarrhea. A colonic biopsy was performed and showed the following.
What are the two diagnoses in this case?
How is acute graft-versus-host disease graded?
What is the most probable diagnosis?
Diagnosis
- Acute graft-versus-host disease, grade IV
- Cytomegalovirus enterocolitis
The sections show portions of large bowel mucosa with a striking lack of crypts. The lamina propria is edematous and shows a relatively sparse infiltrate of chronic inflammatory cells, predominantly lymphocytes and plasma cells. Within the remaining crypts, scattered single cell apoptotic bodies are seen at the base of crypt cells. One crypt shows destruction with large apoptotic bodies. Extensive mucosal sloughing is seen. The overall appearance is consistent with acute graft versus host disease, grade IV. Additionally, several endothelial and stromal cells show enlarged nuclei with prominent nucleoli (owl eye) typical of cytomegalovirus (CMV) inclusions, indicating superimposed CMV enterocolitis.
Grading of Acute Graft-versus-Host Disease in the Colon:
|
Grade
|
Histological Features |
|
I
|
Rare apoptotic cells, without crypt loss |
|
II
|
Loss of individual crypts |
|
III
|
More substantial crypt loss (loss of two or more contiguous crypts) |
|
IV
|
Few or no identifiable crypts, often with mucosal ulceration |
From Sale GE, Shulman HM, McDonald GB, Thomas ED: Gastrointestinal graft-versus-host disease in man: A clinicopathologic study of the rectal biopsy. Am J Surg Pathol 3:291-299, 1979.
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