Graft vs Host Disease

Patient Presentation:
S.K., a 26 yr old female diagnosed with AML, presents with diarrhea; 8-12 watery movements per day, intractable vomiting that is not responsive to anti-emetics, and severe abdominal pain rating a 10/10.  S.K. is 22 days s/p an allogeneic bone marrow transplant from an unknown unrelated donor.  Patient developed symptoms acutely and at the time of presentation was still hospitalized awaiting full engraftment of donor marrow.  Pt relevant labs at time: WBC 1.0, ANC 0.4, Hgb 6.8, Hct  22%, PLTs 12, and positive fecal occult blood test.

Differential List:
Inflammatory Bowel Disease, Infectious colitis (viral) - cytomegalovirus, Infectious colitis- (bacterial) Clostridium difficile, Graft vs Host Disease

Diagnosis:
An upper and lower endoscopy was performed in which findings showed mucosal edema and diffuse bleeding throughout the entire GI tract. Histological findings from biopsies of GI tract revealed crypt cell necrosis.  S.K. was diagnosed with Grade IV GVHD of the GI tract, which is characterized by more than 2L of diarrhea per day positive for blood in the stool.

Treatment:
Pt initiated on immunosuppressive therapy consisting of IV methylprednisolone, cyclosporine, and mycophenolate mofetil.  A nasogastric tube was inserted to continuous low wall suction for upper GI active bleeding and a rectal tube inserted to contain profuse bloody stools.  A fentanyl PCA was initiated for pain control and total parental nutrition initiated as pt unable to maintain oral intake. Normal saline IV started at 100cc/hr to maintain fluid volume and albumin was administered to counteract gastrointestinal protein loss. Pt was RBC and platelet transfusion dependent and was maintained on anti-viral, anti-bacterial, and anti-fungal medications to counteract the treatment of immunosuppressant medications.

Outcome:
Pt’s GVHD was refractory to steroids and was therefore initiated on an experimental drug for GVHD. This drug, etanercept, a protein which inhibits TNF, was to be given subcutaneously once per week. Due to the constant immunosuppression, pt’s ANC was consistently 0 and pt developed an opportunistic respiratory infection of unknown origin.  S.K’s respiratory status became severely compromised, using accessory muscles for breathing and it was attempted to maintain patient on a non-rebreather while attempting to treat the respiratory infection. Pt continued to decompensate and required intubation and transfer to the ICU.  Four days after being transferred to the ICU, the family and medical team decided to withdraw treatment and the patient was terminally extubated.
Case created by Stefanie Kelly, 2011.