The Basic Sequence of Injury in Acute Skin GVHD
Development of maculopapular rashes in patients <100 days post-hematopoietic stem cell transplantation (HSCT) is common. Evaluation often includes skin biopsy for the diagnosis of acute GVHD (aGVHD). The Lerner grading system for cutaneous aGVHD incorporates apoptotic keratinocytes, pattern of inflammation, and degree of epidermal destruction. The timing of the skin biopsy and the severity of the rash will influence the differential diagnosis, which includes drug reaction, chemotherapy toxicity, engraftment syndrome, and infections. More severe reactions raise a differential diagnosis of erythema multiforme, Stevens-Johnson syndrome (SJS), and, SJS’s more severe form, toxic epidermal necrolysis (TEN). Cases of classic aGVHD superimposed with cGVHD are classified as overlap syndrome. The immunopathogenesis of aGVHD involves the interaction of donor T lymphocytes with host tissue, along with costimulatory pathways, cytokines, and other inflammatory cell types.
KeywordsAcute cutaneous GVHD Lerner grading system Late onset of acute GVHD Overlap acute and chronic GVHD
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