Drug-induced skin reactions and acute cutaneous graft-versus-host reaction: a comparative immunohistochemical study

In Vivo Reflectance Confocal Microscopy of Cutaneous Acute Graft-Versus-Host Disease: Concordance with Histopathology and Interobserver Reproducibility of a Glossary with Representative Images

BACKGROUND

The reliability to noninvasively identify features of inflammatory dermatoses by reflectance confocal microscopy (RCM) remains unknown. Lack of formal training among RCM readers can result in inconsistent assessments, limiting clinical utility. Specific consensus terminology with representative images is necessary to ensure consistent feature-level interpretation among RCM readers.

OBJECTIVES

(1) Develop a glossary with representative images of RCM features of cutaneous acute graft-versus-host disease (aGVHD) for consistent interpretation among observers, (2) assess the interobserver reproducibility among RCM readers using the glossary, and (3) determine the concordance between RCM and histopathology for aGVHD features.

METHODS

Through an iterative process of refinement and discussion among five international RCM experts, we developed a glossary with representative images of RCM features of aGVHD. From April to November 2018, patients suspected of aGVHD were imaged with RCM and subsequently biopsied. 17 lesions from 12 patients had clinically and pathologically confirmed cutaneous aGVHD. For each of these lesions, four dermatopathologists and four RCM readers independently evaluated the presence of aGVHD features in scanned histopathology slides and 1.5x1.5 mm RCM submosaics at 4 depths (blockstacks), respectively. RCM cases were adjudicated by a fifth RCM expert. Interobserver reproducibility was calculated by U statistic. Concordance between modalities was determined by fraction agreement.

RESULTS

We present a glossary with representative images of 18 aGVHD features by RCM. The average interobserver reproducibility among RCM readers (75%, confidence interval, CI: 71%-79%) did not differ significantly from dermatopathologists (80%, 76%-85%). The concordance between RCM and histopathology was 59%.

CONCLUSIONS

By using the glossary, the interobserver reproducibility among RCM readers was similar to the interobserver reproducibility among dermatopathologists. There was good concordance between RCM and histopathology to visualize aGVHD features. The implementation of RCM can now be advanced in a variety of inflammatory conditions with a validated glossary and representative image set.

A clinical and histological comparison between acute cutaneous graft-versus-host disease and other maculopapular eruptions following hematopoietic stem cell transplantation: a retrospective cohort

BACKGROUND

Prompt management of acute graft-versus-host disease (GVHD) may prevent its morbidity and mortality. Maculopapular (MP) eruption is a presenting sign of acute GVHD, but differentiation from other causes of MP rash is challenging.

METHODS

A retrospective study was conducted among patients developing MP eruptions after allogeneic hematopoietic stem cell transplantation. We compared the clinical and histopathological differences between an acute cutaneous GVHD (group 1) and other MP eruptions (group 2). We also determined the clinical prognostic indicators linked to acute GVHD severity, morbidity, and mortality.

RESULTS

Of 95 patients identified, 75 met the classification criteria for acute GVHD, and 25 had other MP eruptions. Palm and/or sole involvement was more frequently found (51.4% vs. 12%, odds ratio [OR] [95% confidence interval] = 7 [2.1, 23.7], P < 0.01 and 41.4% vs. 0%, OR 37.2 [2.2, 635], P < 0.01, respectively) in group 1 than in group 2. Comparing the histological features between the two groups, necrotic keratinocytes in basal and spinous layers (92.9% vs. 22.2%, OR 27 [3.5, 594.7], P < 0.01) and (85.7% vs. 33.3%, OR 9.3 [1.4, 60.8], P = 0.02, respectively), diffuse basal vacuolization (42.9% vs. 0%, OR 14.5 [0.7, 298.2], P = 0.04), lymphocyte satellitosis (71.4% vs. 0%, OR 44.3 [2.1, 936.8], P < 0.01), and subepidermal clefts (42.9% vs. 0%, OR 14.5 [0.7, 298.2], P = 0.04) were significantly more apparent in group 1. Among extracutaneous presentations, diarrhea alone and/or accompanied by hyperbilirubinemia (47.1% vs. 16%, OR 4.3 [1.4, 13.1], P = 0.03 and 27.1% vs. 0%, OR 19.3 [1.1, 332.8], P < 0.01, respectively) and newly developed transaminitis (37.1% vs. 12%, OR 3.3 [1.1, 12.6], P = 0.02) suggested the diagnosis of acute GVHD. Mucosal involvement and/or blister formation correlated with severe acute GVHD (OR 26.6 [5.4, 130.4], P < 0.01). Skin and systemic GVHD severity correlated with time to rash resolution (P = 0.03 and P = 0.04, respectively), length of hospital stays (P < 0.01 and P < 0.01, respectively), and mortality (OR 4.87 [1.4, 17.4], P = 0.02 and OR 4.6 [1.3, 16.5], P = 0.02, respectively).

CONCLUSIONS

Our findings may be beneficial tools for establishing the diagnosis of acute GVHD.

Tissue eosinophils and the perils of using skin biopsy specimens to distinguish between drug hypersensitivity and cutaneous graft-versus-host disease

Graft-versus-host disease (GvHD) is a frequent and serious complication of bone-marrow transplantation (BMT), and carries a high morbidity and mortality if not promptly recognized and treated. The rash of acute GvHD is often difficult to distinguish clinically from a drug eruption, and skin biopsies are often performed in an attempt to render a diagnosis. Histologically, eosinophils are classically associated with hypersensitivity reactions, and their presence in inflamed tissue is considered suggestive of a drug-induced dermatitis. We present 3 cases of acute exanthema in BMT recipients in whom the presence of eosinophils on skin biopsy specimen led to an initial diagnosis of drug eruption over GvHD. As a result, these patients experienced delays in the institution of definitive immunosuppressive therapy for GvHD. We review the growing literature suggesting that no single or combined histologic feature, including tissue eosinophils, is useful in differentiating GvHD from drug eruptions in BMT recipients. Indeed, in most cases, the cause of a new-onset blanchable erythematous rash in a BMT recipient is most accurately determined by close examination and follow-up of the clinical features without a skin biopsy.

A multivariate approach for assessing severity of acute graft-versus-host disease in bone marrow transplantation

Patients undergoing bone marrow transplantation are at high risk of developing acute graft-versus-host disease (GVHD) which is a primary limiting factor for this procedure inasmuch as it is responsible for high morbidity rates and is associated with poor survival outcome. To provide improved treatment assessment and better interpretation of clinical outcomes, we need a precise and objective assessment of GVHD. Severity of GVHD is commonly assessed using an imprecise categorical grading system that incorporates skin, gut and liver grades, as well as subjective assessment of clinical performance. These organ grades are based on arbitrary cutpoints of skin rash, diarrhoea volume and bilirubin level. The International Bone Marrow Transplant Registry proposed an alternative grading system based on different combinations of organ involvement and provided estimates of relative risk of treatment failure. On the basis of that work, we developed an empirical mathematical model that quantifies GVHD severity, and that uses continuous, rather than categorical, daily measurements for each organ system. We use model-predicted values as an index of severity for any combination of values. The proposed index allows a more precise comparison of GVHD profiles across different treatment protocols and also permits more refined analyses to address relationships between GVHD and clinical outcomes.

Image cytometry in early graft-versus-host disease

Image cytometry was used to measure the size, shape, and texture of lymphocyte nuclei in 24 skin biopsy specimens retrospectively selected from patients with early, nonspecific, graft-versus-host disease (GVHD)-like eruptions. Half of these patients had progressed to overt GVHD, whereas half had never developed more than a mild nonspecific eruption. Significant differences were detected in the nuclear texture of the eruptions of the two groups, but the differences were not consistent enough to suggest that image cytometry might play a significant role in recognition of early GVHD.

"Rush" skin biopsy specimens in a tertiary medical center: diagnostic yield and clinical utility

BACKGROUND

Skin biopsy specimens are submitted for "rush" or "stat" processing, thereby indicating a sense of urgency about the clinical situation.

OBJECTIVE

Our purpose was to determine the patient population who underwent biopsy on a "rush" basis and assess the way in which interpretation of the skin biopsy specimen influences clinical management.

METHODS

A retrospective study was performed on the "rush" biopsy specimens sequentially requested during 1 year. Histologic findings, the clinical situation, and the effect of the biopsy result on clinical management were determined.

RESULTS

A total of 90 adult patients, many critically ill, were identified. The majority of patients were admitted to hematology-oncology services (58%). The other 42% were admitted to a variety of clinical services. The chief clinical concerns in hematology-oncology patients were graft-versus-host disease and cutaneous infection. Only 5.5% of biopsy specimens taken to exclude graft-versus-host disease were used in immediate clinical decision-making compared with 45% of biopsy specimens for oncology patients with suspected infection and 42% for all other services.

CONCLUSION

Many urgent skin biopsy specimens were not used for immediate clinical decision-making. The usefulness of skin biopsy varies with the clinical situation, and some situations are more prone to yield equivocal histologic data. Knowledge of these situations may reduce the number of unhelpful biopsy specimens. Therapy based on clinical findings had often been initiated before receiving the biopsy results, but biopsy findings are often helpful as confirmatory data. Diagnostic findings were not necessary for a biopsy specimen to provide useful data and nonspecific findings interpreted in light of clinical findings were also useful.

Value of skin biopsies in assessing prognosis and progression of acute graft-versus-host disease

Skin biopsies are commonly performed after allogeneic bone marrow transplantation (BMT) to help establish the origin of a new skin rash in a transplant recipient. Histologic criteria and a grading system for acute graft-versus-host reaction of the skin are well established. Histologic diagnosis, however, can be difficult and is based on interpretation of subtle changes that show significant overlap with features seen in other entities that can be responsible for a skin rash in the posttransplantation period such as drug reactions, viral exanthems, and the effects of chemotherapy. We retrospectively reviewed 179 skin biopsies from 137 patients who had undergone allogeneic BMT. We compared 98 skin biopsies from 71 patients with acute graft-versus-host disease (GvHD) with 81 biopsies from 66 patients who underwent biopsy to exclude GvHD but did not go on to develop the disease on clinical grounds. Two observers reviewed each slide without knowledge of the clinical situation and graded 16 histologic parameters. No single parameter (e.g., dyskeratotic keratinocytes, basal vacuolization, satellitosis, necrotic cells in appendages) achieved statistical significance on univariate analysis. A search for factors to separate GvHD biopsies from non-GvHD biopsies using logistic regression failed to reveal a single best predictor or a combination of predictors. We conclude that skin biopsies after allogeneic BMT are of limited use in predicting the progression of a skin rash to clinical grade II or higher GvHD.

Graft-vs.-host disease

Bone marrow transplantation (BMT) is the treatment of choice for many leukemias, lymphomas, bone marrow failure syndromes, and immunodeficiency disorders, and is the primary and salvage therapy for many solid malignancies. With the establishment of national and international marrow banks, unrelated allogeneic BMT is being performed with increasing frequency. Graft-vs.-host disease (GVHD) remains a major complication of allogeneic BMT, occurring in 25% to 70% of patients despite GVHD prophylaxis, with the skin, gastro-intestinal tract, and liver as primary target organs. Oral findings are seen in both acute and chronic GVHD. In acute GVHD, the oral lesions are often painful, erythematous, ulcerative, and desquamative. In chronic GVHD, they are lichenoid with associated erythema and ulcerations; additionally, they may be associated with a sicca syndrome characterized by xerostomia and progressive salivary gland atrophy. General principles of BMT are discussed, as are systemic and local therapeutic options for oral GVHD.

Immunohistochemical study of graft-versus-host reaction (GVHR)-type drug eruptions

Skin biopsies of graft-versus-host reaction (GVHR)-type drug eruptions in the acute phase were compared immunohistochemically with those in the chronic phase and also with non-GVHR type drug eruptions in the acute phase. Predominance of CD8+ T cells in the epidermal infiltrates, reduction in the number of epidermal OKT6+ dendritic cells (Langerhans cells), and increased expression of HLA-DR and ICAM-1 on keratinocytes were observed in the acute phase of GVHR-type, but not in either the chronic phase of GVHR-type or the acute non-GVHR type. These findings were similar to those of previous reports on skin lesions of acute GVH disease (GVHD) seen after bone marrow transplantation. Therefore, immunohistochemistry is not useful for differential diagnosis between acute GVHR-type drug eruptions and acute cutaneous GVHD. These findings also indicate that similar immunomechanisms may be involved in the pathogenesis of both GVHR-type drug eruptions and cutaneous GVHD.

Clinical, laboratory, and histopathologic indicators of the development of progressive acute graft-versus-host disease

Graft-versus-host disease (GvHD) is the major cause of morbidity and mortality following bone marrow transplantation (BMT). The goal of this study of 69 cyclosporin-treated, allogeneic BMT patients was to identify early clinical, laboratory, or histopathologic indicators of the development of progressive, fatal GvHD. Peak values within 100 d of allogeneic BMT for total bilirubin, stool volume in a day, clinical stage of cutaneous GvHD (based on extent of rash), and overall clinical stage of GvHD (based on a combination of graft-versus-host reactions in the skin, liver, and gastrointestinal tract) were most useful (p less than 0.05, by logistic regression) in identifying those patients with clinically progressive and fatal GvHD. Peak values for each of these parameters were reached an average of 40 d or less after BMT. Each unit increase in peak clinical stage of rash (e.g., stage 2 versus stage 3) was associated with an odds ratio incremental risk of 5.8 for clinical progression of GvHD, and each tenfold increase in peak total bilirubin (e.g., 2 mg/dl versus 20 mg/dl) or stool output in a day (e.g., 100 cm3/d versus 1000 cm3/d) was associated with an incremental risk of 8.4 and 10.6, respectively, for a fatal outcome from GvHD. Number of exocytosed lymphocytes and dyskeratotic epidermal keratinocytes (DEK) per linear millimeter of epidermis, the presence of follicular involvement, and the degree of dermal perivascular lymphocytic infiltration in 121 skin biopsy specimens were not associated with the development of progressive or fatal GvHD. Pretransplant total body irradiation was associated (p = 0.03, by Mann-Whitney U testing) with an increased number of DEK in skin biopsy specimens taken less than 20 d after BMT. This study demonstrates that monitoring of total bilirubin, stool output, extent of rash, and overall clinical stage of GvHD is most useful during the first 40 d after BMT in formulating the prognosis of early acute GvHD in allogeneic BMT patients receiving cyclosporin.

Epidermal Langerhans cells, dermal dendritic cells, and keratinocytes in viral lesions of skin and mucous membranes: an immunohistochemical study

We wanted to evaluate the eventual expression of viral antigens and MHC class II products by keratinocytes as well as the alterations of epidermal Langerhans cells and dermal dendritic cells in viral lesions of skin and mucous membranes. Therefore we investigated 68 biopsy specimens of protracted viral lesions, such as warts, condylomas, and mollusca contagiosa, and of rapidly resolving viral lesions such as herpes simplex virus infection. For this we used immunohistochemical staining techniques and several monoclonal and polyclonal antisera. In most cases investigated viral antigens (human papilloma virus antigens or herpes simplex virus type 1 antigens) could be demonstrated in keratinocytic nuclei. Except for a few viral lesions in which epidermal Langerhans cells were rather numerous, epidermal Langerhans cells were reduced in number or absent in almost all viral lesions. Moreover, epidermal Langerhans cells and dermal dendritic cells showed changes in morphology, distribution, and immunophenotype. These alterations may be caused by a toxic effect of the virus on dendritic cells. HLA-DR+ keratinocytes could be identified in few viral lesions only; HLA-DQ+ keratinocytes were not seen. Possible explanations for this lack of MHC class II expression by keratinocytes are discussed.