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Xie L, Xu J, Xu H, Zhang B, Lin W, Yang T. Multiple autoimmune disorders refractory to glucocorticoids after allogeneic hematopoietic stem cell transplantation: a case report and review of the literature. Front Immunol 2024; 15:1366101. [PMID: 38707905 PMCID: PMC11066190 DOI: 10.3389/fimmu.2024.1366101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/08/2024] [Indexed: 05/07/2024] Open
Abstract
We report here the case of a 50-year-old man who was first diagnosed with myelodysplastic syndrome with excess blasts-2 (MDS-EB-2) and underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT) in 2019, resulting in complete remission. However, he was diagnosed in 2021 with several autoimmune disorders, including autoimmune hepatitis (AIH), Hashimoto's thyroiditis (HT), and autoimmune hemolytic anemia (AIHA). This is referred as multiple autoimmune syndrome (MAS), which is a rare occurrence after allo-HSCT, as previously noted in the literature. Despite being treated with glucocorticoids, cyclosporine A, and other medications, the patient did not fully recover. To address the glucocorticoid-refractory MAS, a four-week course of rituximab (RTX) at a weekly dose of 100mg was administered, which significantly improved the patient's condition. Thus, this case report underscores the importance of implementing alternative treatments in patients with post-transplant autoimmune diseases, who are glucocorticoid-refractory or glucocorticoid-dependent, and highlights the effectiveness of RTX as second-line therapy.
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Affiliation(s)
- Linjun Xie
- Department of Hematology, The First Hospital of Putian City, Putian, China
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Jingjing Xu
- Department of Hematology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Hematology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Institute of Precision Medicine, Fujian Medical University, Fuzhou, China
| | - Huiping Xu
- Department of Clinical Nutrition, The First Hospital of Putian City, Putian, China
| | - Beibei Zhang
- Department of Hematology, The First Hospital of Putian City, Putian, China
| | - Wuqiang Lin
- Department of Hematology, The First Hospital of Putian City, Putian, China
| | - Ting Yang
- Department of Hematology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Hematology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Institute of Precision Medicine, Fujian Medical University, Fuzhou, China
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Stueck AE, Fiel MI. Hepatic graft-versus-host disease: what we know, when to biopsy, and how to diagnose. Hum Pathol 2023; 141:170-182. [PMID: 37541449 DOI: 10.1016/j.humpath.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/19/2023] [Accepted: 07/24/2023] [Indexed: 08/06/2023]
Abstract
Graft-versus-host disease (GVHD) is one of the serious complications that may develop after hematopoietic cell transplantation (HCT), for hematologic malignancies, solid organ transplantation, and other hematologic disorders. GVHD develops due to T lymphocytes present in the graft attacking the host antigens, which results in tissue damage. A significant number of HCT patients develop acute or chronic GVHD, which may affect multiple organs including the liver. The diagnosis of hepatic GVHD (hGVHD) is challenging as many other conditions in HCT patients may lead to liver dysfunction. Particularly challenging among the various conditions that give rise to liver dysfunction is differentiating sinusoidal obstruction syndrome and drug-induced liver injury (DILI) from hGVHD on clinical grounds and laboratory tests. Despite the minimal risks involved in performing a liver biopsy, the information gleaned from the histopathologic changes may help in the management of these very complex patients. There is a spectrum of histologic features found in hGVHD, and most involve histopathologic changes affecting the interlobular bile ducts. These include nuclear and cytoplasmic abnormalities including dysmorphic bile ducts, apoptosis, and cholangiocyte necrosis, among others. The hepatitic form of hGVHD typically shows severe acute hepatitis. With chronic hGVHD, there is progressive bile duct loss and eventually fibrosis. Accurate diagnosis of hGVHD is paramount so that timely treatment and management can be initiated. Techniques to prevent and lower the risk of GVHD from developing have recently evolved. If a diagnosis of acute GVHD is made, the first-line of treatment is steroids. Recurrence is common and steroid resistance or dependency is not unusual in this setting. Second-line therapies differ among institutions and have not been uniformly established. The development of GVHD, particularly hGVHD, is associated with increased morbidity and mortality.
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Affiliation(s)
- Ashley E Stueck
- Department of Pathology, Dalhousie University, 715 - 5788 University Avenue, Halifax, NS, B3H 2Y9, Canada.
| | - M Isabel Fiel
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA.
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Sato N, Marubashi S. How is transfusion-associated graft-versus-host disease similar to, yet different from, organ transplantation-associated graft-versus-host disease? Transfus Apher Sci 2022; 61:103406. [DOI: 10.1016/j.transci.2022.103406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Okamura-Shiki I, Moriguchi M, Uehara T, Fukaya M, Kakuda Y, Nakanuma Y, Ikeda T. Levothyroxine tablet (Thyradin-S)-induced autoimmune-like hepatitis following post-transplant Hashimoto's thyroiditis in a patient after allogenic bone marrow transplantation. Leuk Lymphoma 2019; 60:2082-2084. [PMID: 31204871 DOI: 10.1080/10428194.2018.1563695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Ikue Okamura-Shiki
- a Division of Hematology and Stem Cell Transplantation , Shizuoka Cancer Center , Shizuoka , Japan
| | - Michihisa Moriguchi
- b Division of Interventional Radiology , Shizuoka Cancer Center , Shizuoka , Japan.,c Department of Molecular Gastroenterology and Hepatology , Kyoto Prefectural University of Medicine, Graduate School of Medical Science , Kyoto , Japan
| | - Tokiko Uehara
- d Division of Internal Medicine of Endocrinology and Metabolism , Atami Hospital, International University of Health and Welfare , Shizuoka , Japan
| | - Masafumi Fukaya
- a Division of Hematology and Stem Cell Transplantation , Shizuoka Cancer Center , Shizuoka , Japan
| | - Yuko Kakuda
- e Division of Pathology , Shizuoka Cancer Center , Shizuoka , Japan
| | - Yasuni Nakanuma
- e Division of Pathology , Shizuoka Cancer Center , Shizuoka , Japan
| | - Takashi Ikeda
- a Division of Hematology and Stem Cell Transplantation , Shizuoka Cancer Center , Shizuoka , Japan
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Clinical association of anti-glutathione S-transferase T1 antibodies and de novo immune hepatitis after hematopoietic cell transplantation. Dig Liver Dis 2018; 50:418-419. [PMID: 29409781 DOI: 10.1016/j.dld.2017.12.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 12/29/2017] [Indexed: 12/11/2022]
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Koyama D, Ito M, Yokohata E, Watakabe K, Onodera K, Goto T, Seto A, Watanabe K, Doisaki M, Ozawa Y, Yamaguchi T, Miyamura K. Autoimmune-like hepatitis after allogeneic hematopoietic stem cell transplantation: humoral hepatic GvHD. Bone Marrow Transplant 2016; 52:151-153. [DOI: 10.1038/bmt.2016.202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Abstract
A 59-year-old female received a matched related donor stem cell transplant for chronic myelogenous leukemia. After being successfully treated with prednisone for chronic graft versus host disease that initially started 50 days posttransplant, she developed hepatic dysfunction during the steroid taper on day 531, as evidenced by jaundice, elevated liver enzymes, and increased bilirubin. Liver biopsy showed histology suggestive of autoimmune-like hepatitis, which is a rare manifestation of chronic “hepatitic” graft versus host disease.
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Affiliation(s)
- Nick M. Baniak
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Rani Kanthan
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Zeidan AM, Wozney JL, Torbenson M, Krok K, Bolaños-Meade J. Successful treatment of severe refractory hepatic graft-versus-host disease by cadaveric liver transplant. Leuk Lymphoma 2013; 54:2756-9. [PMID: 23517590 DOI: 10.3109/10428194.2013.788178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Amer M Zeidan
- Department of Oncology, the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University , Baltimore, MD , USA
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Beleoken E, Sobesky R, Le Caer JP, Le Naour F, Sebagh M, Moniaux N, Roche B, Mustafa MZ, Guettier C, Johanet C, Samuel D, Bouhris JH, Duclos-Vallee JC, Ballot E. Immunoproteomic analysis of potentially severe non-graft-versus-host disease hepatitis after allogenic bone marrow transplantation. Hepatology 2013; 57:689-99. [PMID: 22911395 DOI: 10.1002/hep.26024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 08/06/2012] [Indexed: 02/06/2023]
Abstract
UNLABELLED The development of potentially severe non-graft-versus-host disease (GVHD) hepatitis resembling autoimmune hepatitis (AIH) has been reported after bone marrow transplantation (BMT). The aim of this study was to better characterize this form of hepatitis, particularly through the identification of autoantigens recognized by patient sera. Five patients who received an allogeneic BMT for the treatment of hematological diseases developed liver dysfunction with histological features suggestive of AIH. Before and during the onset of hepatic dysfunction, sera were tested on immunoblottings performed with cytosolic, microsomal, mitochondrial, and nuclear proteins from rat liver homogenate and resolved by two-dimensional electrophoresis. Antigenic targets were identified by mass spectrometry. During the year that followed BMT, all patients presented with GVHD. Acute hepatitis then occurred after the withdrawal, or during the tapering, of immunosuppressive therapy. At that time, no patients had a history of liver toxic drug absorption, patent viral infection, or any histopathological findings consistent with GVHD. Immunoreactive spots stained by sera collected at the time of hepatic dysfunction were more numerous and more intensely expressed than those stained by sera collected before. Considerable patient-dependent pattern heterogeneity was observed. Among the 259 spots stained exclusively by sera collected at the time of hepatitis, a total of 240 spots were identified, corresponding to 103 different proteins. Twelve of them were recognized by sera from 3 patients. CONCLUSIONS This is the first immunological description of potentially severe non-GVHD hepatitis occurring after BMT, determined using a proteomic approach and enabling a discussion of the mechanisms that transform an alloimmune reaction into an autoimmune response. Any decision to withdraw immunosuppression after allogeneic BMT should be made with caution.
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Narita A, Muramatsu H, Takahashi Y, Sakaguchi H, Doisaki S, Nishio N, Hama A, Shimada A, Ito M, Kojima S. Autoimmune-like hepatitis following unrelated BMT successfully treated with rituximab. Bone Marrow Transplant 2011; 47:600-2. [PMID: 21666737 DOI: 10.1038/bmt.2011.124] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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