A 52-year-old
liver transplant recipient presented 8 months after
transplantation with oral
thrush, then 3 days later with
oral ulcers and a diffuse
rash, and 5 days later with an acutely reduced white blood cell count,
rash,
fever, and
diarrhea. Bone marrow biopsy revealed severe aplasia. Although
graft-versus-host disease (GVHD) was considered, the late onset of these symptoms was felt to render this etiology unlikely because GVHD usually occurs 2 to 6 weeks after
transplantation. All potentially myelosuppressive medications were discontinued, and the patient was treated with high doses of hematopoietic
growth factors. Because his symptoms continued, chimerism analysis was performed, which indicated that 96% of the peripheral blood mononuclear cells were of liver-donor origin. Ultimately, the patient underwent an allogeneic peripheral blood hematopoietic progenitor cell transplant from a
human leukocyte antigen-identical brother, but he died 5 days after
transplantation of overwhelming Candida kruseii
infection. To our knowledge, this is the first chimerism-analysis-documented case of severe acute GVHD presenting so late after
liver transplantation. It is of note that the patient had no known risks for GVHD in that he was relatively young and shared only one major
human leukocyte antigen with his donor. Consideration should be given to GVHD as a cause of bone marrow aplasia at any time after
organ transplantation. Storage of cell pellets from all transplant recipients and donors is highly recommended to facilitate the diagnostic evaluation.