Answer: Corticosteroids, with cyclosporine or tacrolimus.
First-line therapy for acute graft versus host disease includes corticosteroids, in association with cyclosporine or tacrolimus.
- Clinical Background:
Graft versus host disease involves an immunologically mediated and injurious set of reactions by cells genetically disparate to their host, which can occur in solid organ and bone marrow tranplant recipients.
After bone marrow transplantation, T cells present in the graft, either as contaminants or intentionally introduced into the host, attack the tissues of the transplant recipient after perceiving host tissues as antigenically foreign. The T cells produce an excess of cytokines, including TNF alpha and interferon-gamma. A wide range of host antigens can initiate graft-versus-host-disease, among them the human leukocyte antigens.
Acute graft versus host disease occurs within the first 100 days following bone marrow transplant, and is a syndrome including dermatitis, hepatitis, and enteritis.
Chronic graft versus host disease occurs greater than 100 days following transplantation.
Rates of GVHD vary from between 30-40% among related donors and recipients to 60-80% between unrelated donors and recipients.
GVHD of the distal bowel and colon results in profuse diarrhea, intestinal bleeding, cramping, abdominal pain, and paralytic ileus.
Diagnosis of graft versus host disease is established by clinical judgment, imaging studies, laboratory workup, and biopsy results.
- Radiologic Findings:
Acute gastrointestinal GVHD in children characteristically appears on CT scans as multiple, diffuse, fluid-filled bowel loops with a thin, enhancing layer of bowel wall mucosa.
CT findings of acute GVHD in adults include a variety of bowel findings, including small-bowel wall thickening, engorgement of the vasa recta adjacent to affected bowel segments, stranding of the mesenteric fat, large-bowel wall thickening, and mucosal enhancement.
Cross sectional imaging may also reveal a loss of normal intestinal fold pattern and the intestine can take on a tubular appearance.
Primary prophylaxis for graft versus host disease includes cyclosporine and tacrolimus.
First-line treatment for acute GVHD includes high dose corticosteroids with cyclosporine or tacrolimus.
Treatment of chronic GVHD includes prednisone (a steroid) with or without cyclosporine. Other treatments include mycophenolate mofetil (CellCept) and tacrolimus (Prograf).
- Donnelly and Morris. Acute graft versus host disease in children. Radiology. 199: 265-268, 1996.
- Kalantari et al. CT Features with Pathologic Correlation of Acute Gastrointestinal Graft-Versus-Host Disease After Bone Marrow Transplantation in Adults. AJR. 181:1621-1625, 2003.
- Lee et al. Computed Body Tomography with MRI Correlation. Lippincott Williams and Wilkins. 2006: 805-806.
We welcome your feedback, please send questions and comments to Marcel Maya, MD