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Y. Tsunemi, H. Ihn, H. Saeki, K. Tamaki, Epithelioid granulomas in post‐transplantation chronic graft‐vs.‐host disease, British Journal of Dermatology, Volume 149, Issue 4, 1 October 2003, Pages 898–899, https://doi.org/10.1046/j.1365-2133.2003.05581.x
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Sir, Chronic graft‐vs.‐host disease (cGVHD) demonstrates various clinical and laboratory findings. There are, however, no reports of granulomatous lesion associated with cGVHD.
We herein describe a patient with cGVHD who showed histopathological findings composed of both the lichenoid reaction of cGVHD and epithelioid granulomas.
A 27‐year‐old Japanese woman was diagnosed as having chronic myeloid leukaemia in June 1996 and was treated with bone marrow transplantation from an HLA‐matched unrelated male donor in April 1998. She experienced acute GVHD including liver dysfunction, diarrhoea and skin eruption, and cGVHD including liver dysfunction and skin eruption of early lichenoid phase and late sclerotic phase. Treatment for cGVHD with prednisolone and ciclosporin was begun in September 1998.
In July 2002, when she was taking 125 mg of ciclosporin every other day without any signs of cGVHD, she noted skin eruptions on the thighs and legs. These eruptions began to spread to the upper extremities, chest and abdomen. Clinical examination revealed bean‐sized indurated scaly annular erythematous macules in the upper and lower extremities and half‐rice sized erythematous or brownish papules arranged annularly in the chest and abdomen (Fig. 1a,b). A biopsy specimen taken from the leg showed exocytosis of lymphocytes in the epidermis, follicles and eccrine glands, liquefactive degeneration of the basal layer, and poorly demarcated granulomas without caseation necrosis, composed of epithelioid histiocytes, Langhans‐type multinucleated giant cells and many lymphocytes in the dermis. These granulomas were located close to the epidermis and the appendages (Fig. 2). Immunohistochemical study revealed that keratinocytes overlaying the granulomas were positive for HLA‐DR and CD1a+ cells in the epidermis were decreased. CD4+ lymphocytes and CD8+ lymphocytes infiltrated into the epidermis. Lymphocytes forming the granulomas were mostly positive for CD4 and strongly positive for CD45RO. Direct immunofluorescence study revealed granular deposition of C3 along the basement membrane zone. Ziehl–Neelsen stain showed no acid‐fast bacteria. Abnormal laboratory data were as follows: mild anaemia, elevated levels of serum angiotensin‐converting enzyme (ACE) (35·3 IU L−1; normal < 21·4), positive PCNA‐like antinuclear antibody at a titre of 1 : 320. Chest X‐ray, chest computed tomography, spirography, electrocardiogram, cardiac ultrasonography and ophthalmological studies showed no abnormal findings.
