Clinical Presentation And Pathobiology Of Acute Gvhd

GVHD occurs in two forms, "acute" and "chronic," defined separately by the timing of onset posttrans-plant and by differences in the clinical presentation and pathology of affected target organs. Acute GVHD, by classical definition, is GVHD that occurs within 100 days of HSCT, usually around the time of leukocyte engraftment or shortly thereafter. Though this operational term is useful in delineating GVHD occurring immediately posttransplant from the more indolent and progressive changes of chronic GVHD, it is important to note that acute GVHD can occur beyond 100 days posttransplant, particularly in the setting of donor lymphocyte infusions (DLI) used in the prevention or treatment of disease relapse. There are three principal target tissues affected in acute GVHD—the skin, liver, and gut. Although the clinical staging and the overall grading of acute GVHD is based on the relative level of involvement of these three tissues (Table 98.1), other organs, especially the lymphoid tissues and the bone marrow, are targets of the GVHD reaction.

The most common tissue affected in acute GVHD is the skin, with over 80% of patients with GVHD manifesting skin eruptions.5 The typical skin presentation consists of a maculopapular rash that can resemble a sunburn, initially involving the ears, neck, shoulders, upper chest and back, and the palms and soles of the extremities. The extent of skin surface involved and the presence of bullae or desquamation define the different stages of skin involvement. The clinical findings of cutaneous GVHD are corroborated by histologic analysis of skin biopsy material, and, therefore, discrete pathologic criteria contribute to the diagnosis of cutaneous GVHD (Table 98.1).6 However, the characteristic pathologic changes of acute cutaneous GVHD are not

Table 98.1

Histologic grading for acute cutaneous GVHD

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