Graft-versus-host disease after liver transplantation complicated by systemic aspergillosis with pancarditis

Acute graft-versus-host disease (GVHD) is a common complication after bone marrow transplantation, with characteristic rash and diarrhea being the mos t common features. After liver transplantation, however, this phenomenon is very rare. Most transplant patients are on a variety of medications, inclu ding immunosuppressants; therefore, the differential diagnosis of skin rash or diarrhea is broad. A 37-year-old man who underwent liver transplantatio n for primary biliary cirrhosis, and developed a rash and watery diarrhea, is presented. Skin and colonic biopsies confirmed acute GVHD. A pulse of in travenous steroids was given. The skin rash improved, but he developed panc ytopenia. His course was complicated by central line infection, jugular and subclavian vein thrombosis, pseudomembranous colitis, recurrent bacteremia , cholestasis on total parenteral nutrition and cytomegalovirus infection. After the onset of pleuritic chest pain and clinical sepsis, spiral compute d tomography scan of his chest and abdomen revealed septic infarcts in mult iple organs. Despite empirical treatment with amphotericin B, he died of mu ltiorgan dysfunction syndrome within 72 h. Autopsy revealed systemic asperg illosis with pancarditis, endocardial vegetations, and septic pulmonary, sp lenic, hepatic and renal infarcts. The pathogenesis and experience with thi s rare, but often fatal, complication of liver transplantation are reviewed . In contrast to GVHD after bone marrow transplantation, pancytopenia is co mmon and liver dysfunction is rare. One should have a high level of suspici on in the liver transplant recipient presenting with rash and/or diarrhea.