Late appearance of acute graft-vs-host disease after suspending or tapering immunosuppressive drugs

Background: Graft-vs-host disease (GVHD) is divided into acute and chronic phases based on time and clinical and histological features. The criterion of 100 days after transplantation for separating acute GVHD from chronic GV HD has been challenged on the following points: (1) the lichenoid rash of c hronic GVHD may be observed as early as day 31 and acute GVHD may persist a fter day 100 in some cases, and (2) specific histological features do not c onsistently separate acute from chronic GVHD defined as the number of days after transplantation. However, the appearance of acute cutaneous GVHD afte r day 100 is not well established. Observations: Three patients developed a rash with clinical and histologica l features of acute GVHD between days 153 and 192 after allogeneic bone mar row transplantation or peripheral blood stem cell transplantation. III all patients, the late flare of acute GVHD occurred after tapering or suspendin g the immunosuppressive regimen with cyclosporine or corticosteroids, and w as accompanied by stigmata of chronic GVHD in other target organs. Conclusions: The rash of acute GVHD may be observed as late as 192 days aft er transplantation, especially after tapering or suspending the immunosuppr essive drugs, and should be considered in the differential diagnosis of lat e erythematous eruptions after transplantation.