Columnar epidermal necrosis: a unique manifestation of transfusion-associated cutaneous graft-vs-host disease

Acquired ichthyosis as a manifestation of acute cutaneous graft-versus-host disease

Acquired ichythosis has been described in adult hematopoietic stem cell transplant recipients. While some authors have suggested the association of acquired ichythosis with cutaneous graft-versus-host disease, the evidence to support this association is rare. We describe a patient who developed enteritis secondary to acute graft-versus-host disease and had concomitant ichthyosiform lesions. Several months later, he was diagnosed with cutaneous graft-versus-host disease. This patient is presented to suggest that acquired ichthyosis is an underrecognized manifestation of acute cutaneous graft-versus-host disease. Given the important prognostic implications of this diagnosis, we recommend a low threshold for performing a skin biopsy to rule out GVHD in the appropriate clinical setting.

Life-threatening graft-vs-host disease

Hematopoietic stem cell transplant (SCT) is considered standard therapy for a variety of malignant and nonmalignant diseases. Graft-versus-host disease (GVHD) still represents today a major complication of hematopoietic SCT. Two types of GVHD have traditionally been recognized on the basis of the time of onset following transplantation, distinct pathobiological pathways, and different clinical presentations. The acute form commonly breaks out 2 to 6 weeks after transplantation, affecting up to 60% of patients receiving allogeneic transplants from HLA identical donors. Transfer of immunocompetent donor T cells contained in the graft may undergo alloreactivity against recipient cells because of major or minor histocompatibility antigens disparities between the donor and the immunosuppressed host. Target specificity in acute GVHD involves preferential injury to epithelial surfaces of the skin and mucous membranes, biliary ducts of the liver, and crypts of the intestinal tract. Chronic GVHD affects approximately 30% to 80% of patients surviving 6 months or longer after stem cell transplantation and is the leading cause of nonrelapse deaths occurring more than 2 years after transplantation. Chronic GVHD is a multiorgan syndrome with clinical features suggesting some autoimmune diseases, and possibly both alloreactive and autoreactive T cell clones are involved in its pathophysiology. Although GVHD may convey beneficial graft-versus-leukemia/lymphoma effects, it also entails a significant risk of morbidity and mortality. Patients with mild GVHD need only minimal, if any, immunosuppressive treatment, whereas prognosis of patients with extensive disease or resistant to standard immunosuppressive treatment may be dismal. Early recognition of GVHD followed by prompt therapeutic intervention may prevent the progression to higher-grade disease and improve the outcome for patients receiving hematopoietic SCT.

Lichen planus showing columnar epidermal necrosis

We describe a 9-year-old boy who presented with very itchy papules and plaques on both knees. Histologically, focal columnar epidermal necrosis was seen associated with features of classic lichen planus. A literature search using PubMed revealed that only two cases of transfusion-associated lichenoid graft-versus-host reaction showing columnar epidermal necrosis have been previously reported. Our case is the first of lichen planus showing columnar epidermal necrosis. In that lichenoid graft-versus-host reaction is a special form of lichen planus, it is possible to speculate that columnar epidermal necrosis may be a unique feature of lichen planus.