A35 ACUTE HEPATITIS AS AN ATYPICAL PRESENTATION OF GRAFT-VERSUS-HOST DISEASE IN A PATIENT POST HEMATOPOIETIC STEM CELL TRANSPLANTATION

Graft-versus host disease (GVHD) is a complication of hematopoietic stem cell transplantation (HSCT) that frequently affects the gastrointestinal tract, but can also have hepatic, ophthalmic and dermatological manifestations at time of diagnosis. GVHD that affects the liver typically presents as a cholestatic transaminitis due to biliary tree damage and dysfunction. However, this is typically mild, delayed in the clinical timeline and rarely is the presenting symptom at time of diagnosis. To describe an atypical presentation with acute hepatitis in a patient with GVHD N/A A 20 year old man with early T-cell precursor acute lymphoblastic leukemia (BCR-ABL+) presented with an acute hepatitis 84 days after a second, matched 9/10, unrelated allogeneic HSCT for secondary failure of the first graft. Serum aspartate aminotransferase (AST), serum alanine aminotransferase (ALT), and serum alkaline phosphatase (ALP) levels were 700 IU/L and 1282 IU/L, and 576 IU/L respectively. His total bilirubin was 59 μmol/L. He previously had received myeloablative therapy for his initial HSCT, was transfusion dependent, but was requiring IVIG and granulocyte colony-stimulating factor in an attempt to achieve consistent engraftment. Otherwise, no other hepatotoxic medications were noted and viral causes were excluded (hepatitis A, B, C, E, VZV, CMV, HSV). On day 96, he developed a lower extremity rash with skin biopsy revealing an interface dermatitis with frequent dyskeratotic cells and multifocal epidermal-dermal separation. Subsequently, a liver biopsy was done that showed marked ductopenia (>80%), cholestasis; there was little to no inflammation or ductular reaction confirming GVHD. The patient was then started on high dose methylprednisone and cyclosporine on day 106 with clinical improvement. Our case highlights the importance of considering acute GVHD as part of the initial diagnosis of an acute transaminitis following HSCT. This was an atypical presentation because there were no documented cutaneous and gastrointestinal manifestations prior to diagnosis and no initial cholestatic hepatitis. Cutaneous GVHD initially presents at a median post-transplant day of 19, ranging from 5–47. Following the skin, the next most commonly affected organ is the liver in acute GVHD. The mechanism by which GVHD presents as a cholestatic versus hepatitis pattern has not been fully investigated. Some studies do suggest the overexpression of major histocompatibility complex class I antigens in hepatocytes, cytokine/T-cell subset interactions, and apoptosis induced Fas-Fas ligands may lead to this distinction. Finally, other causes of hepatocellular injury post HSCT must be excluded, including viral etiologies, drug induced, sudden withdrawl of immunosupressives, and preparative chemotherapeutic regimens. None

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