When donor T cells attack: The curious case of liver transplant-associated acute graft-versus-host-disease.

Graft versus host disease is a rare but deadly complication of solid organ transplant. Clinical features of graft-versus-host-disease are non-specific, which may lead to delayed diagnosis as more common conditions including infections or drug reactions are considered. We describe a 54-year-old male patient who underwent liver transplantation for alcohol use disorder-related cirrhosis and developed acute graft-versus-host disease. Initial clinical presentation included dermatitis, bone marrow failure and enteritis. Results of skin biopsy and cytogenetic studies were consistent with liver transplant-associated acute graft-versus-host disease. The importance of this case is to highlight to transplant physicians and surgeons the challenges of diagnosing graft-versus-host-disease. In our case, pre-existing partnerships among the liver and hematopoietic stem cell transplant teams, transfusion medicine specialists, critical care specialists and facilitated timely communication relevant to confirming graft-versus-host disease. We propose an algorithm to assist in the workup of suspected graft-versus-host disease. Because this condition is characterized by high mortality, a high index of suspicion is imperative for prompt diagnosis and optimal management of the donor-recipient immune interaction when patients present with classic clinical features.

The impact of red blood cell transfusion on mortality and treatment efficacy in patients treated with radiation: A systematic review.

INTRODUCTION: Packed red blood cell (RBC) transfusion is frequently used in patients undergoing radiotherapy (RT) because retrospective data suggest that anemic patients may respond sub-optimally to RT. No high-quality evidence currently exists to guide transfusion practices and establish hemoglobin (Hb) transfusion thresholds for this patient population, and practice varies significantly across centers. This systematic review investigated whether maintaining higher Hb via transfusion in radiation oncology patients leads to improved outcomes. METHODS: We performed a literature search of studies comparing RBC transfusion thresholds in radiation oncology patients. Included studies assessed patients receiving RT for malignancy of any diagnosis or stage. Excluded studies did not evaluate Hb or transfusion as an intervention or outcome. The primary outcome was overall survival. Secondary outcomes included locoregional control, number of transfusions and adverse events. RESULTS: One study met inclusion criteria. The study pooled results from two randomized controlled trials that stratified anemic patients with head and neck squamous cell carcinoma to RBC transfusion versus no transfusion. The study found no significant differences in overall survival or locoregional control after five years, despite increased Hb levels in the transfused group. We conducted a narrative review by extracting data from 10 non-comparative studies involving transfusion in patients receiving RT. Results demonstrated no consistent conclusions regarding whether transfusions improve or worsen outcomes. CONCLUSIONS: There is a lack of data on the effects of RBC transfusion on outcomes in patients undergoing RT. Well-designed prospective studies are needed in this area.

Muscle aches and pains: do I have leukemia?

We describe a 65-year-old man who presented with 'aches and pains' localized to the lower extremities, and was diagnosed with acute myeloid leukemia (AML). We hypothesize that this case represents an atypical presentation of AML with an immune-mediated necrotizing-like myopathy as a possible paraneoplastic manifestation of the disease, which improved after initiating chemotherapy. Our patient received a full course of 7 + 3 chemotherapy with cytarabine and daunorubicin. Proximal leg weakness and pain improved markedly following this treatment, establishing a temporal relationship between the possible paraneoplastic manifestation and treatment of underlying disease. Associations between malignancy and myopathies such as polymyositis and dermatomyositis have been well established in the literature. However, paraneoplastic IMNM is still a rare clinical phenomenon and has infrequently been associated with AML. This case may suggest myopathy and associated muscle 'aches and pains' as possible presenting symptoms of underlying AML, highlighting the heterogeneity of the clinical manifestations of this disease.