Solid organ graft-versus-host disease in a recipient of a COVID-19 positive liver graft

N Ashcherkin; S Pisipati; J Athale; E J Carey; D Chascsa; J Adamski; S Shah

doi:10.1016/j.liver.2023.100154

Solid organ graft-versus-host disease in a recipient of a COVID-19 positive liver graft

J Liver Transpl. 2023 May:10:100154. doi: 10.1016/j.liver.2023.100154. Epub 2023 Apr 19.

Authors

N Ashcherkin¹, S Pisipati², J Athale^{3

4}, E J Carey^{2

5}, D Chascsa^{2

5}, J Adamski⁶, S Shah⁴

Affiliations

¹ Department of Internal Medicine, Mayo Clinic, AZ, USA.
² Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, USA.
³ Department of Critical Care, Mayo Clinic Arizona, USA.
⁴ Division of Hematology and Medical Oncology, Mayo Clinic Arizona, USA.
⁵ Transplant Center, Mayo Clinic Arizona, USA.
⁶ Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, USA.

Abstract

A 66-year-old male with end-stage liver disease (ESLD) secondary to non-alcoholic fatty liver disease (NAFLD), complicated by hepatocellular carcinoma (HCC), underwent deceased donor liver transplantation from a Coronavirus disease 2019 (COVID-19) positive donor. He presented a month later with fever, diarrhea and pancytopenia which led to hospitalization. The hospital course was notable for respiratory failure, attributed to invasive aspergillosis, as well as a diffuse rash. A bone marrow biopsy revealed hypocellular marrow without specific findings. In the following days, laboratory parameters raised concern for secondary hemophagocytic lymphohistiocytosis (HLH). Clinical concern also grew for solid organ transplant graft-versus-host-disease (SOT-GVHD) based on repeat marrow biopsy with elevated donor-derived CD3+ T cells on chimerism. After, a multidisciplinary discussion, the patient was started on ruxolitinib, in addition to high dose steroids, to address both SOT-GVHD and secondary HLH. Patient developed symptoms concerning for hemorrhagic stroke and was transitioned to comfort care. Although GVHD has been studied extensively in hematopoietic stem cell transplant (HSCT) patients, it is a rare entity in SOT with a lack of guidelines for management. Additionally, whether COVID-19 may play a role in development of SOT-GVDH has not been explored.

Keywords: End-stage liver disease; Hemophagocytic lymphohistiocytosis; Non-alcoholic fatty liver disease; Solid-organ transplant graftversus-host disease.