BMTCN Chapter 5: Graft-versus-Host Disease fully solved 2023

BMTCN Chapter 5: Graft-versus-Host Disease fully solved 2023 T.R. is a 28-year-old woman with acute myeloid leukemia in her second complete remission who is admitted for a matched unrelated allogeneic stem cell transplantation. Her conditioning regimen is as follows: Myeloablation (busulfan/cyclophosphamide) and immunosuppression with tacrolimus and methotrexate (5 mg/m2 on days +1, +3, +6, and +11). She did not receive methotrexate on day +11 because of severe mucositis. Her transplant course was complicated by mucositis, neutropenic fever, and Clostridium difficile diarrhea. T.R. had no symptoms of graft-versus-host disease (GVHD) during the hospital course. Her blood counts recovered, and she was discharged to home. Day +30 bone marrow showed 100% donor. A clinic visit on day +50 revealed a new maculopapular rash covering 40% of T.R.'s body. She is staged as grade 2. The skin biopsy is consistent with GVHD. What is the initial management? A. Check tacrolimus level. B. Start systemic steroids. C. Start topical steroids. D. A and C - correct answer D. A and C The patient's immunosuppressive drugs need to be at a therapeutic level. Try to use as little additional immunosuppression as is necessary to control GVHD so as to maintain allo- effect of the transplant against any residual leukemia. Often, grade 1 or 2 skin GVHD responds to topical steroids. T.R.'s tacrolimus level is therapeutic at 11. One week later, at the scheduled clinic visit, her rash has decreased to grade 1. T.R. reports "watery diarrhea" five times per day. She is admitted to the hospital for further evaluation and treatment. How should the patient be managed? (1) Continue PO medications. (2) Add antidiarrheal agents. (3) Rule out infectious etiology of diarrhea.