Gastrointestinal Bleeding, the First Presentation of Acute GVHD in Two Patients with Thalassemia after BMT

Abstract

Engraftment by donor lymphocytes in an immunologically compromised host can result in donor T-cell activation against host major histocompatibility complex antigens, with resultant GVHD. The acute form of GVHD (aGVHD) is characterized by erythroderma, cholestatic hepatitis, and enteritis. The intestinal symptoms of aGVHD include crampy abdominal pain and watery diarrhea, often with blood. The conditioning regimen and infectious agents may produce similar symptoms. Severe intestinal aGVHD is a life-threatening event and associated with high mortality. In this case report, we describe two patients with major thalassemia who experienced acute gastrointestinal GVHD. One of them experienced it after peripheral blood transplantation at day +13, and the other after bone marrow transplantation at day +14. The first presentation was severe GI bleeding, and then 2 litters per day diarrhea. Besides standard prophylaxis with Cyclosporine and Methotrexate, Methylprednisolone 2mg/kg per day commenced because GI bleeding started and afterward supportive treatment means were continued. Following administration of Methylprednisolone, the amount of GI bleeding and diarrhea declined; in addition, the need for whole blood transfusion and blood products decreased. Both children had no problem in follow-up. Engraftment evaluation by the VNTR method showed 100 percent validity. GI bleeding after transplantation can be a major presentation of aGVHD, which requires precise attention, and on-time treatment. The elimination of other causes of GI bleeding and diarrhea, in addition to the two other factors mentioned above, would increase the survival rate of patients greatly.