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Move over Lues: Graft-versus-host disease is the new mimicker king

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By Warren R. Heymann, MD
May 9, 2016

I have always been intrigued by graft-versus-host disease (GVH). I first learned of the disorder in my college immunology course when it was referred to as a cause of “runting syndrome” in mice.

In the context of transplant recipients, classical features of acute and chronic GVH are usually recognizable by the morbilliform (acute) and lichenoid or sclerodermoid (chronic) findings. Increasingly, however, unusual variants of GVH are being reported including atopic dermatitis-like (1), psoriasiform (2), icthythosis, keratosis pilaris-like, erythema-multiforme-like, exfoliative erythroderma, alopecia, or dyspigmentation (3).

Today, however, was the coup-de-grâce — reading about the acral verruca-like presentation of chronic graft-versus-host disease. I don’t know how long I would have treated these lesions like warts until I would have gotten around to biopsying them.

Park et al presented four cases with acral “warts” that were unresponsive to standard therapies such as cryotherapy or topical 5-fluorouracil. Because of their recalcitrance to therapy, biopsies were performed revealing hyperkeratosis, acanthosis, vacuolar alteration and dyskeratotic cells, consistent with verrucous GVH. The lesions resolved with topical tacrolimus, clobetasol, or other steroids (some with occlusion) (4).

I think there is a larger lesson here, other than recognizing that chronic GVH may present as acral warts. I’m beginning to think that if Osler were alive today, he would say that if one knows GVH, one knows medicine. Any diagnosis rendered in a transplant patient should be suspected as a potential GVH mimicker. If the patient does not respond quickly to an expected therapy, biopsies should be performed post haste, followed by a therapeutic shift, if appropriate.

1. Wei J, et al. Atopic dermatitis-like presentation of graft-versus-host disease: A novel form of chronic cutaneous graft-versus-host disease. J Am Acad Dermatol 2013; 69; 34-39.
2. Jang S, et al. Chronic graft-versus-host disease mimicking psoriasis in a patient with hemophagocytic lymphohistiocytosis. Ann Dermatol 2016; 28: 90-93
3. Kim SJ, et al. Clinicopathologic characteristics of cutaneous graft-versus-host diseases: A retrospective study in Korean patients. Int J Dermatol 2010; 49: 1386-92.
4. Park JH, et al. Acral verruca-like presentation of chronic graft-vs.-host disease. J Cutan Pathol 2016; 43: 236-241.

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