Skin Graft-versus-host Disease Following Autologous Stem Cell Transplantation for Multiple Myeloma
A 59-year-old man was diagnosed with kappa-light chain MM. Protein electrophoresis and assays revealed elevated kappa-light chain levels. He had a serum albumin level of 3.0 g/dl, a β2 microglobulin level of 12.6 mg/L, and renal insufficiency. Bone marrow examination revealed 39% atypical plasma cells with complex karyotypes including t(11;14), and plain radiographs showed multiple compression fractures in the thoracic vertebrae. The patient received induction chemotherapy with bortezomib, melphalan, and prednisone; he achieved a partial response after 2 courses of this regimen. He was then treated with a high dose of melphalan (200 mg/m2), followed by stem cell support in a cell dose of 4.65×106 CD34+ cells/kg.\nOn day 19 post-transplantation, the patient presented with fever and diffuse, erythematous, and maculopapular rashes covering 54% of his body surface area, including the trunk and extremities. Laboratory examination revealed mild anemia and a normal leukocyte count/differentiation. The C-reactive protein level was increased to 6.38 mg/dl (reference range, 0~0.3 mg/dl). However, an extensive workup for infectious etiologies was negative, and empiric antibiotic therapy proved to be ineffective. A skin biopsy taken from the trunk revealed exocytosis with basal vacuolar degeneration and sparse inflammatory infiltration in the dermis, being consistent with findings of auto-GVHD (). Periodic Acid Schiff (PAS), Gomori Methenamine Silver (GMS), and Ziehl-Neelson stainings of tissue sections were all negative, as were tissue cultures for bacteria and fungi. The skin rashes progressed, becoming intensely erythematous with desquamation. To treat such auto-GVHD symptoms, the patient was started on prednisone (0.5 mg/kg/day). The skin rashes began to resolve, but tapering of the steroid worsened his skin rashes, subsequently disturbing reduction in steroid doses for approximately 3 months.\nOn day 112 post-transplantation, the patient developed dyspnea with fever. He was diagnosed with Peumocystis jeroveci peumonia (PJP), and his conditions improved after sulfamethoxazole/trimethoprim (bactrim) treatment along with methylprednisolone (1 mg/kg) IV daily. It was noted that his skin rashes improved while the steroid doses were increased to treat hypoxia due to PJP. However, tapering of the steroid led to an aggravation of skin lesions with generalized erythroderma and desquamation. Eventually, the patient was re-started on methylprednisolone (1 mg/kg) IV daily. Currently, his skin rashes have improved on slow prednisone tapering ().