Associates' Presentations
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Wait! Is that blood irradiated? A man, a transfusion, a rash.

P.F. Harris, M.D. (Associate); E.C. Williams, University of Wisconsin - Madison, Madison, WI.

This is a case study of a 48 year old man who was in good health until 12/96 when he developed a flu-like illness. By the end of 1/97 the patient had developed protracted nausea and vomiting; a creatinine was 15 and a chest x-ray showed pulmonary infiltrates. He received two units of PRBC's due to pancytopenia. Renal biopsy showed interstitial nephritis. The patient subsequently developed a fever, a rash, GI bleeding, lever failure, and seizures. Serial bone marrow biopsies progressed from a 2% population of odd-appearing polyclonal T cells to complete marrow fibrosis. CSF also showed a 2% population of odd looking lymphocytes. Skin biopsy showed dermoepidermal apoptosis and perivascular infiltrates. The patient developed sepsis and died in 4/97. HLA typing of his blood showed DR 11, - ; whereas HLA typing of his buccal mucosa showed DR 11, 14. His mother's HLA type at DR was 13, 14 (no other living relatives). We concluded that the patient's circulating lymphocytes were not his own - he contracted graft-vs-host disease from a blood transfusion.

Discussion - Transfusion-associated graft-versus-host disease (TAGVHD) is a rare complication of transfusion of nonirradiated blood, occurring when lymphocyte-contaminated PRBC's from a donor homozygous for an HLA haplotype is transfused into a heterozygous recipient, traditionally thought only to occur in immunocompromised (e.g. leukemia) patients. Since the 1980's, TAGVHD in presumed immunocompetent patients has been recognized, but reports remain extremely rare. This is the first reported case of TAGVHD in a patient with renal failure and pancytopenia. It is also the first case report to document involvement of the CSF in TAGVHD. It may be time to expand the indications for irradiation of blood prior to transfusion.

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