Psoriasiform Eruption Associated With Graft-Versus-Host ... - Cutis

Psoriasiform Eruption Associated With
Graft-Versus-Host Disease
Shijima Taguchi, MD; Yasuhiro Kawachi, MD; Yasuhiro Fujisawa, MD; Yasuhiro Nakamura, MD;
Junichi Furuta, MD; Fujio Otsuka, MD
Practice Points
Typical cutaneous manifestations of acute graft-versus-host disease (GVHD) are maculopapular eruptions
and perifollicular papules.
Psoriasiform eruption can occur as a rare manifestation of acute GVHD.
Graft-versus-host disease (GVHD) is a frequent
complication of bone marrow transplantation
(BMT) that can be classified as acute or
chronic. Characteristic cutaneous manifestations
of acute GVHD, which generally occurs within
3 months following BMT, include maculopapular
exanthema and perifollicular papular lesions. Psoriasiform
skin eruption as a manifestation of acute
GVHD is rare. We report the case of a 4-year-old
boy who developed a generalized psoriasiform
eruption shortly after undergoing an allogeneic
BMT. Histologic features of both psoriasis and
acute GVHD were present.
Cutis. 2013;92:151-153.
Graft-versus-host disease (GVHD) is a frequent
complication of bone marrow transplantation
(BMT) that can be classified as
acute or chronic. 1 Characteristic cutaneous manifestations
of acute GVHD, which generally occur
within 3 months following BMT, include maculopapular
exanthema and perifollicular papular lesions.
Chronic GVHD, which usually occurs more than
3 months after BMT, typically presents as lichen planus
or scleroderma. 1 We report a rare case of acute
cutaneous GVHD mimicking psoriasis vulgaris in a
4-year-old boy following allogeneic BMT.
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Case Report
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A 4-year-old boy was diagnosed with acute lymphocytic
leukemia (pro-B acute lymphoblastic leukemia,
biphenotypic type). The patient had no history of
rash or arthropathy, and his parents had no symptoms
or history of psoriasis. He underwent allogeneic
From the Department of Dermatology, Faculty of Medicine, University
of Tsukuba, Japan.
The authors report no conflict of interest.
Correspondence: Yasuhiro Kawachi, MD, Department of
Dermatology, Faculty of Medicine, University of Tsukuba, 1-1-1,
Tennodai, Tsukuba 305-8575, Japan (kyasuhir@md.tsukuba.ac.jp).
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BMT from an unrelated HLA antigen–matched
female donor with no documented history of psoriasis.
The patient received prophylactic treatment
against GVHD, which included oral tacrolimus
(average dose, 0.2 mg/kg daily) starting 1 day before
BMT. On day 60 following BMT, the dosage of tacrolimus
was tapered to 0.06 mg/kg daily. The patient
developed patchy erythema on the face, trunk,
and extremities with no other general symptoms
(Figure 1). The eruptions consisted of keratotic erythematous
papules and plaques with whitish scales
and clinical features that were similar to psoriasis.
Histopathology of a sample lesion from the abdomen
indicated acanthosis with elongation of rete ridges,
confluent parakeratosis with Munro microabscess,
and dilatation of blood vessels with perivascular
infiltration of lymphocytes in the upper dermis
(Figures 2A and 2B). Focal satellite cell necrosis
in the epidermis also was observed (Figure 2C).
Immunohistochemical studies indicated infiltration
of CD8 lymphocytes in the upper dermis and predominant
CD8 exocytotic cells in the epidermis.
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Psoriasiform Eruption Associated With GVHD
Additionally, a marked decrease in the number of
CD1a Langerhans cells was noted in the psoriatic
lesion in the epidermis compared to contiguous
normal skin (Figure 2D). Based on these clinical and
histopathologic findings, a diagnosis of psoriasiform
eruption associated with acute GVHD was made.
Systemic steroid therapy with oral prednisolone
(3 mg/kg daily) was administered for 2 weeks and
then was tapered slowly. After his skin lesions and
general condition rapidly improved, the patient was
discharged from the hospital 1 month later (day 118
following BMT); however, the eruptions recurred
when the dose of oral prednisolone was tapered to
1 mg/kg daily. As the patient’s condition worsened,
he returned to the hospital and was administered
oral methotrexate (10 mg weekly). Because this
treatment was effective, the patient left the hospital
after 2 weeks and his condition remained good thereafter
with the same treatment.
Comment
Cutaneous involvement is common in GVHD.
Typical cutaneous manifestations of acute GVHD
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include maculopapular eruptions and perifollicular
papules. 1 Psoriasiform eruptions following BMT are
rare. Several cases showing the development of
psoriasis vulgaris after BMT from donors with a history
of psoriasis or resolution of psoriasis after BMT
from a normal donor have been reported, 2,3 suggesting
an adoptive transfer of susceptibility to psoriasis
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from a donor
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with a genetic background of psoriasis.
Although it is possible that our case was the result of
transmission via BMT from a donor with nonsymptomatic
subclinical psoriasis, we treated the psoriasiform
eruptions in our patient as associated with acute
Figure 1. Widespread erythematous papules and GVHD rather than immunoadoptive psoriasis vulgaris
because the donor had no documented plaques with whitish scales on the back.
history
Figure 2. The epidermis
showed characteristic histopathologic
changes of psoriasis
with Munro microabscess (arrow
in B)(A and B)(H&E; original
magnifications 40 and 200,
respectively). Focal satellite cell
necrosis (arrow) of keratinocytes
was seen in the epidermis
(C)(H&E, original magnification
200). CD1a Langerhans cells
(arrows) were present in normal
skin (left) and absent in the
epidermis of the psoriatic lesion
(right)(D)(original magnification
40).
A
B
C
D
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Psoriasiform Eruption Associated With GVHD
of psoriasis. Histologically, satellite cell necrosis
and depletion of CD1a Langerhans cells from the
epidermis, which is characteristic of GVHD, 4 were
observed in the psoriasiform eruptions. According to
a PubMed search of articles indexed for MEDLINE
using the term graft-versus-host disease psoriasis,
2 other reports of psoriasiform eruptions associated
with GVHD have been reported in the literature. 5,6
Conclusion
We present a rare case of acute cutaneous GVHD
mimicking psoriasis vulgaris in a 4-year-old boy following
allogeneic BMT. Our case presents histologic
features of both psoriasis and acute GVHD.
REFERENCES
1. Aractingi S, Chosidow O. Cutaneous graft-versus-host disease.
Arch Dermatol. 1998;134:602-612.
2. Masszi T, Farkas A, Remenyi P, et al. Ten-year remission
of psoriasis after allogeneic but not autologous
bone marrow transplantation. Dermatology. 2006;212:
88-89.
3. Slavin S, Nagler A, Varadi G, et al. Graft vs autoimmunity
following allogeneic non-myeloablative blood stem
cell transplantation in a patient with chronic myelogenous
leukemia and severe systemic psoriasis and psoriatic polyarthritis.
Exp Hematol. 2000;28:853-857.
4. Lampert IA, Janossy G, Suitters AJ, et al. Immunological
analysis of the skin in graft versus host disease. Clin Exp
Immunol. 1982;50:123-131.
5. Kawakami Y, Oyama N, Nakamura K, et al. Psoriasiform
eruption associated with graft-versus-host disease. Acta
Derm Venereol. 2007;87:436-438.
6. Matsushita T, Hasegawa M, Shirasaki F, et al. A case of
acute cutaneous graft-versus-host disease mimicking psoriasis
vulgaris. Dermatology. 2008;216:64-67.
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