Pancreas to Skin and Beyond: A Curious Case of Graft Versus Host Disease in a Kidney-Pancreas Transplant

A 51-year-old gentleman with complications from long-standing type 1 diabetes mellitus underwent simultaneous pancreas and pre-emptive kidney transplant at our center, with rabbit anti-thymocyte globulin and methylprednisolone induction. Three months post-transplant he presented for evaluation of a diffuse lichenoid cutaneous eruption. An extensive infectious workup was unrevealing, and skin punch biopsy showed interface vacuolar dermatitis, suggestive of graft-versus-host disease (GVHD) of the skin. The patient then developed acute transaminitis and neutropenia, and biopsies of the liver and bone marrow done subsequently also confirmed GVHD of these organs, with microchimerism assay on the bone marrow showing 43% of the T-cells were of donor origin. The patient improved with initiation of systemic and topical corticosteroids. Although a rare entity in solid organ transplantation, this case highlights the importance of considering solid organ transplant graft-versus-host disease (SOT-GVHD), particularly in patients receiving organs with a larger volume of passenger donor T-lymphocytes, such as is seen with intestinal, liver, and pancreas transplants.