Graft versus Host Disease
Graft vs host disease (GVHD) occurs when the donor immunocompetent cells recognize the host as foreign. Generally, it involves the skin, gut, liver and lungs but any system may be involved. Acute GVHD usually occurs within the first 3 months post HCT. Oral GVHD usually presents as a lichenoid mucositis with or without ulceration. The ulcerations as seen in the following examples can cause significant pain and inability to eat, perform oral hygiene procedures and generally function. It is a serious complication that requires systemic therapy with steroids and immunosuppressants. If asymptomatic, no treatment is recommended as the presence of some GVHD is desirable because of graft versus leukemia effect. Chronic GVHD occurs later (over 100 days) post HCT. In the oral cavity, GVHD may also involve the salivary glands and hyposalivation results with the attendant dental problems of root caries. Fibrosis of the oral soft tissues may result in trismus and atrophy and recession of the gingiva may lead to dental sensitivity.
In these examples, lichen planus like changes are seen. These consist of fine white lines or white plaques. Secondary ulcerations may be a source of pain and dysfunction. The histologic features of these lesions would be identical to lichen planus; therefore the pathologist must be made aware of the history of an allogeneic HCT to make the diagnosis of GVHD.
These photos show a more acute case of GVHD where ulceration predominate.
This 56 male received an allogeneic stem cell transplant one year previous for AML. He presents with severe oral GVH of the buccal mucosa bilaterally as large ulcerations with erythematous rim. The tongue shows a lichenoid mucositis. He is also being treated for GVH of eyes, liver and gut.
The oral GVH was treated with topical steroids and although not totally resolved, he is now able to eat more comfortably. The elapsed time was 3 months.