Defenition of GVHD

- multisystem disorders that occurs when immune cells transplanted from a

non-identical donor (the graft) recognize the transplant recipient (the host)
as foreign, thereby initiating an immune reaction that causes disease in the
transplant recipient.
 :‫ ימים או לפי תסמינים כרוניים ואקוטיים‬100 ‫של‬cut-off ‫מחולק לפי‬

 Hyperacute GVHD, which is rare with current HLA typing, occurs

in the first 14 days post HCT.
 acute GVHD in the first 100 days,
 chronic GVHD after the first 100 days.
although the specific timing is approximate.
Hyperacute GVHD - Hyperacute and
acute GVHD are the consequence of HLA
mismatch between the donor and recipient.
With accurate HLA typing using molecular
methods, hyperacute GVHD is very rare.

Hyperacute GVHD - occurs in the first 14

days post-transplant and is frequently (88
%) associated with both skin involvement
and noncardiogenic pulmonary edema
Acute GVHD - develops in the first 100
days following allogeneic HCT, although it
is recognized that signs and symptoms can
occur later in some patients' acute GVHD.
It rarely affects the lung directly,
although it can be a risk factor for :
noncardiogenic pulmonary edema,
diffuse alveolar hemorrhage, and later
development of airflow obstruction.
Chronic GVHD - Pulmonary involvement is
present in approximately 50% of patients
as obstructive and/or restrictive
changes .
While a clinical diagnosis of bronchiolitis
obliterans is suggestive of chronic
GVHD, pathologic evidence of bronchiolitis
obliterans is diagnostic .
Bronchiolitis obliterans organizing
pneumonia = BOOP is seen in both acute
and chronic GVHD
Early symptoms of bronchiolitis
obliterans:
 mild dyspnea on exertion
 dry and non-productive cough.
 progression to significant dyspnea
on exertion,
 decreased exercise tolerance,
 non-productive cough.
 Pulmonary involvement can
ultimately progress to oxygen
dependency,
 immobility,
 death related to pulmonary
infections.
 clinical diagnosis of bronchiolitis obliterans is made when all of the
following are met:

●Forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio

<0.7 and FEV1 <75 percent of predicted.

●Evidence of air trapping or small airway thickening or bronchiectasis on

chest CT, residual volume >120 percent, or pathologic confirmation of
constrictive bronchiolitis.

●Absence of infection in the respiratory tract, documented with investigations

directed by clinical symptoms.

●*Histologically, the bronchioles are destroyed with fibrous obliteration of the

lumen; granulation tissue frequently extends into the alveolar ducts.

)‫(*אותו דפוס היסטולוגי של הרס כרוני באיבר מושתל‬

 BAL -

Pulmonary complications of GVHD:

showing increasingly

bloody return in

sequential lavages and

>20 % hemosiderin-

laden macrophages

Cryptogenic organizing chronic CT: Lung biopsy ‫כן‬

pneumonia/organizing

patchy air-space

pneumonia (formerly

consolidation,

known as bronchiolitis

obliterans organizing ground-glass opacities,

pneumonia =

small nodular

BOOP)
opacities, "reverse halo

sign"

Bronchiolitis Chronic CT initially clear; Spirometry ‫הגבלה‬ ‫לעיתים‬

obliterans ‫בזרימת אויר‬

>>>>>>>>

Skin biopsy for GVHD

as progresses, CT may

show : mosaic ground

glass opacities and

bronchiectasis

Pulmonary cytolytic Chronic Low grade fever, cough CT: peripheral nodules BAL to rule out Yes, findings are

thrombi infection; lung biopsy basophilic cytolytic

thrombi in the small to

medium distal

pulmonary vessels with

entrapped monocytes

Pulmonary veno- chronic GVHD ‫ירידה ב‬diffusing CXR: pleural effusion Right heart For definitive diagnosis