Graft-versus-host disease differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Shyam Patel [2] M. Khurram Afzal, MD [3]

Overview

The differential diagnosis of GvHD is broad given the complexity of post-transplant patients. Infectious etiologies must be considered in persons who under stem cell transplant. A skin rash in the post-transplant setting, for example, could reflect infectious dermatitis or skin GvHD. Liver dysfunction in the post-transplant setting, for example, can reflect an infectious hepatitis of liver GvHD. Gastrointestinal symptoms in the post-transplant setting, for example, could reflect infectious enteritis/colitis or GI GvHD. Chronic graft-versus-host disease must be differentiated from other diseases that cause skin thickening such as scleredema, scleromyxedema, eosinophilic fasciitis, scleroderma, drug induced scleroderma, scleroderma overlap syndromes, diabetic cheiroarthropathy, myxedema, and nephrogenic systemic fibrosis.

Differential Diagnosis

The differential diagnosis for GvHD can be categorized into the specific organs involved. When a post-transplant patient develops skin, liver, or [Gastrointestinal tract|GI,]] symptoms, there are numerous possibilities regarding the etiology, as post-transplant patients are immunocompromised and at risk for infections. The clinical manifestations of infection in the skin, liver, or GI tract can mimic symptoms of GvHD.

For skin signs and symptoms, differential diagnosis includes:

For liver signs and symptoms, differential diagnosis includes:

For gastrointestinal signs and symptoms, differential diagnosis includes:

Differentiating Chronic graft-versus-host disease from other Diseases

Differentiating Chronic graft-versus-host disease from other Diseases

Diseases Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab Findings Imaging Histopathology
Skin thickening Raynaud phenomenon Heart burn Edema (swelling) Sclerodactyly Telangiectasia Impaired mobility Autoantibodies Blood indices
Scleroderma[2][3] Chronic graft-versus-host disease[4][5] +

(induration)

- - - - - +
  • N/A
Limited cutaneous systemic sclerosis (CREST syndrome) +

(induration)

+ + +/- + + +/-
  • Nailfold microvascular changes on nailfold video capillaroscopy (NVC)[6]
  • Chest HRCT scan showing evidence of pulmonary fibrosis
  • Nailfold microvascular changes
  • Dilated capillary loops
  • Microhemmorhages
Scleredema

(Buschke's disease)[8]

+ - - + - - +
  • N/A
  • N/A
Scleromyxedema

(lichen myxedematosus)[9][10]

+

(waxy yellow-red papules)

+/- +/- + - - -
  • N/A
  • N/A
Eosinophilic fasciitis[11][12] +

(orange peel-peau d'orange appearance)

- - + - - -
  • N/A
  • Normal appearance on nailfold video capillaroscopy (NVC)
  • Fasciitis present on the trunk sparing extremities
  • Visible collapse of superficial veins when the limb is elevated
  • Hands and feet are not involved
Drug-induced scleroderma[13][14] + + +/- +/- + +/- -
  • N/A
  • N/A
  • N/A
Diffuse cutaneous systemic sclerosis +

(induration)

+ + +/- + + +/-
  • Nailfold microvascular changes
  • Dilated capillary loops
  • Microhemmorhages
Scleroderma overlap syndromes[16][17][18][19] Scleroderma-systemic lupus erythematosus overlap +

(rash)

+ + +/- + + +/-
  • N/A
Scleroderma-polymyositis overlap +

(rash)

+ + +/- + + +/-
  • Anti-Ro52 antibody
  • Antinuclear antibody (ANA)
  • Anti-Jo-1 antibody
  • Anti-SRP antibody
  • Anti-Mi-2 antibody
  • Anti-centromere antibody (ACA)
  • Anti-topoisomerase-I (Scl-70) antibody
  • Anti-RNA polymerase III antibody
  • N/A
Scleroderma-rheumatoid arthritis overlap +

(rash)

+ + +/- + + +/-
  • N/A
  • Anti-Ro52 antibody
  • Anti-CCP antibody
Endocrine disorders Diabetic cheiroarthropathy[21][22] +

(waxy skin)

- - - + - +
  • N/A
  • N/A
  • N/A
Myxedema[23] +

(coarse skin)

- - + - - -
  • Anti-TPO antibody
  • Anti-Tg antibody
  • N/A
Serum TSH
Renal diseases Nephrogenic systemic fibrosis[24] +

(induration)

- - + + - -
  • N/A
  • N/A

References

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