Three weeks after orthotopic liver transplantation, a patient develops fever, a maculopapular rash on the trunk and palms, watery diarrhoea, and pancytopenia. Skin biopsy shows apoptotic keratinocytes. The most likely diagnosis is:

• A Post-transplant lymphoproliferative disorder
• B Acute cellular rejection of the liver
• C Graft versus host disease ✓
• D Stevens-Johnson syndrome from sulphonamide antibiotics

Explanation

Among solid organs, liver (and small bowel) transplants contain substantial passenger lymphoid tissue, so donor lymphocytes can engraft and attack recipient skin, gut and marrow, producing fever, rash, diarrhoea and pancytopenia. Acute hepatic rejection presents as jaundice and rising transaminases rather than rash and diarrhoea, which distinguishes it. PTLD presents as lymphoid masses, often EBV related, not diffuse mucocutaneous and haematological involvement.

Reference: Sabiston Textbook of Surgery, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.