What’s Your Diagnosis?
By Giovanni De Petris, M.D., Alexandra Corominas Cishek, M.D., and Ivana Dzeletovic, M.D.
Severe diarrhea following bone marrow transplantation is not always caused by GVHD
Published previously in Gastroenterology (2014;146:e5-6)
A 35-year-old man com- plained of persistent di- arrhea 40 days after bone marrow transplant. Esoph- agogastroduodenoscopy (EGD) and biopsies showed
graft-versus-host disease (GVHD)
grade IV (of Lerner) and gastric ulcers
with cytomegalovirus (CMV) infection.
Biopsies from the colonoscopy showed
GVHD (histologically compatible with
grade II of Lerner). The patient was
treated and showed improvement of
his symptoms but diarrhea persisted.
Follow-up EGD presented diffuse
improvement of the erythema in stom-
ach and duodenum; the colonoscopy
was normal. The pathology in each site
showed no evidence of GVHD or CMV,
and regenerative changes of the muco-
sa. Four days later, worsening of symp-
toms occurred despite treatment, with
severe diarrhea ( 4 L/d), intermittently
bloody, and mild abdominal pain.
The laboratory results were hemo-
globin, 10 g/dL; white blood cell count,
2,000 cells/microL; platelets, 60,000/
microL; blood urea nitrogen/creatinine,
normal; mild electrolyte abnormalities;
lactate dehydrogenase, 450 U/L; and
blood film, pancytopenia, no circulating
lymphoma cells, no schistocytes. Colo-
noscopy (Figures A and B) with the le-
sions depicted present throughout the
colon and the colon biopsies histology
(Figures C and D) are shown. n
What is this condition?
Dr. De Petris and Dr. Corominas Cishek
are in the Department of Pathology,
Mayo Clinic in Arizona, Scottsdale;
and Dr. Dzeletovic is in the Department of Gastroenterology, Mayo Clinic
in Arizona, Scottsdale.
See The Answer on page 30