Acute Graft-Versus-Host Disease After Deceased-Donor Liver Transplantation: A Case Report

BACKGROUND Acute graft-versus-host disease is a rare but highly fatal complication of liver transplantation, with a reported mortality rate exceeding 70%. Most patients are diagnosed at 3 to 6 weeks postoperatively. Early diagnosis remains challenging because of nonspecific symptoms and overlapping presentations of infections and drug reactions. CASE REPORT We report the case of a 48-year-old woman with end-stage liver disease secondary to primary biliary cholangitis who underwent deceased-donor liver transplantation. On postoperative day 16, she developed abrupt-onset anemia without bleeding, followed by a high-grade fever, erythematous rash, profuse diarrhea, and pancytopenia. Blood cultures and viral studies were negative, despite clinical deterioration. Punch biopsy of the trunk on postoperative day 20 confirmed acute graft-versus-host disease. She was treated with high-dose corticosteroids and enhanced immunosuppression but showed no improvement, meeting the criteria for steroid-refractory graft-versus-host disease. She died of multiorgan failure on postoperative day 30. This is one of the earliest biopsy-confirmed cases of graft-versus-host disease reported after deceased-donor liver transplantation. CONCLUSIONS This case highlights the importance of early clinical suspicion of graft-versus-host disease after liver transplantation, even before the full triad of symptoms manifests. Isolated anemia may be an early warning sign. Therefore, prompt histopathological confirmation via skin biopsy is essential. Current treatment strategies for steroid-refractory graft-versus-host disease are limited, underscoring the need for further therapeutic advances.