Graft-Versus-Host Disease After Liver Transplantation: Diagnostic and Therapeutic Challenges

Graft-versus-host disease (GVHD) is a rare but severe complication following solid organ transplantation, with limited literature guiding diagnosis and management. We present a 55-year-old man with alcohol-associated end-stage liver disease who developed GVHD approximately one month after orthotopic liver transplantation (LT). He was initially admitted for persistent fever and concern for sepsis, with subsequent development of progressive pancytopenia and a non-pruritic maculopapular rash with mucosal involvement. Skin biopsy performed on hospital day 10 supported the diagnosis of GVHD, and donor chimerism testing demonstrated 70% donor-derived CD3+ lymphocytes. He improved with high-dose intravenous methylprednisolone and remained clinically stable on ruxolitinib maintenance therapy at two-month post-discharge follow-up. GVHD following LT should be considered early in patients with non-specific presentations, such as unexplained fever, cytopenias, rash, or mucosal findings. Early recognition, tissue biopsy, and chimerism testing may facilitate timely intervention and improve outcomes in this rare condition associated with high mortality.