Sequential Passenger Lymphocyte Syndrome and Skin-Predominant Acute Graft-vs-Host Disease After Liver Transplantation

Passenger lymphocyte syndrome (PLS) and acute graft-vs-host disease (aGVHD) both arise from donor lymphocytes but represent distinct immune-mediated complications rarely documented sequentially in the same recipient. We report a 63-year-old woman who developed severe hemolytic anemia on postoperative day 1 after minor ABO blood group system-mismatched liver transplantation, consistent with PLS, followed 8 weeks later by skin-predominant aGVHD supported by skin biopsy and peripheral blood chimerism. Early diagnosis and treatment with high-dose corticosteroids led to rapid improvement. This case highlights that these complications can occur in sequence and underscores the prognostic importance of organ involvement pattern and early biopsy.