Report Highlights Case of Shellfish Allergy–Induced Overlap Chronic GVHD Following SCT

Although its incidence is reported, allergy-induced graft versus host disease (GVHD) is not well understood. In a recent case report, researchers outlined the case of a patient with shellfish allergy–induced overlap chronic GVHD (ocGVHD)—a case of GVHD that has components of both acute and chronic GVHD.

The patient, who had a documented history of JAK2+ essential thrombosis and subsequent myelofibrosis, has no history of shellfish allergies, while his stem cell transplant (SCT) donor had a known shellfish hypersensitivity. While uncommon, the researchers say the shellfish allergy trigger could contribute to the presentation of ocGVHD if the acute component emerged later than expected “because T-cell activation was not triggered by human leukocyte antigen discrepancies between donor and recipient but, rather, by food hypersensitivity.”

Based on the findings, the researchers suggest that, “Further study into the pathomechanisms behind donor-derived food-, medication-, or environmental hypersensitivity-induced GVHD is needed. Clinicians may recommend empirical avoidance of known donor allergens in SCT recipients.”

In the current case study, the man, in his 50s, presented with throat pain 5 months after his transplantation. A week prior, he had facial and oral swelling hours after eating shellfish followed with a rash on several parts of his body, conjunctival injection, and lip peeling.

When presenting to doctors, observations and testing confirmed an ocGVHD diagnosis:

• The patient had anorexia, mild dysphagia, rhinorrhea, and intermittent cough
• Examination showed facial swelling, skin redness, gray-brown patches, eyelid redness, bilateral conjunctival injected, and crusted erosions on the lips, as well as a diffuse, superficial scale and macules on several parts of his body
• Laboratory results showed elevated levels of eosinophils, elevated liver function tests, and low serum tacrolimus levels
• Punch biopsy showed vacuolar interface dermatitis

Based on the ocGVHD diagnosis, the patient’s dosage of tacrolimus was increased. He also began receiving prednisone, topical corticosteroid ointments, oral rinses, calcineurin inhibitor ointments, topical analgesics, and artificial tears. After 5 months, the disease worsened, and cGVHD was determined in the eye, skin, and mouth. Liver involvement was also suspected. The patient’s regimen was switched to sirolimuc, ruxolitinib, and rituximab.

“Exposure of hematopoietic SCT recipients to donor allergenic drugs has been reported to precede the development of GVHD and may incite tissue damage and T cell activation. One study of donor allergenic drug exposure 60 days after transplantation found 2 cases of diagnosed and 1 case of suspected aGVHD. In another study, dog-dander hypersensitivity was reported in an unrelated hematopoietic transplant recipient 20 months after transplantation, even with repeated exposure to dogs in the preceding months.”

Reference

Braun H, Cheeley J. Shellfish allergy—induced overlap chronic graft-versus-host disease. JAAD Case Rep. 2021;17:100-102.