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A 38-year-old man received a myeloablative conditioning regimen and peripheral blood stem cell transplant (PBSCT) from his HLA-identical sister for AML in early second relapse. The patient developed Grade II acute GVHD on day 40 after transplantation which responded promptly to steroids at 2 mg/kg/day. A steroid taper was begun.
When his steroid dose reached 0.25 mg/kg/day, a new raised rash with plaque-like lesions involving 36% of his body surface area and mouth sores developed. Liver function tests were five times normal, and a platelet count was 40,000. Steroids were increased to 1 mg/kg/day for the diagnosis of chronic GVHD, and tacrolimus was continued. Unfortunately, when seen two weeks later his skin rash was almost confluent, oral examination showed an extensive lichen-planus-like eruption, liver function tests were now 10 times normal, and his platelet count was 20,000. The patient is quite symptomatic and reports that he lost 20 pounds and is unable to accomplish his normal activities.
What therapy would you recommend?
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| (A report on the votes will be
presented next month, along with one expert’s commentary.)
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