Abstract
Background
Skin chronic rejection (CR) in vascularised composite allotransplantation has not yet been included in the Banff classification. We report a face-transplant patient who developed cutaneous clinicopathologic changes suggestive of CR.
Methods
The recipient is a 27 year-old man with a severe disfigurement of the lower face by a pyrotechnic explosion. He received in November 2009 a facial allograft that included bilateral mandible, cheeks, lips and chin. Initial immunosuppression included steroids, mycophenolate mofetil, tacrolimus, antithymocyte globulins and bone-marrow infusion.
Results
During the follow-up the recipient developed primary asymptomatic EBV infection, followed by EBV+ B-cell lymphoma and hepatic leiomyosarcoma, for which the immunosuppressive treatment was greatly reduced. During the first post-transplant year, acute rejection (AR) episodes were completely reversed with steroids. Subsequently, several episodes of AR occurred that were difficult to reverse with steroids and Campath-1; they manifested clinically with graft erythema and histologically with lichenoid changes of the epidermis and appendages. Since the second post-transplant year the allografted facial skin became progressively sclerotic and presented pigmented macules on a background of hypopigmentation and telangiectases, realizing a poikilodermatous aspect. Skin biopsies showed epidermal atrophy, basal cell vacuolization and diffuse dermal sclerosis. In the superficial dermis there were rare CD3+ and CD4+ lymphocytes and in the deep dermis few TIA+1 cytotoxic lymphocytes. The large vessels seemed unaffected while dermal capillaries showed thickened walls and narrowed lumina. Donor specific anti-HLA class II antibodies were detected transiently in January 2010.
Conclusions
These so far undescribed changes are suggestive of CR and should be considered for inclusion in the revised version of the Banff-CTA classification of rejection.