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SKIN DISEASES IN ORGAN AND BONE MARROW TRANSPLANTATION: INTRODUCTION

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Organ transplant recipients are chronically immunosuppressed and their T cell function is impaired. Ensuing diseases are mostly infections and are similar to those occurring in other conditions associated with T cell impairment, such as AIDS. In addition, organ transplant recipients are at great risk for developing nonmelanoma skin cancer and other cancers. Bone marrow and stem cell graft recipients are candidates for graft-versus-host disease (GVHD).

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MOST COMMON INFECTIONS ASSOCIATED WITH ORGAN TRANSPLANTATION

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SKIN CANCERS ASSOCIATED WITH ORGAN TRANSPLANTATION

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  • Nonmelanoma skin cancer is the most common malignancy in adult solid organ transplant patients*.

  • The majority are squamous cell carcinomas (SCC) (Section 11).

  • The risk of developing SCC increases exponentially with the length of immunosuppression.

  • The cumulative incidence is 80% after 20 years of immunosuppression in renal transplantation. SCC in posttransplant patients are aggressive.

  • HPV infection is implicated in the pathogenesis.

  • Other epithelial proliferative lesions are actinic keratoses, keratoacanthomas, porokeratosis, appendage tumors, and Merkel cell carcinomas (Section 11).

  • Children and adults with organ transplants may also be at higher risk for the development of melanoma (Section 12).

  • Lymphoproliferative disorders are common in graft recipients and related to Epstein–Barr virus-mediated proliferation of B cells and most are lymphomas of B cell origin. Cutaneous T cell lymphomas account for 30% of cutaneous lymphomas in transplant patients (Section 21).

  • Kaposi sarcoma occurs in immunosuppressed transplant recipients with an incidence of 0.5 to 5%. All cases are associated with Kaposi sarcoma-associated herpesvirus (KSHV) infection (Section 21).

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*Clinical manifestations are discussed in their respective sections.

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GRAFT-VERSUS-HOST DISEASE (GVHD) ICD-10: T86.0

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  • GVHD is the totality of organ dysfunction caused by the action of histoincompatible, immunocompetent donor cells against the tissues of an immunocompetent host.

  • Graft-versus-host reaction (GVHR) is the expression of GVHD in a specific organ (e.g., cutaneous GVHR).

  • Acute cutaneous GVHD, usually occurring 10 to 100 days after bone marrow transplantation (BMT). However, diagnosis now rests of clinical features, not the number of days following transplantation. It is the earliest and most frequent GVHR. Liver and GI tract GVHR are also common.

  • Chronic cutaneous GVHD generally occurs >100 days after allogeneic BMT and manifests as lichenoid and sclerodermoid changes. Again, clinical features now define the diagnosis as opposed to days post-transplantation.

  • Incidence. Allogeneic BMT: 20 to 80% of successful engraftments. Autologous BMT: Mild cutaneous GVHR occurs in 8%. Low incidence after blood transfusion in immunosuppressed patients, maternal-fetal transfer in immunodeficiency disease.

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ACUTE CUTANEOUS GVHD

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  • During the first months after BMT (usually between 10 and 100 days but acute disease can occur even after development of chronic GVHD): mild pruritus, localized/generalized; pain on pressure of the palms and soles. Nausea/vomiting, abdominal pain; watery diarrhea. Jaundice; dark yellow urine.

  • Skin Lesions...

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