Rare cutaneous graft-versus-host disease after autologous chimeric antigen receptor T-cell therapy

Summary: A 76-year-old male with diffuse large B-cell lymphoma presented with seven days of pruritic erythroderma. Allopurinol was started 1 month prior and stopped 4 days prior to presentation. Notably, the patient received his first infusion of Pola-BR 2 weeks prior to onset. He previously received 6 cycles of R-CHOP, 3 cycles of RICE, autologous chimeric antigen receptor T-cell therapy (CART) (axicabtagene ciloleucel), and 1 cycle of Pola-BR. Histopathology demonstrated interface dermatitis with dyskeratotic keratinocytes and prominent dermal eosinophils, concerning for a drug reaction (potentially from allopurinol) versus viral reaction. Despite discontinuation of allopurinol and use of clobetasol wet wraps, the patient’s eruption did not improve. Given decreasing clinical suspicion of a drug reaction and limited improvement, additional biopsies were performed and his initial biopsies were reviewed again. All demonstrated an interface dermatitis with follicular involvement concerning for potential graft-versus-host-disease (GVHD). His clinical presentation and histopathology in the setting of his history favored GVHD from autologous CART therapy. GVHD has been described in 10-33% of patients receiving other kinds of CART therapy, but never autologous therapy. This case is intended to highlight a diagnostic dilemma, that we believe is the first case of GVHD from an autologous type of CART treatment.