Case Presentation: Patient With Triple-Relapsed Chronic Graft-Versus-Host Disease
Patient Case:
A 52-year-old man underwent peripheral blood stem cell transplantation from an HLA-matched sibling donor for high-risk myelodysplastic syndrome (MDS). Conditioning was with fludarabine and melphalan. Graft-versus-host disease (GVHD) prophylaxis included tacrolimus and methotrexate.
By 9 months post-transplant, he developed multiorgan chronic GVHD, with involvement of the skin (lichen planus-like and erythematous rash progressing to sclerosis), oral mucosa (painful ulcers and sensitivity), eyes (dryness, pain, and sensitivity), and gastrointestinal tract (diarrhea, cramping).
Initial treatment with sirolimus and prednisone provided partial improvement, but sirolimus was discontinued due to concerns about edema and cytopenias. Ibrutinib was initiated for persistent rash and mucosal disease, leading to some clinical improvement; however, the patient developed significant diarrhea, requiring cessation of the drug.
Ruxolitinib was then introduced, with moderate control of symptoms, but his course was complicated by recurrent bacterial respiratory infections and herpes virus reactivation.
After poor response to belumosudil, which was trialed for persistent sclerosis, the patient worsened to have disabling skin thickening, joint stiffness, and impaired mobility.
Given the refractory nature of his disease and limited options, axatilimab was then considered.
