Graft-versus-host disease physical examination: Difference between revisions

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==Overview==
==Overview==
The physical exam for GvHD focuses on the organ involved, including the skin, liver, and GI tract.
The physical exam for GvHD focuses on the organ involved, including the skin, liver, and GI tract. Rash and hyperpigmentation are the most common skin exam findings. Jaundice and abdominal tenderness are the most common liver and GI tract exam findings. The lungs or eyes can also be involved in more rare cases. A detailed physical exam is important for an accurate assessment of GvHD diagnosis and for assessment of the severity of the disease.


==Physical Examination==
==Physical Examination==
*Skin: Exam findings include erythema, morbilliform rash, hyperpigmentation.
'''Skin'''


*Liver: Exam findings include jaundice, pruritis, leg swelling, tenderness in the right upper quadrant of the abdomen, bleeding from coagulopathy.
*[[Erythema]]<ref name="pmid24914139">{{cite journal| author=Socié G, Ritz J| title=Current issues in chronic graft-versus-host disease. | journal=Blood | year= 2014 | volume= 124 | issue= 3 | pages= 374-84 | pmid=24914139 | doi=10.1182/blood-2014-01-514752 | pmc=4102710 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24914139  }} </ref>
*[[Maculopapular rash]]<ref name="pmid24914139">{{cite journal| author=Socié G, Ritz J| title=Current issues in chronic graft-versus-host disease. | journal=Blood | year= 2014 | volume= 124 | issue= 3 | pages= 374-84 | pmid=24914139 | doi=10.1182/blood-2014-01-514752 | pmc=4102710 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24914139  }} </ref>
*[[Hyperpigmentation]]<ref name="pmid24914139">{{cite journal| author=Socié G, Ritz J| title=Current issues in chronic graft-versus-host disease. | journal=Blood | year= 2014 | volume= 124 | issue= 3 | pages= 374-84 | pmid=24914139 | doi=10.1182/blood-2014-01-514752 | pmc=4102710 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24914139  }} </ref>
*[[Lichen planus]]-like lesions<ref name="pmid24914139">{{cite journal| author=Socié G, Ritz J| title=Current issues in chronic graft-versus-host disease. | journal=Blood | year= 2014 | volume= 124 | issue= 3 | pages= 374-84 | pmid=24914139 | doi=10.1182/blood-2014-01-514752 | pmc=4102710 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24914139  }} </ref>
*Bullae<ref name="pmid24227989">{{cite journal| author=Nassar A, Tabbara KF, Aljurf M| title=Ocular manifestations of graft-versus-host disease. | journal=Saudi J Ophthalmol | year= 2013 | volume= 27 | issue= 3 | pages= 215-22 | pmid=24227989 | doi=10.1016/j.sjopt.2013.06.007 | pmc=3770225 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24227989  }} </ref>
*Desquamation<ref name="pmid24227989">{{cite journal| author=Nassar A, Tabbara KF, Aljurf M| title=Ocular manifestations of graft-versus-host disease. | journal=Saudi J Ophthalmol | year= 2013 | volume= 27 | issue= 3 | pages= 215-22 | pmid=24227989 | doi=10.1016/j.sjopt.2013.06.007 | pmc=3770225 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24227989  }} </ref>


*GI tract: Exam findings include abdominal tenderness, diarrhea, hyperactive or hypoactive bowel sounds.
'''Liver'''


*[[Jaundice]]<ref name="pmid24914139">{{cite journal| author=Socié G, Ritz J| title=Current issues in chronic graft-versus-host disease. | journal=Blood | year= 2014 | volume= 124 | issue= 3 | pages= 374-84 | pmid=24914139 | doi=10.1182/blood-2014-01-514752 | pmc=4102710 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24914139  }} </ref>
*[[Pruritis]]<ref name="pmid24914139">{{cite journal| author=Socié G, Ritz J| title=Current issues in chronic graft-versus-host disease. | journal=Blood | year= 2014 | volume= 124 | issue= 3 | pages= 374-84 | pmid=24914139 | doi=10.1182/blood-2014-01-514752 | pmc=4102710 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24914139  }} </ref>
*[[Icterus|Scleral icterus]]<ref name="pmid24914139">{{cite journal| author=Socié G, Ritz J| title=Current issues in chronic graft-versus-host disease. | journal=Blood | year= 2014 | volume= 124 | issue= 3 | pages= 374-84 | pmid=24914139 | doi=10.1182/blood-2014-01-514752 | pmc=4102710 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24914139  }} </ref>
*[[Leg swelling]]<ref name="pmid24914139">{{cite journal| author=Socié G, Ritz J| title=Current issues in chronic graft-versus-host disease. | journal=Blood | year= 2014 | volume= 124 | issue= 3 | pages= 374-84 | pmid=24914139 | doi=10.1182/blood-2014-01-514752 | pmc=4102710 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24914139  }} </ref>
*Tenderness in the [[right upper quadrant]] of the abdomen<ref name="pmid24914139">{{cite journal| author=Socié G, Ritz J| title=Current issues in chronic graft-versus-host disease. | journal=Blood | year= 2014 | volume= 124 | issue= 3 | pages= 374-84 | pmid=24914139 | doi=10.1182/blood-2014-01-514752 | pmc=4102710 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24914139  }} </ref>
*Bleeding from [[coagulopathy]]<ref name="pmid24914139">{{cite journal| author=Socié G, Ritz J| title=Current issues in chronic graft-versus-host disease. | journal=Blood | year= 2014 | volume= 124 | issue= 3 | pages= 374-84 | pmid=24914139 | doi=10.1182/blood-2014-01-514752 | pmc=4102710 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24914139  }} </ref>
*Signs of [[Cholestasis|cholestatic hepatitis]]<ref name="pmid24914139">{{cite journal| author=Socié G, Ritz J| title=Current issues in chronic graft-versus-host disease. | journal=Blood | year= 2014 | volume= 124 | issue= 3 | pages= 374-84 | pmid=24914139 | doi=10.1182/blood-2014-01-514752 | pmc=4102710 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24914139  }} </ref>
'''GI tract'''
*A[[Abdominal tenderness|bdominal tenderness]]
*[[Diarrhea]]
*Hyperactive or hypoactive [[bowel sounds]]
*[[Anorexia]]<ref name="pmid26729898">{{cite journal| author=McDonald GB| title=How I treat acute graft-versus-host disease of the gastrointestinal tract and the liver. | journal=Blood | year= 2016 | volume= 127 | issue= 12 | pages= 1544-50 | pmid=26729898 | doi=10.1182/blood-2015-10-612747 | pmc=4807421 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26729898  }} </ref>
*[[Early satiety]]<ref name="pmid26729898">{{cite journal| author=McDonald GB| title=How I treat acute graft-versus-host disease of the gastrointestinal tract and the liver. | journal=Blood | year= 2016 | volume= 127 | issue= 12 | pages= 1544-50 | pmid=26729898 | doi=10.1182/blood-2015-10-612747 | pmc=4807421 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26729898  }} </ref>
'''Lungs'''
*Decreased [[breath sounds]]
*[[Crackles]] (if fluid fills the [[Alveoli|alveolar space]])
'''Other organs'''
Other physical exam findings are based on the particular organ involved.
*Eye: If there is evidence of ocular GvHD, a full ophthalmologic exam should be done.<ref name="pmid25655798">{{cite journal| author=Herretes S, Ross DB, Duffort S, Barreras H, Yaohong T, Saeed AM et al.| title=Recruitment of Donor T Cells to the Eyes During Ocular GVHD in Recipients of MHC-Matched Allogeneic Hematopoietic Stem Cell Transplants. | journal=Invest Ophthalmol Vis Sci | year= 2015 | volume= 56 | issue= 4 | pages= 2348-57 | pmid=25655798 | doi=10.1167/iovs.14-15630 | pmc=4406104 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25655798  }} </ref> Ocular GvHD can occur in up to 60% of patients, but the clinical exam findings and severity of disease is variable from patient to patient. Findings in ocular GvHD include:
*[[Retinopathy|Ocular perforation]]
*[[Conjunctivitis|Conjunctival damage]]
*[[Keratopathy]] (corneal damage),
*[[Dry eyes]]
*[[Milphosis]] (Loss of eyelashes)
Multiple layers of the eye can be affected, including the [[Eyelid|lid]], [[Lacrimal gland|lacrimal glands]], and [[choroid]].<ref name="pmid24227989">{{cite journal| author=Nassar A, Tabbara KF, Aljurf M| title=Ocular manifestations of graft-versus-host disease. | journal=Saudi J Ophthalmol | year= 2013 | volume= 27 | issue= 3 | pages= 215-22 | pmid=24227989 | doi=10.1016/j.sjopt.2013.06.007 | pmc=3770225 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24227989  }} </ref> [[Fluorescein (Ophthalmic)|Fluorescein staining]] of the eye can be performed.<ref name="pmid25655798">{{cite journal| author=Herretes S, Ross DB, Duffort S, Barreras H, Yaohong T, Saeed AM et al.| title=Recruitment of Donor T Cells to the Eyes During Ocular GVHD in Recipients of MHC-Matched Allogeneic Hematopoietic Stem Cell Transplants. | journal=Invest Ophthalmol Vis Sci | year= 2015 | volume= 56 | issue= 4 | pages= 2348-57 | pmid=25655798 | doi=10.1167/iovs.14-15630 | pmc=4406104 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25655798  }} </ref>


==References==
==References==
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[[Category:Primary care]]
[[Category:Hematology]]
[[Category:Hematology]]
[[Category:Immunology]]
[[Category:Immunology]]

Latest revision as of 21:56, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Shyam Patel [2]

Overview

The physical exam for GvHD focuses on the organ involved, including the skin, liver, and GI tract. Rash and hyperpigmentation are the most common skin exam findings. Jaundice and abdominal tenderness are the most common liver and GI tract exam findings. The lungs or eyes can also be involved in more rare cases. A detailed physical exam is important for an accurate assessment of GvHD diagnosis and for assessment of the severity of the disease.

Physical Examination

Skin

Liver

GI tract

Lungs

Other organs

Other physical exam findings are based on the particular organ involved.

  • Eye: If there is evidence of ocular GvHD, a full ophthalmologic exam should be done.[4] Ocular GvHD can occur in up to 60% of patients, but the clinical exam findings and severity of disease is variable from patient to patient. Findings in ocular GvHD include:
  • Ocular perforation
  • Conjunctival damage
  • Keratopathy (corneal damage),
  • Dry eyes
  • Milphosis (Loss of eyelashes)

Multiple layers of the eye can be affected, including the lid, lacrimal glands, and choroid.[2] Fluorescein staining of the eye can be performed.[4]

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Socié G, Ritz J (2014). "Current issues in chronic graft-versus-host disease". Blood. 124 (3): 374–84. doi:10.1182/blood-2014-01-514752. PMC 4102710. PMID 24914139.
  2. ↑ 2.0 2.1 2.2 Nassar A, Tabbara KF, Aljurf M (2013). "Ocular manifestations of graft-versus-host disease". Saudi J Ophthalmol. 27 (3): 215–22. doi:10.1016/j.sjopt.2013.06.007. PMC 3770225. PMID 24227989.
  3. ↑ 3.0 3.1 McDonald GB (2016). "How I treat acute graft-versus-host disease of the gastrointestinal tract and the liver". Blood. 127 (12): 1544–50. doi:10.1182/blood-2015-10-612747. PMC 4807421. PMID 26729898.
  4. ↑ 4.0 4.1 Herretes S, Ross DB, Duffort S, Barreras H, Yaohong T, Saeed AM; et al. (2015). "Recruitment of Donor T Cells to the Eyes During Ocular GVHD in Recipients of MHC-Matched Allogeneic Hematopoietic Stem Cell Transplants". Invest Ophthalmol Vis Sci. 56 (4): 2348–57. doi:10.1167/iovs.14-15630. PMC 4406104. PMID 25655798.

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