*Purpose: Graft versus host disease (GVHD) is a rare cause of morbidity and mortality in solid organ transplant (SOT) recipients; the estimated prevalence is 1-2% in liver transplant recipients (Sharma A et al. Ann Transplant 2012).

*Methods: We describe a case of a 62 year old male with a history of end-stage liver disease secondary to alcoholism, hepatitis C and Alpha-1 Anti-trypsin deficiency who underwent orthotopic liver transplantation (OLT)(CMV recipient positive) one month prior. Immunosuppression (IS) included prednisone, tacrolimus and mycophenolate (MMF). Prophylaxis included acyclovir and trimethoprim-sulfamethoxazole.

*Results: On post-operative day (POD) 38, he developed fever and hematochezia. He was empirically started on broad spectrum antimicrobials, including ganciclovir for possible CMV colitis, and MMF was held. Colonoscopy showed diffuse areas of erythematous mucosa with shallow petechiae and ulceration (Fig. 1)

. Samples were sent for infectious workup including tissue staining for CMV, Epstein-Barr virus, and adenovirus plus stool samples for gastrointestinal (GI) multiplex panel and a Clostridioides difficile test. They were all negative. Pathology showed ulcerated colonic mucosa/inflamed granulation tissue with lymphoplasmacytic inflammation and some neutrophils consistent with GVHD (Fig. 2)

.

Human leukocyte antigen typing showed 3-5% donor lymphocytes, indicative for GVHD as defined by >1% macrochimerism. In addition, the patient developed skin lesions which were biopsy-consistent with GVHD. As a result, IS was increased, first with pulse dose steroids and then alemtuzumab was given. There was minimal response. Unfortunately, he suffered multiple infectious complications including Saccharomyces fungemia and disseminated adenovirus infection that are actively being treated.

*Conclusions: GVHD in SOT recipients is a rare entity (Sharma A et al. Ann Transplant 2012). It should be considered in patients presenting with skin lesions, fever, GI symptoms and a negative infectious work up. Unfortunately, treatment is difficult and mortality high, exceeding 75% with most patients dying from infections or bleeding due to bone marrow failure (Zhang Y et al, Arch Pathol Lab Med 2009)

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