Figure/Graphic 2a-c: Stem cell transplant
A 36-year-old man received allogenic hematopoietic stem cell transplant after non-Hodgkin lymphoma. Three months after the procedure, he developed graft-versus-host disease (GVHD) with sicca syndrome and dermatitis. He was treated with low-dose steroids and mycophenolate. Over the ensuing months, mild proximal weakness and raised serum creatin-kinase appeared. He was diagnosed with steroid myopathy by his haematologist and steroids were tapered. On examination, he presented with scapular and pelvic weaknesses together with severe cramps after voluntary contraction. EMG demonstrated myopathic potentials and neuromyotonia. MRI showed a high STIR signal on axial muscles (A, arrow) suggestive of muscle inflammation. A deltoid muscle biopsy was performed. MHC type-1 expression of the muscle fibres in a perifascicular fashion was demonstrated with immunofluorescence (B). Hematoxilin-eosin staining (C) showed myopathic muscle fibres and inflammatory infiltrates. The patient was diagnosed with myositis and neuromyotonia as a manifestation of GVHD. He was treated with rituximab, mycophenolate, and low-dose steroids with gradual improvement.