Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
Graduate Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
Microsurgery. 2020 Feb;40(2):217-223. doi: 10.1002/micr.30439. Epub 2019 Feb 15.
Acute rejection is not uncommon after vascularized composite allotransplantation. We reported the effects of adjunctive topical immunosuppressant with topical tacrolimus (Protopic®) and steroid cream (Clobetasol®) in the management of acute rejection in two hand transplantation patients. Case 1 is a 45-year-old male with distal forearm deficit 4 years ago and Case 2 is a 30-year-old male with a proximal forearm deficiency 2 years ago, respectively. Both of them suffered from occupational accident and received hand allotransplantation. Induction was performed with antithymocyte globulins and methylprednisolone. Maintenance therapy consisted of tacrolimus (FK506), mycophenolate mofetil, and prednisone. Both cases experienced acute rejection, which we treated with topical tacrolimus and Clobetasol for 2 weeks, combined with systemic immunosuppressant maintenance therapy without adding pulse-steroid therapy. Clinically, both cases recovered after adjunctive treatments. The skin biopsies showed significantly decreased perivascular lymphocyte infiltration after topical treatment. Immunohistochemical staining showed that CD3+ T-cells and CD20+ B-cells were suppressed in the recovery phase. FoxP3-positive regulatory T cells were increased after treatment. Topical tacrolimus and Clobetasol as an adjunctive treatment with maintenance systemic immunosuppressives may be useful to control acute rejection, which correlated with modulation of lymphocyte activation, especially T cells. The treatment needs further investigation with gaining more comparable data.
急性排斥反应在血管化复合组织移植后并不罕见。我们报告了在两名手部移植患者中，局部应用他克莫司（普特彼®）和皮质类固醇乳膏（卤米松®）作为辅助局部免疫抑制剂治疗急性排斥反应的效果。病例 1 为一名 45 岁男性，4 年前前臂远端缺损；病例 2 为一名 30 岁男性，2 年前前臂近端缺损，均因职业事故接受手部同种异体移植。诱导治疗采用抗胸腺细胞球蛋白和甲基强的松龙。维持治疗包括他克莫司（FK506）、霉酚酸酯和泼尼松。两名患者均发生急性排斥反应，我们采用局部他克莫司和卤米松治疗 2 周，同时联合全身免疫抑制剂维持治疗，未加用脉冲类固醇治疗。临床观察发现，辅助治疗后患者均恢复。皮肤活检显示，局部治疗后，血管周围淋巴细胞浸润明显减少。免疫组化染色显示，在恢复阶段 CD3+T 细胞和 CD20+B 细胞受到抑制，FoxP3 阳性调节性 T 细胞增加。局部他克莫司和卤米松作为全身免疫抑制剂维持治疗的辅助治疗，可能有助于控制急性排斥反应，这与淋巴细胞活化的调节有关，特别是 T 细胞。该治疗方法需要进一步研究，以获得更多可比数据。
