(Kiosk 2) Achilles Rupture in Setting of GVHD

Case Diagnosis: Bilateral Achilles Tendon Rupture in the setting of Graft Versus Host Disease.

Case Description or Program Description: A 58 year-old male with myelodysplastic syndrome was hospitalized for HLA matched donor peripheral blood stem cell transplantation, with hospitalization significant for multiple infections and GVHD with cutaneous, gastrointestinal and hepatic involvement requiring high dose steroids. He became very deconditioned, only able to ambulate short distances with a walker. Following discharge, he took a few steps with a walker, then felt and heard a sudden “pop” in both ankles. He experienced severe pain and swelling of bilateral ankles.

Setting: University of Washington Cancer Rehabilitation Clinic

Assessment/Results: An MRI was obtained which revealed complete rupture of bilateral Achilles tendons. Walking was initially limited by pain, weakness and deconditioning, requiring use of a wheelchair for community mobility. He was not a surgical candidate due to medical complexity, and concern for sclerotic GVHD affecting his skin and tendons. He was referred to rehabilitation medicine for non-operative management including casting and physical therapy

Discussion (relevance): Graft-versus-host disease is a multisystem complication following hematopoietic stem cell transplantation. The etiology of this reaction is due to transplanted immune cells identifying host cells as invasive and initiating an immune response resulting in tissue inflammation and commonly fibrosis. Organ systems most commonly affected are skin, gastrointestinal tract, liver, lungs and mucosa. This gentleman had multiple confounding factors which may have contributed to his injury including recent fluoroquinolone use, prolonged immobilization, steroid-induced myopathy and GVHD with steroid-resistant cutaneous involvement. Rehabilitation services including physiatry, prosthetics/orthotics, and physical therapy were vital in improving his mobility and pain.

Conclusions: In conjunction with other medical comorbidities, patients with graft-versus-host disease are at risk for further injury after they leave the hospital and reintegrate to their daily lives. Early rehabilitation and screening can play a role in injury prevention, which can include musculoskeletal ultrasound to evaluate tendon integrity and referral to therapy services to maintain range of motion and joint stability.