Track

Case Reports

Abstract

Vascularized composite allotransplantations (VCA) offer reconstructive options to restore form and function in patients with devastating tissue loss. However, its long-term success is hindered by chronic rejection (CR), a poorly defined entity in the current Banff classification for skin-containing composite tissue allografts. While the cutaneous manifestations of acute cellular rejection (ACR) are well-characterized, CR remains less understood. We present two cases of VCA CR with sclerodermatous histopathologic features, expanding the clinical spectrum of this process.

The first case involves a 40-year-old male recipient of abdominal wall, penile, and scrotal transplants following blast trauma. Despite initial stable graft function under tacrolimus-based immunosuppression, he experienced recurrent ACR and subsequently developed morphea-like dermal sclerosis on subsequent biopsies. The second case describes a 38-year-old male who received bilateral upper extremity transplants who developed recurrent ACR and progressive functional decline. Skin biopsies evolved from classic ACR to show deep dermal fibrosis.

These cases highlight the emerging recognition of sclerodermatous changes as a manifestation of CR in non-facial VCAs. Such fibrosis may represent a late-stage, irreversible process, underscoring the need for early identification and therapeutic intervention. These findings provide novel histopathologic data supporting the inclusion of sclerodermatous CR in future updates to the Banff classification and may inform optimization of immunosuppressive strategies to enhance graft durability, reduce morbidity, and improve patient outcomes.