graft versus host disease refers to the inflammatory and/or fibrosing manifestations that may arise at various times after transplantation of any organ containing lymphoid cells , which react against and damage tissues in the immunocompromised host . the gvhd syndrome has traditionally been subdivided into two syndromes : acute gvhd and chronic gvhd . graft versus host reaction ( gvhr ) is the expression of gvhd in a specific organ . transfusion - associated ( ta ) gvhd is a rare but probably underdiagnosed disorder , which , although usually fatal , may evolve into chronic graft - versus - host disease . a 55-year - old female presented with complaints of increased pigmentation all over body since 4 years . the pigmentation initially started over right thigh and later spread to involve the entire body within few months . the patient gave history of receiving 2 units of cross - matched , unrelated , compatible blood for low hemoglobin ( 7.5 g % ) about 6 months prior to the onset of pigmentation . the patient had attained menopause about 15 years back with no history of irregular menses or menorrhagia previously . palms and soles showed reticular hyperpigmentation with atrophic skin over digits [ figures 1a , 1b and 2 ] . ( b ) : reticulate hyperpigmentation present all over the body  anterior aspect reticulate hyperpigmentation , atrophic skin over palms oral cavity showed reticular hyperpigmentation over buccal mucosa [ figure 3 ] . hair over the scalp was sparse and lateral eyebrows were lost [ figure 4 ] . nails showed longitudinal ridging , distal niche , pterygium formation and atrophic changes [ figure 5 ] . reticulate hyperpigmentation over buccal mucosa , lips non - scarring diffuse alopecia over scalp , reticulate hyperpigmentation over the face distal niche , longitudinal ridging and pterygium over finger nails dermatoscopic study of pigmentation showed reticular pattern with dark brown - black pigment granules concentrating more at the corners of the network . based on history and clinical features , differential diagnoses of lichen planus pigmentosus , connective tissue disease and chronic graft versus host disease were considered and relevant investigations were done . investigations showed microcytic hypochromic anemia with hemoglobin of 9.5 g% , raised esr ( 50 mm / hr ) , reactive crp with negative ana and ra factor . her liver function tests , renal function tests , random blood sugar , serum calcium , uric acid , and thyroid profile were within normal limits . histopathological examination showed thick basket weave and laminated orthokeratotic stratum corneum , flattened epidermis , focal hypergranulosis , basal cell vacuolization , individual necrotic keratinocytes at dermoepidermal junction and thick , innumerable melanophages with sparse lymphocytic infiltrate in widened papillary dermis [ figures 6 and 7 ] . histopathology  10 ( h and e )  thick basket weave , laminated orthokeratotic stratum corneum , flattened epidermis , focal hypergranulosis , basal cell vacuolization , individual necrotic keratinocytes at dermoepidermal junction and thick , innumerable melanophages with sparse lymphocytic infiltrate in widened papillary dermis histopathology  40 ( h and e )  prominent orthokeratosis , individual necrotic keratinocytes , basal cell vacuolization in the background of history of blood transfusion , onset of symptoms after 6 months of blood transfusion , clinical features and histopathologic features , a diagnosis of lichenoid variant of chronic cutaneous graft versus host reaction was made . the patient was started on oral prednisolone 40 mg od and azathioprine 50 mg od , topical emollients and advised regarding photoprotection . however , the patient failed to follow up after starting treatment . gvhd occurs when immunocompetent t cells from a donor recognize and react against  foreign  tissue antigens in an immunocompromised host . it may be the result of autoreactive t cells that escape negative selection in the thymus which has been damaged by preconditioning treatment , acute gvhd and/or age - related atrophy . the th2 immune responses of these donor - derived cd4 + t cells then stimulate host b cells to synthesize autoantibodies . in addition , ifn production by activated t cells induces hla - dr expression on keratinocytes , making them targets for a similar reaction . it is commonly observed after allogeneic bone marrow transplantation , ( regularly used in the management of leukemias , lymphoma , immunodeficiency and inborn errors of metabolism ) , but ta gvhd is only rarely reported . ta gvhd is recognized to occur following transfusion of blood , after materno fetal transfer of lymphoid cells , and peripheral blood stem cell transfer . although early reports of ta gvhd were recognized in immunocompromised hosts , more recent cases have been documented in immunocompetent transfusion recipients . it has been documented after transfusion of unirradiated blood components , whole blood , fresh ( nonfrozen ) plasma , red blood cells , and platelets . transfusions from donors homozygous for an hla haplotype to a recipient sharing this haplotype may predispose to ta gvhd in immunocompetent patient . there is an extremely high fatality rate for established acute ta gvhd , reaching 90% in some reports . because of the very high early mortality , chronic gvhd secondary to blood transfusion has only rarely been reported . it may appear de novo , or following acute gvhd , in continuity or after a variable symptom - free period . it is usually a multisystem disease ; localized disease also occurs , in which individual organs ( usually skin or liver ) are affected . the severity of individual organ involvement does not correlate well with the overall survival ; the patient 's functional performance is a better indicator of survival . it can develop spontaneously or be triggered by several events , notably uv irradiation , physical trauma , zoster , or even borrelia infections . lichenoid lesions occur early , typically on periorbital skin , ears , palms , and soles . a slowly progressive erythematous rash on the face , palms and soles becomes lichenoid , with changes resembling lichen planus in many sites . thinning of the nails , pterygium formation , phimosis , or vaginal strictures may also develop . oral involvement is very common , with areas of erythema and atrophy , lichenoid or hyperkeratotic plaques , ulceration , and atrophic glossitis . reticulate patchy hyperpigmentation and , less commonly , hypopigmentation , poikiloderma , vitiligo ( which may be total ) , erythema , atrophy , alopecia , multiple follicular papules , deep ulcerations of the buttocks and legs , and dystrophic nail changes are other features . both acute and chronic gvhd cause an interface dermatitis which may be a lichenoid lymphocytic infiltrate or predominantly vacuolar damage of basal cells . satellitosis  is particularly suggestive of gvhd , although no single histological feature is pathognomonic . the lichenoid lesions are similar to acute gvhd lesions , with a superficial dermal lymphocytic infiltrate , moderate exocytosis , and a variable degree of keratinocyte necrosis . igm may occur at the dermal  epidermal junction , with granular deposits of igm , iga and c3 in the walls of dermal vessels . corticosteroids are the first choice for the treatment of chronic gvhd , but approximately 30% of patients require secondary systemic treatment . the lichenoid variant is usually well - controlled with a combination of corticosteroids and cyclosporine . cyclophosphamide , methotrexate , azathioprine , mycophenolate mofetil , pentostatin , or high - dose thalidomide and hydroxychloroquine may be used if the first - line therapy fails . puva photochemotherapy and narrow - band uvb phototherapy are other options for skin involvement , while extracorporeal photochemotherapy may improve cutaneous as well as systemic involvement . granulocyte colony - stimulating factor , antilymphocyte globulin , tacrolimus , biological therapies , including etanercept , and particularly rituximab , may be helpful for steroid - resistant disease . patients with the lichenoid type of eruption have a worse prognosis , with 80% mortality at 10 years . prevention includes gamma irradiation of the lymphocyte - containing blood products and the use of third- or fourth - generation leukoreduction filters , although not 100% efficacious . graft versus host disease can be induced when blood products containing viable lymphocytes engraft in recipients after transfusion . we hereby report a case of graft versus host disease occurring 6 months post blood transfusion . the disease affected skin , mucosa , hair and nails of the patient with no systemic symptoms and histology was suggestive of lichenoid gvhd . chronic lichenoid gvhd , a disease usually seen post solid organ transplantation can rarely occur post blood transfusion.it can be limited only to skin , mucosa , nail and hair , without any systemic involvement and not causing much of functional impairment . chronic lichenoid gvhd , a disease usually seen post solid organ transplantation can rarely occur post blood transfusion . it can be limited only to skin , mucosa , nail and hair , without any systemic involvement and not causing much of functional impairment .
chronic graft versus host disease ( gvhd ) is a less frequently seen disease that occurs post solid organ or bone marrow transplantation . chronic gvhd occurring post blood transfusion is an even more uncommon disease . 
 it can present either as a lichenoid disease or as a sclerodermatous disease involving multiple systems . in this article 
 , we report a case of chronic graft versus host reaction occurring in skin secondary to blood transfusion .