When viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.

Graft versus host disease

Last reviewed: 4 Sep 2023
Last updated: 25 Jan 2023



History and exam

Key diagnostic factors

  • allogeneic hematopoietic cell transplantation (HCT) recipient
  • unrelated donor
  • multiparous female donor
  • diffuse maculopapular rash with fever
  • nausea, abdominal pain, and profuse diarrhea
More key diagnostic factors

Other diagnostic factors

  • day +14 after HCT
  • cyclophosphamide + total body irradiation (Cy/TBI) conditioning regimen
  • peripheral blood stem cells as donor source
  • new-onset painful mouth sores
  • hyperpigmented skin lesions
  • dry, gritty, and painful eyes
  • dry, irritated vagina and vulva
  • jaundice
  • hepatomegaly
  • scleroderma
Other diagnostic factors

Risk factors

  • HLA disparity
  • recipient or donor in older age group
  • female donor with male recipient
  • multiparous female donor
  • advanced malignant condition
  • high-intensity conditioning radiation regimen
  • peripheral blood stem cells as source of transplant
  • absent or suboptimal GVHD prophylaxis
  • non-Asian or non-Hispanic ethnicity
  • cytomegalovirus (CMV) seropositive
  • splenectomy
  • low performance status score
  • low socioeconomic status
More risk factors

Diagnostic investigations

1st investigations to order

  • CBC
  • serum electrolytes
  • liver functions tests
  • urinalysis
  • urine culture
  • blood culture
  • stool culture
  • viral polymerase chain reaction (PCR)
More 1st investigations to order

Investigations to consider

  • CT abdomen
  • Doppler ultrasound of the liver
  • tissue biopsy (skin, liver, gastrointestinal tract, oral lesions, or lung)
  • pulmonary function tests
  • high-resolution CT chest
  • bronchoalveolar lavage (BAL) and culture
  • echocardiogram
  • barium swallow or upper gastrointestinal endoscopy
  • 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) scan
More investigations to consider

Treatment algorithm


hematopoietic cell transplantation (HCT) recipient


acute: grade I

acute: grade II-IV





Sung Won Choi, MD, MS
Sung Won Choi


Department of Pediatrics

Division of Pediatric Hematology Oncology/Blood and Marrow Transplantation

University of Michigan

Ann Arbor



SWC is an author of a number of references cited in this topic.

Lyndsey Runaas, MD
Lyndsey Runaas

Assistant Professor, Hematology and Oncology

Division of Hematology/Oncology

Medical College of Wisconsin




LR declares that she has no competing interests.


Dr Sung Choi and Dr Lyndsey Runaas would like to gratefully acknowledge Dr Pavan Reddy, a previous contributor to this topic.


PR is an author of a number of references cited in this topic.

Peer reviewers

Corey Cutler, MD, MPH, FRCPC

Associate Professor of Medicine

Harvard Medical School

Dana-Farber Cancer Institute




CC declares that he has no competing interests.

Waseem Qasim, BMedSci (Hons), MBBS, MRCP (UK), MRCPCH, PhD

Senior Lecturer

Institute of Child Health

Consultant in Paediatric Immunology & Bone Marrow Transplantation

Great Ormond Street Hospital




WQ declares that he has no competing interests.

  • Graft versus host disease images
  • Differentials

    • Drug rash
    • Radiation rash
    • Bacterial gastroenteritis
    More Differentials
  • Guidelines

    • NCCN clinical practice guidelines in oncology: hematopoietic cell transplantation​
    • Dental management of pediatric patients receiving immunosuppressive therapy and/or head and neck radiation​
    More Guidelines
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer