Multiple spider angiomas in a patient with chronic hepatic graft-versus-host disease
Spider angiomas—tiny red vascular lesions with a central “body” and radiating “legs”—are most often linked to advanced liver cirrhosis. But a 2020 case report from Peking University People’s Hospital highlights a rare connection: multiple spider angiomas in a man with chronic hepatic graft-versus-host disease (GVHD), a common complication of life-saving stem cell transplants.
The patient was a 40-year-old man with a history of acute myeloid leukemia (AML), who underwent a hematopoietic stem-cell transplant (HSCT) 7 years earlier. Just 5 months after his transplant, he developed chronic hepatic GVHD—a condition where donated stem cells attack the recipient’s healthy liver (and sometimes skin or gut). For years, his liver function tests (LFTs) remained abnormal, a sign of ongoing liver injury.
Over two years, he noticed multiple red spots spreading across his neck, arms, and upper trunk. Dermatologists identified these as classic spider angiomas: dilated blood vessels with a central arteriole (the “spider’s body”) and thin, radiating branches (the “legs”). Pressing the center made the entire lesion fade—a telltale sign of these vascular growths. He also had tender gynecomastia (enlarged breast tissue in men), a clue to hormone imbalances often seen when the liver can’t properly metabolize estrogen.
Tests confirmed his liver was struggling: elevated total bilirubin (29.8 mmol/L, normal <21), direct bilirubin (15.1 mmol/L, normal <7), and total bile acids (56.1 mmol/L, normal 40). Crucially, he tested negative for hepatitis B and C, had no history of alcohol use, and hadn’t taken drugs that affect estrogen—ruling out common causes of liver-related spider angiomas. An abdominal ultrasound showed a nodular liver surface (a sign of scarring) but no esophageal varices (a more severe cirrhosis complication).
Doctors diagnosed his spider angiomas as a complication of chronic hepatic GVHD. He was treated with systemic steroids, which successfully normalized his liver function—but the spider angiomas remained. This makes sense: steroids calm the immune attack on the liver but don’t reverse existing blood vessel changes from long-term injury.
Hepatic GVHD typically causes cholestatic liver injury (bile can’t flow properly) alongside symptoms like skin rashes or diarrhea (Norvell, 2015). While cirrhosis from GVHD is rare, long-term abnormal LFTs raise that risk significantly (Wang et al., 2016). This case is unusual because multiple spider angiomas—usually a sign of advanced cirrhosis—are rarely linked to GVHD. It suggests even without full-blown cirrhosis, long-term liver injury from GVHD can trigger the hormone and vascular changes that cause spider angiomas.
Spider angiomas aren’t always harmful: 10–15% of healthy kids and young adults have a single lesion. Multiple lesions are more concerning—common in pregnant women (estrogen changes) or people on oral contraceptives. But in men, they almost always point to chronic liver disease like alcoholic cirrhosis or hepatitis C (Vedamurthy & Vedamurthy, 2008; Sood et al., 2015). GVHD-related spider angiomas are rare.
Scientists don’t fully understand why spider angiomas form, but hormone imbalances play a role. Men with cirrhosis often have high estradiol (a female hormone) relative to testosterone, which dilates blood vessels. Other factors include elevated cytokines—proteins like substance P, vascular endothelial growth factor (VEGF), and basic fibroblast growth factor (bFGF)—that promote blood vessel growth and dilation (Yalcin et al., 2013).
The case was reported by dermatologists Ying Gu, Kun Li, Xia Wu, and Jian-Zhong Zhang from the Department of Dermatology at Peking University People’s Hospital in Beijing, China. They emphasize the importance of linking skin findings to underlying systemic disease—especially in patients with a history of stem cell transplants.
This case was published in the Chinese Medical Journal in 2020 (Gu et al., 2020). The authors obtained full patient consent for publishing his clinical information and images.
doi.org/10.1097/CM9.0000000000000707
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