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Introduction: Hand transplantation is becoming more common place and as patients and follow-up accumulate, so do experiences treating acute rejection. We report a case of acute rejection on single drug immunosuppression following a period of non-compliance which was resistant to steroid boluses. He displayed clinical signs of continued inflammation consisting of edema and erythematous maculo-papular lesions.  Cutaneous biopsies revealed moderate to high grade acute cellular rejection celluar inflammatory infiltrates, increased C4d staining, cutaneous adnexal loss and deep microangiopathic vessel changes despite normal radial and ulnar artery surveillance by high resolution ultrasound.

Methods: The patient was admitted and underwent 1.5mg/kg/day thymoglobulin infusion x 4 days. He was monitored closely for signs of infection and complications such as “cytokine storm”. His transplanted hand was also monitored for signs of improvement. Cutaneous biopsies were repeated beginning 2 weeks following treatment.

Results: Following treatment with 4 days of thymoglobulin infusion, his graft demonstrated diminished edema, evolution of skin lesions from erythematous to brown macules which continued to fade, and resumption of hair growth which had been lost. Chronic changes such as decreased number of adnexal structures were unchanged but inflammatory infiltrates were diminished at the adnexae and througout the biopsy specimen.  C4d stains decreased to previous background levels.

Summary: Episodes of rejection have occurred in almost all hand transplant patients reported to date. Steroid resistant rejection is less common and requires careful consideration of multiple options and may be successfully treated with pulsed thymoglobulin therapy.