Diagnose This (September 21, 2020)

What is this finding and what is the significance in the transplant setting?

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The light microscopic image depicts an artery with endothelialitis characterized by mononuclear cell inflammation under the arterial intima. This finding is compatible with a diagnosis of acute vascular rejection, grade IIA. Importantly, vascular rejection need not be seen in association with interstitial inflammation or tubulitis and for scoring purposes, the worst artery present (i.e. showing the most severe arteritis) dictates the overall v- score. Finally, vascular rejection can be seen not only in pure T-cell mediated rejection but can also be seen with acute antibody-mediated rejection.