Heard a case in Renal Grand Rounds this morning regarding an elderly (72 year-old) 1st-time cadavaric renal transplant recipient who presented during his 3rd month post-transplant with fever, an elevated creatinine, and a CT scan showing mediastinal lymphadenopathy. An extensive infectious diseases workup was performed. The patient was CMV negative and his donor was CMV positive. However, while the patient was also EBV negative, his donor was EBV positive. A renal biopsy demonstrated that the patient had an EBV-positive lymphoid infiltrate, consistent with post-transplant lymphoproliferative disorder. The patient was appropriately treated with a reduction in immunosuppression and R-CHOP chemotherapy, but unfortunately he had a number of medical complications and passed away in the midst of treatment.
The case highlights a few interesting aspects of PTLD. First, the vast majority of PTLD cases arise from EBV infection, and of these the majority derive from the recipient, as opposed to the donor. Second, you have to be careful with overimmunosuppression of patients in this category: elderly individuals who are EBV-negative. This patient was given a fairly potent immunosuppression regimen of thymoglobulin, MMF, and tacrolimus, though in retrospect perhaps thymoglobulin could have been avoided. Finally, although PTLD is traditionally thought of as a complication of renal transplant which occurs after 6 months, it is certainly possible for the disease to occur earlier.