Two cases of post transplant lymphoproliferative disorder in lung transplant recipients

Abstract

Post-transplant lymphoproliferative disease (PTLD) is a serious, often fatal complication after solid organ transplantation. The incidence of PTLD is greater among heart (2 approximately 13%), lung (12%) and heart/lung (5 approximately 9%) transplant recipients than among liver (2%), renal (1 approximately 3%) and bone marrow (1 approximately 2%) transplants recipients. The difference in the incidence of PTLD may be partly attributed to the higher dose of immunosuppressant therapy used for heart and lung transplantation. The Epstein-Barr virus (EBV) infection status of the donor and recipient before a transplant, and high dose of immunosuppressive drugs are considered major risk factors. Recently, 2 cases of PTLD in a single lung and a heart-lung transplantation recipient were encountered. Both patients presented with multiple pulmonary nodules in the transplanted lung, which developed 6 months and 2 years after the transplantation, respectively. Following a transthoracic lung biopsy for diagnostic confirmation, one patient underwent chemotherapy for PTLD and the other conservative care for an accompanying viral infection. Both patients showed rapid clinical deterioration, without response to treatment, and then rapidly succumbed. Herein, our experiences are reported, with a review of the literature.

Figure 1.

A plain chest radiograph (A) and a computerized tomograph (B, C) of case 1, revealing multiple, variably sized nodular lesions in both upper lung fields. Multiple mediastinal lymphadenopathies are also shown in the right lobe paratracheal and subcarinal areas. Microscopic findings of a transthoracic lung biopsy show irregular thickening of the alveolar septa and perivascular connective tissue, due to the diffuse infiltration of atypical lymphoid cells, which were confirmed as being of B-cell lineage by immunohistochemical staining (D, × 100 & × 200, H-E).

Figure 2.

Radiograph of case 2 showing multiple air spaced nodules, which had speculated margins accompanied by peripheral ground glass opacity at the left upper lobe, with collapse of the lingular segment. The native right lung shows severe emphysematous changes (A, B, C). A percutaneous transthoracic needle biopsy specimen shows aggregation of lymphocytes, and an immunohistochemical study of these revealed a positive reaction to L-26, but negative reactions to UCHL-1, Kappa, Lambda, cytokeratin and Ki-1, suggesting a malignant lymphoma, which was later confirmed as a high grade B-cell type malignant lymphoma (D, × 100 & × 200, H-E).