Dynamic Presentations of Recurrent Post-Transplant Lymphoproliferative Disorder in a Heart Transplant Recipient: A Rare Case Study

Abstract

Post-transplant lymphoproliferative disorders (PTLD) are complications that arise from post-transplantation immunosuppressive therapy. Although Epstein-Barr virus (EBV) viremia is often seen in PTLD, it is not a definitive feature for diagnosis. We report a rare case of recurrent PTLD in a 26-year-old heart transplant recipient on high-dose tacrolimus who presented with emesis, fatigue, and bloody diarrhea. Although substantial EBV viremia was seen in the first PTLD episode, the current episode was a gastrointestinal manifestation with barely detectable circulating EBV. The patient's history of gastrointestinal disease delayed definitive diagnosis, which was later established through endoscopy and biopsy sample analysis.

Keywords: Crohn's disease; EBV; PTLD; inflammatory bowel disease.

Figure 1.

Sigmoid colon—deep serpiginous ulcer (white arrow).

Figure 2.

A hematoxylin and eosin stained section at 4× magnification (A) from the sigmoid colon biopsy showing colonic mucosa with architectural distortion and Paneth cell metaplasia (arrowhead) and (B) increased lamina propria plasmacytic inflammation. (C) Immunostaining for CD138 highlights numerous plasma cells in the lamina propria, which were polyclonal per kappa and lambda in situ stains (not pictured). CD138 immunostaining revealed normal expression in the colonic epithelium. (D) An EBV in situ stain highlights scattered lamina propria inflammatory cells (arrowhead). The features were most consistent with EBV-positive plasma cell hyperplasia described for early post-transplant lymphoproliferative disorder lesions. EBV, Epstein-Barr virus.