1894 Gastrointestinal Post-Transplant Lymphoproliferative Disorder (PTLD) With Rapidly Forming Characteristic Lesions After Heart Transplantation: A Case Report

Abstract

INTRODUCTION: Post-transplantation lymphoproliferative disorders (PTLDs) are the second most common neoplasms in adult transplant recipients. Epstein-Barr virus infection in the setting of immunosuppressive therapy is implicated etiologically in most cases. More than half of PTLD cases present with extra-nodal involvement including the GI tract. Few reports have described the endoscopic findings. We present a case of rapidly progressive PTLD involving the GI tract with gross lesions that developed less than 2 months after a macroscopically normal upper and lower endoscopy. CASE DESCRIPTION/METHODS: A 37-year-old female with history of orthotopic heart transplant 3 months prior for transposition of the great arteries was admitted to the hospital with 3 weeks of non-bloody diarrhea. Her immunosuppressive regimen included tacrolimus, mycophenolate and prednisone. Extensive serologic and fecal testing was performed with no evidence of systemic CMV, EBV, HSV (serum PCR), clostridium difficile, or other bacterial intestinal infection. She underwent diagnostic upper and lower endoscopy with no grossly visible lesions. Random colon biopsies demonstrated increased lamina propria eosinophils and eosinophilic crypt abscesses suggestive of drug-effect. A presumptive diagnosis of mycophenolate induced colitis was made. Symptoms resolved however during her hospitalization and she was continued on mycophenolate. She presented 6 weeks later with 3 weeks of recurrent non-bloody diarrhea. Repeat serologic and fecal testing revealed EBV and CMV viremia. CT abdomen and pelvis with IV contrast was unremarkable. Repeat upper and lower endoscopy revealed multiple new ulcerated nodular lesions 1 cm in size (Figures 1 and 2) in the stomach, duodenum, terminal ileum and entire colon. Biopsies showed monomorphic PTLD, diffuse large B-cell type, with EBV positive staining. DISCUSSION: PTLD can be isolated to the gastrointestinal tract in immunocompromised post-transplant patients. Endoscopy with biopsy is required to establish the diagnosis. When there is high suspicion for PTLD, consideration should be given for repeat endoscopy even with recent normal examination as macroscopic and microscopic findings may develop rapidly.