2007 Post Transplant Lymphoproliferative Disorder: A Rare Cause of Gastrointestinal Blood Loss Anemia

Abstract

INTRODUCTION: Post transplant lymphoproliferative disorder (PTLD) is a rare complication after solid organ or stem cell transplant. Gastrointestinal tract is a common site of PTLD proliferation but PTLD related GI bleeding is rare. WE here by present a young Caucasian male on chronic immunosuppression for disease donor kidney transplant who presented with severe iron deficiency anemia related to GI blood loss from PTLD. CASE DESCRIPTION/METHODS: A 33-year-old Caucasian male with H/O Alport syndrome with ESRD S/P kidney transplant in 2012 on chronic immunosuppression with azathioprine and tacrolimus presented with 3 months of abdominal pain and intermittent melena. Hb was 5.4 g/dl, iron 7 mg/dl, ferritin 5 ng/ml. CT abdomen with dilated ileal loop with wall thickening and lobular contour. After resuscitation, patient underwent EGD and colonoscopy. EGD was unremarkable and colonoscopy revealed normal colon but nodular pattern in the terminal ileum (Figure 1). Multiple biopsies were taken. Histopathology and immunohistochemical staining were noted as florid follicular hyperplasia and rare EBV-positive cells, compatible with non-destructive PTLD (Figure 2) and positive CD 20 and high KI-67 proliferation index (Figure 3). Patients was discharged with reduction of his immunosuppressant therapy along with weekly rituximab. DISCUSSION: Gastrointestinal tract is the most common extranodal location of PTLD. EBV is a risk factor for PTLD and is associated with more than 80% of cases. Uncontrolled proliferation of EBV transformed B cells in the setting of compromised T cell mediated immunity due to immune suppression is involved in the pathogenesis if PTLD. Gastrointestinal manifestations may include obstruction, perforation and, very rarely, bleeding. Endoscopic manifestation include ulcers or nodular lesions with or without central ulceration and histologically lymphoid hyperplasia to lymphoma with nearly 80% positive EBV staining. Management is reduction of immune suppression; R-CHOP is an alternative in high risk patients. Early diagnosis and prompt treatment is cornerstone of PTLD gastrointestinal involvement.