S1590 Post-Transplant Lymphoproliferative Disorder of a Pancreas Allograft Presenting as Pancreatic Necrosis

Abstract

INTRODUCTION: Post-transplant lymphoproliferative disorder (PTLD) is a serious and often fatal complication of solid-organ transplants, with incidence up to 13%. PTLD can be seen in pancreas transplant recipients, but allograft involvement is rare. Epstein Barr virus (EBV) infection and high immunosuppression regimen increases the risk of PTLD. This is a case of PTLD of a pancreas allograft presenting as pancreatic necrosis. CASE DESCRIPTION/METHODS: A 41-year-old female with end-stage renal disease secondary to diabetes who received a simultaneous pancreas-kidney transplant 6 months ago presented with abdominal pain and pancytopenia concerning for PTLD. Routine testing revealed recent development of EBV viremia (greater than 30,000 copies/mL). Immunosuppressants included tacrolimus, mycophenolate, and low dose prednisone. White blood cell count and lipase values were normal. Imaging of the transplanted pancreas revealed inflammation and a 1.0 × 1.5cm peripancreatic fluid collection in the right lower quadrant, suggestive of necrosis. Based on cross-sectional imaging, Interventional Radiology deemed that the inflammation precluded adequate sampling of the allograft. Endoscopic ultrasound (EUS) with biopsy of the transplanted pancreas was requested. The transplanted pancreas was endosonographically visualized from the cecum, showing a 0.6 × 0.5cm hypoechoic heterogenous pancreatic head lesion consistent with necrosis (Figures A and B). Trans-colonic FNA was deferred due to risk of infecting the sterile necrotic cavity. Pancreatectomy was performed 1 week later due to fevers, persistent abdominal pain, and enlarging peripancreatic fluid collection. Pathology revealed extensive necrosis infiltrated by lymphocytes and plasma cells consistent with PTLD (Figure C). DISCUSSION: Our patient had a unique presentation of PTLD with necrosis of the transplanted pancreas. Early diagnosis and treatment of rejection are critical in preventing failure of the transplanted organ. Minimally invasive diagnostic methods like EUS are gaining popularity. EUS of pancreas allografts is usually performed via a trans-duodenal approach. Due to our patient's duodenojejunostomy anastomosis, EUS was performed via the colon, which is unique. Expert review of cross-sectional imaging and knowing the institutional pancreas transplant technique will help determine an effective EUS approach. Early tissue diagnosis using EUS guided sampling must be strongly considered in pancreas allografts to detect and treat post-transplant complications.Figure 1.: Endosonographic Imaging of Transplanted Pancreas.Figure 2.: Endosonographic Imaging of Transplanted Pancreas with Hypoechoic Pancreatic Head Lesion.Figure 3.: Transplanted Pancreas with Lymphocytic and Plasma Cell Infiltration Consistent with PTLD and Extensive Necrosis.