Elevated serum immunoglobulin preceding primary cutaneous posttransplant lymphoproliferative disorder

Post-Transplant Lymphoproliferative Disorder, Monomorphic Type, in a Kidney Transplant Patient After Administration of Anti-Influenza Vaccine

ABSTRACT

Post-transplant lymphoproliferative disorders (PTLD) are rare complications in solid organ transplant patients. Their pathogenesis is largely unknown and closely linked to low immunity, which allows uncontrolled lymphocyte proliferation. Although transplant patients receive annual influenza vaccination as a preventive protocol, we have not found any cases where the flu vaccine triggered a PTLD. We present the case of a 49-year-old female kidney transplant recipient who developed an Epstein-Barr virus-negative PTLD, CD30+ anaplastic monomorphic type, ALK-, which presented the day after a single dose of anti-influenza vaccine. The initial clinical presentation was subcutaneous, but imaging studies revealed multiorgan involvement.

Post-transplant lymphoproliferative disorder with cutaneous involvement: A series of four cases

BACKGROUND

Post-transplant lymphoproliferative disorders (PTLD) are lymphoid proliferations associated with post-transplant immunosuppression. Most originate from B cells and are associated with Epstein-Barr virus (EBV) infection. Although extranodal involvement is common, cutaneous presentation is rare.

OBJECTIVE

To report and characterize cutaneous manifestations of PTLD from clinical, histopathologic, and immunohistochemistry standpoints.

METHODS

Patients' information was obtained retrospectively by reviewing medical records. Skin biopsies were submitted to histological and immunohistochemistry analysis, and EBV detection was performed by in situ hybridization and polymerase chain reaction (PCR) analysis. Staging examinations were included. A literature review of reported cutaneous PTLD cases was performed.

RESULTS

We describe two cases of primary cutaneous and 2 cases of systemic PTLD with secondary cutaneous manifestations. All had late onset disease, which presented at least 6 years after transplantation. Histopathologic findings were compatible with monomorphic PTLD in three cases and plasmacytic hyperplasia in one case. EBV was detected in two patients. Both patients with systemic disease had fatal outcome, and those with primary cutaneous involvement responded to treatment.

LIMITATIONS

Due to the rare incidence of cutaneous manifestation of PTLD, the analysis of a large number of cases was not possible.

CONCLUSION

Although rare, PTLD should be considered in the differential diagnosis of late onset cutaneous complications post-renal transplant.

Cutaneous presentation of post-renal transplant lymphoproliferative disorder: a series of four cases

We report detailed histological and molecular characteristics of four post transplant lymphoproliferative disorders (PTLD) presenting in the skin of renal transplant patients, and their clinical outcome. Three had B-cell lymphomas (cases 1-3), and one had a T-cell lymphoma (case 4). All B-cell lymphomas showed Epstein-Barr virus (EBV) by immunohistochemistry (IHC) or in situ hybridization (ISH). Cases 1 and 2 were large cell lymphomas, and case 3 a plasmacytoma. Case 1 showed light chain restriction and heavy chain gene rearrangement by polymerase chain reaction (PCR). The patient was then diagnosed with an abdominal lymphoma and died of sepsis. Case 2 had no recoverable DNA. Case 3 had a plasmacytoma that showed monoclonal light chain restriction on IHC and an oligoclonal heavy chain rearrangement by PCR. In cases 2 and 3, the lesions regressed following reduction of immunosuppression, and died 1.5 and 8 years later from unrelated medical causes. Case 4 was a CD 30+ anaplastic large T-cell lymphoma with no EBV detected by IHC, ISH and PCR, and died of heart failure 2 years later. Cutaneous manifestations of PTLD are rare, show wide array of clinical and pathological features, and generally have a favorable prognosis. EBV appears to be associated only with B-cell cutaneous lymphomas.