Adenotonsillar enlargement in pediatric organ transplant recipients: a cross-sectional analysis

Nondestructive versus advanced post-transplant lymphoproliferative disorder in a single-center pediatric kidney transplant population

BACKGROUND

Pediatric kidney transplant recipients are at risk for the development of post-transplant lymphoproliferative disorders (PTLD), a group of potentially devastating diseases that present on a spectrum of severity ranging from nondestructive PTLD to more histologically destructive lesions. Currently, there is inadequate evidence to guide evaluation and management of nondestructive PTLD.

METHODS

This is a single-center case series of pediatric kidney transplant recipients between January 1, 2008 and December 31, 2019, who were diagnosed with PTLD. The aim was to describe clinical characteristics, presentation, and management of nondestructive versus advanced PTLD.

RESULTS

Eighteen patients were diagnosed with nondestructive PTLD and seven with more advanced PTLD histopathology. The majority (66.7%) of nondestructive PTLD patients (n = 16) presented with tonsillar hypertrophy and/or snoring and were managed conservatively, with minimal reduction in tacrolimus dose and no further evaluation. No patient progressed to more advanced PTLD. Advanced PTLD patients (n = 7) were more likely to present with fever, elevated creatinine, a new mass of gastrointestinal symptoms. They received workup with imaging and oncology consultation, and were managed with chemotherapy.

CONCLUSIONS

Patients with nondestructive PTLD often present with symptoms of sleep-disordered breathing and can be managed conservatively with excellent clinical outcomes. More study is needed to guide care of this under-researched population.

A review of adenotonsillar hypertrophy and adenotonsillectomy in children after solid organ transplantation

OBJECTIVE

Paediatric solid organ transplantation is an increasingly successful treatment. Improved survival is paralleled by increased secondary complications of immunosuppression, including post-transplant lymphoproliferative disease (PTLD). PTLD frequently presents in Waldeyer's lymphatic ring. Adenotonsillar hypertrophy (ATH) is common in children, however in children after transplant, ATH may indicate PTLD. We review the literature on ATH and the role of adenotonsillectomy in children after transplantation.

METHODS

A comprehensive literature search was performed on the 26 th September 2017 of Ovid Medline (1996-September 2017), Embase (1996-2017) and EBM reviews (Cochrane database of systematic reviews 2005-September 20 th 2017). Results were limited to English language publications within the last 20 years. Abstracts were screened for relevance to PTLD and ATH in the paediatric solid organ transplantation population. Screening of the bibliographies identified further articles.

RESULTS

85 unique articles were screened to yield 18 relevant publications. 10 were retrospective studies and 8 were prospective studies.

CONCLUSION

In children, we report a PTLD incidence of up to 15%, with up to 63% of cases presenting in the head and neck. Histological examination of adenotonsillectomy specimens found PTLD in a mean 5.7% (range 0-39%). We found a lack of prospective studies into this topic and further high quality research is needed. Clinical assessment of ATH in children after transplantation and when to perform a diagnostic adenotonsillectomy remains challenging. Children with ATH warrant prompt further investigation and support from colleagues in transplantation and oncology is required. .

Posttransplant Lymphoproliferative Disorder: Otolaryngological Manifestations and Management

Objective

Posttransplant lymphoproliferative disorder (PTLD) is a unifying term for a spectrum of lymphoid expansion entities brought about by immunosuppression and is strongly associated with Epstein-Barr virus (EBV). Otolaryngological findings tend to present early in the clinical course; therefore, disease awareness among otolaryngologists is of utmost importance. This review synthesizes the body of literature pertaining to PTLD involving the head and neck, summarizes contemporary management, and highlights areas for future research.

Data Sources

PubMed/Medline.

Review Methods

Primary literature search of the Medline database was performed for all titles published in the past 10 years pertaining to PTLD. The database search included PTLD combined with a collection of otolaryngological MeSH terms. Full manuscripts were reviewed based on relevance of their title and abstract. Selection into this review was according to clinical and scientific relevance.

Conclusion

Adenotonsillar focus is common in children in whom adenotonsillectomy may be diagnostic and prevents potentially morbid airway obstruction. Sinonasal PTLD may mimic fungal infection. Laryngotracheal involvement predominately presents in children with symptoms of airway obstruction. PTLD limited to the esophagus is rare. Oral PTLD is rare and phenotypically varied. Cutaneous presentation of PTLD is infrequent, yet one-third of cases affects the head and neck. PTLD may present as cervical lymphadenopathy.

Implications for Practice

PTLD consideration is vital when evaluating posttransplant patients. Children and EBV-seronegative patients should receive otolaryngological follow-up after transplant. PTLD treatment is multidisciplinary and typically led by lymphoma specialists. Formal partnerships between otolaryngologists and transplant centers may improve patient care and research quality.

Utility of Head and Neck Biopsies in the Evaluation of Posttransplant Lymphoproliferative Disorder

OBJECTIVE: To determine the diagnostic yield of head and neck biopsies in the evaluation of PTLD in children and to explore whether this yield was related to pretransplant Epstein-Barr virus (EBV) serostatus.

STUDY DESIGN: This is a retrospective study of pediatric, post-solid-organ transplant recipients who have undergone a biopsy in the head and neck region to establish a diagnosis of PTLD.

RESULTS: Fifty-six biopsies were performed in 46 patients four to 120 months after solid-organ transplantation. Biopsies yielded PTLD in 39.1% of patients. The odds of developing PTLD if a patient was seropositive for EBV at the time of transplantation was 0.26 (95% confidence interval, 0.064-1.056; P = 0.054).

CONCLUSIONS: The high diagnostic yield of PTLD suggests that biopsies should be performed if PTLD is suspected in pediatric posttransplant patients. The results demonstrate a trend toward lower risk of PTLD among patients with pretransplant exposure to EBV.

Increased incidence of adenoidectomy and tonsillectomy in children with renal transplantation

BACKGROUND

Previous studies have found that pediatric solid organ transplant recipients suffer from adenotonsillar hyperplasia. However, as this condition is also common in normal children, it remains unclear whether the incidence is truly increased. The aim of this study was to compare the incidences of surgery on the adenoids and tonsils of normal children with those receiving renal transplants and to define risk factors in the transplant population.

METHODS

Data on 49 consecutive children from a single renal transplant unit were compared to data from a large governmental survey of healthy German children (KiGGS). For analysis of 'survival without operation', controls were matched for gender, region and immigration status (n = 8,650), as well as for age to compare incidence rates (n = 637).

RESULTS

The age-matched solid organ transplant recipients had a higher incidence of adenoidectomies [2.3-fold, [95 % confidence interval (CI) for relative risk 1.6-3.3) and a higher incidence of tonsillectomies/tonsillotomies (3.5-fold, 95 % CI 2.1-5.7). The normal peak of adenoidectomies was delayed by 2 years in the pre-school group, and transplanted teenagers showed an extra peak for both operations. Boys and those transplanted at a younger age were significantly more likely to need adenoidectomies. Ciclosporin levels, Epstein-Barr virus and cytomegalovirus infections did not influence the incidence of operations.

CONCLUSION

Children receiving renal transplants are at markedly increased risk of adenotonsillar hyperplasia requiring surgery, especially males and young recipients.

Obstructive sleep apnea (OSA): a complication of acute infectious mononucleosis infection in a child

Independently, obstructive sleep apnea (OSA) and infectious mononucleosis are not uncommon in the pediatric population, but acute onset of OSA, as a respiratory complication in the setting of acute EBV infection is extremely uncommon. Previous reports of this clinical entity are sparse and from nearly two decades ago. Urgent adenotonsillectomy was commonly advocated. This complication may be managed medically with systemic corticosteroids and non-invasive continuous positive airway pressure (CPAP), and a case is presented to highlight an updated management approach to this rarely encountered clinical problem in children.

Adenotonsillar pathology in post-transplant patients

OBJECTIVE/HYPOTHESIS

The purpose of this study is to evaluate the efficacy of adenotonsillar hypertrophy, Epstein-Barr virus (EBV) titers, and flow cytometry in the evaluation of post-transplant lymphoproliferative disease (PTLD) in an at-risk pediatric population and to propose flow cytometry is the most effective means of diagnosis and directed treatment.

STUDY DESIGN/METHODS

The authors conducted a retrospective chart review of all pediatric transplant patients referred for adenotonsillectomy at a tertiary care center between May 2000 and May 2003. Thirteen patients were identified. All tonsils were evaluated for follicular lymphoid hyperplasia and atypical lymphoid cells. Seven of thirteen samples were stained for EBV RNA, and twelve of thirteen samples were tested using flow cytometry. Positive flow cytometry diagnosis was based on the presence of atypical lymphocytes, gene arrangement, or both.

RESULTS

Seven of thirteen (7/13) examined patients were found to have adenotonsillar hypertrophy. Ten of thirteen (10/13) patients had elevated EBV serum titers. Four of thirteen (4/13) patients were found PTLD positive by flow cytometry. Of the four positive patients, all four patients were found to have elevated EBV titers and only two patients had adenotonsillar hypertrophy.

CONCLUSIONS

Adenotonsillar hypertrophy is not a sensitive indicator of PTLD. EBV serum titers are sensitive but nonspecific. Flow cytometry is the most effective diagnostic modality and allows physicians to tailor treatment to specific forms of PTLD.

The validity of the OSA-18 among three groups of pediatric patients

OBJECTIVE

To compare the signs and symptoms of obstructive sleep apnea syndrome in three groups of pediatric patients; solid organ transplant recipients, healthy children, and children with leukemia; in order to examine the effects of chronic illness on the obstructive sleep apnea-18-item questionnaire and to investigate its validity as a screening tool for obstructive sleep apnea in the pediatric solid organ transplant population.

METHODS

In this cross-sectional study, there were two hundred and six subjects; 46 kidney transplant recipients, 59 liver transplant recipients, 34 patients with leukemia, and 67 healthy children. Adenotonsillar enlargement was assessed by using the obstructive sleep apnea-18-item questionnaire and by performing a focused physical examination of the oral and nasal cavity at the time of the child's routine visit in either the transplant clinic, outpatient oncology center, or general pediatric clinic.

RESULTS

Comparison of questionnaire scores amongst the three groups showed significant differences between the healthy children and liver transplant recipients as well as those with leukemia. There was a significant difference in the physical examination scores of the children with leukemia as compared to the other groups.

CONCLUSIONS

Adenotonsillar enlargement in pediatric transplant recipients can be an early indication of post-transplantation lymphoproliferative disorder. However, the prevalence of adenotonsillar enlargement in the transplant population does not appear to differ from that of the healthy population. Additionally, scores on the OSA-18 in the transplant population were confounded by chronic illness. Further prospective studies need to be performed to develop a screening tool to identify transplant recipients at risk for post-transplantation adenotonsillar lymphoma.