Primary central nervous system posttransplantation lymphoproliferative disorder after heart and lung transplantation

Primary central nervous system lymphoma after heart transplantation: A case report and literature review

RATIONALE

The heart transplantation is the most important treatment for patients with end-stage severe heart disease who failed to conventional therapy. Post-transplant lymphoproliferative disorder is the second most common malignancy in heart transplant recipients. However, primary central nervous system lymphoma (PCNSL) after heart transplantation is an extremely rare condition.

PATIENTS CONCERNS

This report described a 53-year-old male who was diagnosed as PCNSL 17 months after heart transplantation.

DIAGNOSES

The patient was admitted to the local hospital presenting with dizziness, headache, and reduced left-sided power and sensation for 1 week. He had a medical history of heart transplantation because of the dilated cardiomyopathy 17 months ago and had a 17-month history of immunosuppressive therapy with tacrolimus. A computed tomography scan of the brain revealed a bulky mass in the right temporal lobe. The emergency intracranial mass resection and cerebral decompression were performed in our hospital. The histopathology of the brain lesions showed diffuse large B-cell lymphoma. A further FDG positron emission tomography-computed tomography scan of the whole body showed no significantly increased metabolic activity in other regions. The final diagnosis of this patient was PCNSL after heart transplantation.

INTERVENTIONS

Given the poor health condition, with the patient's consent, the whole brain radiotherapy was performed with supportive care.

OUTCOMES

The disease deteriorated rapidly during the period of receiving radiotherapy, and he died within 2 months from the diagnosis.

LESSONS

PCNSL after heart transplantation is an extremely rare phenomenon with extremely poor prognosis. We should pay close attention to the heart recipients, especially when the patients present with neurological symptoms and signs. The available treatment options for PCNS-post-transplant lymphoproliferative disorder include the reduction of immunosuppressive drugs, immune-chemotherapy, operation, radiotherapy. However, individual treatments for heart transplant recipients with PCNSL should be based on the performance status and tolerance to treatment, combined with the doctor's experience and supportive care.

A case report: pause and consider the late complications of heart transplantation

Background

A 75-year-old woman with a past medical history significant for non-ischaemic cardiomyopathy status post orthotopic heart transplant, type II diabetes mellitus, hypertension, chronic kidney disease stage III, chronic anaemia, and chronic diarrhoea presented with nausea, vomiting, and an unexplained fall 23 years after original transplantation.

Case summary

During her hospital stay, she had multiple episodes of sinus arrest with syncope, preceded by seizure like activity. She was stabilized, and broad work up revealed an occult brain mass that was ultimately resected and consistent with post-transplant lymphoproliferative disease.

Discussion

Features that make this case study unique include the late onset and location of the malignancy, the absence of Epstein–Barr virus involvement, and asystole that was potentially neurologically mediated and induced by a brain space occupying mass. This case offers insight into potential late parasympathetic reinnervation of transplanted hearts, adds to the growing literature regarding the connection between the brain and the heart, and reviews potential complications in patients with a remote history of heart transplantation.

Primary Central Nervous System Hodgkin Lymphoma-Like Posttransplant Lymphoproliferative Disorder

BACKGROUND

Posttransplant lymphoproliferative disorder (PTLD) is a rare condition occurring after organ transplantation. PTLD comprises 4 subtypes, of which Hodgkin lymphoma (HL) type and HL-like type (currently included in polymorphic type) account for only about 1%-3% of cases. Primary central nervous system PTLD is also rare; most cases are Epstein-Barr virus-positive, B-cell PTLD. To our knowledge, no case of HL-like PTLD has been documented.

CASE DESCRIPTION

A 43-year-old woman who underwent kidney transplantation for IgA nephropathy 14 years previously presented to the emergency department with seizure. Gadolinium-enhanced T1-weighted magnetic resonance imaging showed a ring-enhancing mass in the left temporal lobe. Gross total removal of the tumor was performed, and pathologic examination revealed findings consistent with HL-like PTLD. The patient's immunosuppressants were subsequently reduced, and she received postoperative systemic therapy with rituximab and radiation therapy. Follow-up magnetic resonance imaging showed no signs of relapse.

CONCLUSIONS

This represents an extremely rare case of a patient with HL-like PTLD occurring as a primary central nervous system lesion.

Incidence and outcomes of primary central nervous system lymphoma in solid organ transplant recipients

Primary central nervous system lymphoma (PCNSL) risk is greatly increased in immunosuppressed human immunodeficiency virus-infected people. Using data from the US transplant registry linked with 17 cancer registries (1987-2014), we studied PCNSL and systemic non-Hodgkin lymphoma (NHL) in 288 029 solid organ transplant recipients. Transplant recipients had elevated incidence for PCNSL compared with the general population (standardized incidence ratio = 65.1; N = 168), and this elevation was stronger than for systemic NHL (standardized incidence ratio=11.5; N = 2043). Compared to kidney recipients, PCNSL incidence was lower in liver recipients (adjusted incidence rate ratio [aIRR] = 0.52), similar in heart and/or lung recipients, and higher in other/multiple organ recipients (aIRR = 2.45). PCNSL incidence was higher in Asians/Pacific Islanders than non-Hispanic whites (aIRR = 2.09); after induction immunosuppression with alemtuzumab (aIRR = 3.12), monoclonal antibodies (aIRR = 1.83), or polyclonal antibodies (aIRR = 2.03); in recipients who were Epstein-Barr virus-seronegative at the time of transplant and at risk of primary infection (aIRR = 1.95); and within the first 1.5 years after transplant. Compared to other recipients, those with PCNSL had increased risk of death (adjusted hazard ratio [aHR] = 11.79) or graft failure/retransplantation (aHR = 3.24). Recipients with PCNSL also had higher mortality than those with systemic NHL (aHR = 1.48). In conclusion, PCNSL risk is highly elevated among transplant recipients, and it carries a poor prognosis.