Post-transplant lymphoproliferative disorders presenting as gingival overgrowth in patients immunosuppressed with ciclosporin. A report of two cases

Drug-induced gingival overgrowth: A critical insight into case reports from over two decades

Drug-induced gingival overgrowth (DIGO) is a well-recognized adverse effect of certain systemic medications. Calcium channel blockers, anticonvulsants, and immunosuppressants are frequently implicated drugs in the etiology of DIGO. Drug variables, plaque-induced inflammation, and genetic factors are the three important factors in the expression of gingival changes after systemic medication use. Careful clinical examination and thorough history taking form the basis for diagnosis of DIGO. Histopathological examination is often neglected; however, it is an important aid that helps in differential diagnosis. Cessation or change of drug and meticulous plaque control often leads to regression of the lesion, which however might need surgical correction for optimal maintenance of gingival health. The purpose of the present article is to review case reports and case series published in the last two decades and to assimilate and compile the information for clinical applications such as diagnosis and therapeutic management of DIGO.

Epstein-Barr virus (EBV)--associated posttransplant lymphoproliferative disorder appearing as mandibular gingival ulcers

Posttransplant lymphoproliferative disorders (PTLDs) comprise a spectrum of complications that affect immunocompromised patients following hematopoietic stem cell transplantation or solid organ transplantation. Its incidence varies depending on the transplanted organ, occurring in approximately 2.3% of kidney transplantations. A 31-year-old woman was referred to the Dental Clinic of the State University of Western Paraná for evaluation of an oral lesion. Her medical history revealed a previous diagnosis of hypertension, Epstein-Barr virus (EBV) seropositivity, and kidney transplantation 12 years prior. She was under standard immunosuppressive therapy. Intraoral examination identified a gingival necrotic lesion with extension to the posterior right lower alveolar bone. An incisional biopsy was performed. Histologic examination showed lymphocytic proliferation of cells with small and hyperchromatic nuclei, atypical mitosis, and cells with large and pale nuclei showing prominent nucleoli permeating connective tissue, muscle fibers, and adipocytes. Correlation of clinical, histologic, and immunohistochemical findings led to a diagnosis of polymorphic EBV-associated PTLD rich in B and T cells.

Posttransplant lymphoproliferative disorder presenting as a nonhealing extraction socket: a case report and review of the literature

Posttransplant lymphoproliferative disorder (PTLD) is a well-recognized complication of long-term immunosuppression following hematopoietic or solid organ transplantation and is associated with significant morbidity and mortality. We present a unique case of PTLD that manifested with a nonhealing dental extraction socket 17 years after renal transplantation. We summarize the existing literature and present a review of an additional 25 cases. These highlight the variable clinical presentations of PTLD within the oral cavity and clear potential for delayed presentation at this anatomical subsite.

EBV-associated polymorphic posttransplant lymphoproliferative disorder presenting as gingival ulcers

Posttransplant lymphoproliferative disorders (PTLDs) present a wide clinicopathological spectrum, varying from the usual Epstein-Barr virus (EBV)-driven infectious mononucleosis-type polyclonal proliferations to EBV-positive or EBV-negative proliferations indistinguishable from overt lymphomas that occur in immunocompetent individuals. PTLDs characteristically have a predilection for extranodal sites and association with EBV.These disorders are usually B-cell type, although T-cell and rare cases involving both T- and B-cell types have also been described. The initial treatment consists in decreasing the immnosupressive therapy, usually with favorable results. The authors report on a rare case of a 19-year-old girl, with post-renal transplantation EBV-associated polymorphic lymphoproliferative gingival ulcerated lesions. To the best of their knowledge, this is the first case described in the English-language literature of polymorphic PTLD involving both B-cell and T-cell lineages, with an unusual immunoprofile affecting the mouth. The authors warn that this condition could be easily misdiagnosed as malignant lymphoma if not properly recognized.

Monomorphic post-transplant lymphoproliferative disorder of the tongue: case report and review of literature

Background

Post-transplant lymphoproliferative disorder (PTLD) is a spectrum of hematological diseases arising in context of immunosuppression after organ transplantation. PTLD can involve any organ; however, it is extremely rare in oral cavity.

Methods

Using morphologic and immunophenotypic approaches we have studied a case of monomorphic PTLD of the tongue that developed in a patient following unilateral kidney and pancreas transplantation on immunosuppressive therapy. Additionally, cases of PTLD in the oral cavity were reviewed in the English literature.

Results

The neoplasm showed large cell morphology and B-cell phenotype. In situ hybridization for Epstein-Barr virus was positive. Complete remission was obtained after decreasing immunosuppressive therapy. The patient remained in remission at 790 days' follow up.

Conclusion

This rare case increased our awareness of PTLD in the oral cavity of patients following solid organ transplantation and immunosuppressive therapy.

Monomorphic Epstein-Barr virus (EBV)-associated large B-cell posttransplant lymphoproliferative disorder presenting as a tongue ulcer in a pancreatic transplant patient

Posttransplant lymphoproliferative disorders are a group of lymphoid proliferations and lymphomas that develop as a consequence of immunosuppression in recipients of solid organ or bone marrow allografts. We describe an unusual oral presentation of posttransplant Epstein-Barr virus-associated diffuse large B-cell lymphoma in a 45-year-old woman after pancreatic transplant.

Non-Hodgkin's lymphoma manifest as gingival hyperplasia in a renal transplant recipient

Gingival hyperplasia is a frequent complication in transplant patients who receive cyclosporine or calcium channel blockers. We studied an unusual case involving a renal transplant recipient with post-transplant non-Hodgkin's lymphoma that manifested as gingival hyperplasia. We initially consider that it was a side effect of cyclosporine and nifedipine. The lesion did not respond to dose reductions or the withdrawal of cyclosporine and nifedipine, and the gingival hyperplasia progressed in a localized fashion, becoming ulcerated and bleeding easily. Histological examination revealed the presence of malignant lymphoma.

Cyclosporin-induced gingival overgrowth in children

Cyclosporin is a potent immunosuppressant drug commonly used to prevent organ transplant rejection. In recent years, there has been a widening of its therapeutic use and an increase in the number of patients undergoing transplantation. Gingival overgrowth is one of several oral side-effects of cyclosporin, with a quoted prevalence of between 8% and 100%. There is continued debate over the factors which modify the degree of overgrowth, including individual sensitivity, age, dose of drug, duration of drug therapy and the presence of dental plaque. The exact mechanism of gingival overgrowth is still being debated, but appears to be caused by a combination of the proliferation of fibroblasts within the gingival tissue, an increase in the deposition of collagen and extracellular matrix, and a decrease in phagocytosis with a net gain in gingival tissue mass. A number of treatment options are utilized in the treatment of gingival overgrowth, including CO2 laser surgery, improved oral hygiene, the use of antibiotics such as metronidazole and azithromycin, and surgical intervention. In the clinical application of cyclosporin, there is little correlation between cyclosporin dose, serum trough levels and total exposure to the drug, making it difficult to achieve the desired therapeutic response. These problems were previously further complicated by the variability of absorption of the drug via the gastrointestinal tract. The original cyclosporin formulation, Sandimmune, was replaced by a new formulation, Neoral, which has a more reliable absorption, and gives a closer correlation between trough concentration levels and individual bioavailability. There is a conflict of opinion over whether or not the side-effect profile of Neoral varies from its precursor Sandimmune. It has yet to be seen whether the increased bioavailability of Neoral will result in an increased severity and prevalence of gingival overgrowth. An alternative immunosuppressant drug, tacrolimus, which is a macrolide antibiotic with a different side-effect profile, has emerged as a substitute for cyclosporin in organ transplantation. However, there have been conflicting reports of its side-effects and its capacity to cause gingival overgrowth.

Post-transplant lymphoproliferative disorder of the cervix

BACKGROUND

Post-transplant lymphoproliferative disorder involving the female genital tract is a rare event.

CASE

A 67-year-old female status post orthotopic liver transplant 5 years previously for hepatitis B and sarcoidosis presented with vaginal bleeding. Endometrial biopsy revealed a high-grade malignant tumor with immunologic marker studies consistent with lymphoma. The patient underwent an exploratory laparotomy, modified radical hysterectomy, bilateral salpingo oophorectomy, bilateral selective pelvic and para-aortic lymphadenectomy, and omentectomy. Final pathology confirmed monomorphic B-cell post-transplantation lymphoproliferative disorder consistent with non-Hodgkin's B cell lymphoma confined to the endocervix and lower uterine segment. She remains recurrence free after 4 years with no adjuvant therapy.

CONCLUSION

Post-transplant complications can present in the female reproductive organs. Gynecologic oncologists need to be aware of this disease process when treating patients for gynecologic symptoms after transplant surgery.