Gastrointestinal manifestations, risk factors, and management in patients with post-transplant lymphoproliferative disorder: A systematic review

Navigating Epstein-Barr Virus (EBV) and Post-Transplant Lymphoproliferative Disorder (PTLD) in Pediatric Liver Transplantation: Current Knowledge and Strategies for Treatment and Surveillance

Epstein-Barr virus (EBV) is strongly associated with the development of post-transplant lymphoproliferative disorder (PTLD) in pediatric liver transplant recipients. PTLD is one of the most common malignancies following liver transplantation and is associated with significant morbidity and mortality. Factors such as EBV-serostatus mismatch and prolonged or high levels of immunosuppression impact a patient's risk of developing PTLD. While pre-transplant EBV serological screening and post-transplant monitoring of EBV-DNA levels are strongly recommended, universal guidelines for its prevention and management are lacking. Due to a lack of robust prospective studies, current clinical practices vary widely. The treatment of PTLD typically involves reducing immunosuppression and using targeted therapies such as rituximab, or chemotherapy for refractory cases. This review aims to address our current understanding of EBV's relationship with PTLD, evaluate the available treatment modalities, and highlight evolving strategies for using EBV as a biomarker for PTLD screening and prevention.

Post-Transplant Lymphoproliferative Disorder at the Porta Hepatis Causing Hepatic Artery Stenosis and Cholestasis

BACKGROUND Post-transplant lymphoproliferative disorder (PTLD) encompasses a group of disorders ranging from hyperplastic to malignant lymphoid proliferations in the post-transplant period owing to immunosuppression, often in the setting of EBV transformation. PTLD is a rare complication of immunosuppression that, like lymphomas, can have a variable presentation based on disease localization. We report a case of PTLD mass effect at the porta hepatis for the first time in the literature, resulting in hepatic artery stenosis (HAS) and common hepatic duct obstruction. CASE REPORT A 54-year-old woman presented with cholestasis 4 months after receiving a deceased donor liver transplant. MRCP revealed a mass at the porta hepatis causing biliary compression, which resolved with subsequent biliary stenting. The woman presented again 3 weeks later with a similar presentation. CT revealed that the mass had enlarged, causing HAS, which resolved with subsequent hepatic artery stenting. The biopsy revealed PTLD, and the patient was successfully managed with rituximab and a reduction of her immunosuppressive regimen. CONCLUSIONS This case report describes a rare occurrence of PTLD, which particularly impacting the porta hepatis, resulting in HAS and compression of the bile duct. PTLD should be considered in the differential diagnosis for obstructive jaundice and hepatic artery compression, even in the early post-transplant months, when these symptoms are often attributed to surgical factors.

Clinical imaging and pathology analysis of Epstein-Barr virus-associated monomorphic lymphoproliferative disease after liver transplantation in children-a retrospective case series

Background

Post-transplant lymphoproliferative disease (PTLD) is a significant complication that can arise following solid organ transplantation or hematopoietic stem cell transplantation. It encompasses a spectrum of lymphoproliferative lesions, ranging from benign reactive hyperplasia to malignant tumors, and is among the most severe complications following liver transplantation in children. It is essential for clinicians to gain a comprehensive understanding of the prevention, clinical manifestations, early diagnosis, and treatment strategies for PTLD in order to reduce mortality rates.

Case Description

This study presents an analysis of six pediatric patients (three females and three males) diagnosed with monomorphic PTLD occurred at intervals of 1 month and 3 years post-transplantation. Five were localized in the gastrointestinal tract, while one was identified in the lymph nodes. The pathological diagnoses included diffuse large B-cell lymphoma (DLBCL) in three instances, Burkitt lymphoma in two, and peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS) in one. Testing for Epstein-Barr virus-encoded RNA (EBER) yielded positive results in all cases. Following the reduction or cessation of immunosuppressive, antineoplastic, and anti-inflammatory medications, three patients succumbed within three months, while the remaining three patients were monitored for a duration of 6 to 13 months and remained in good condition.

Conclusions

The clinical manifestations of PTLD following liver transplantation are complex. Close monitoring of serum Epstein-Barr virus (EBV) levels after transplantation, along with early diagnosis of PTLD through imaging and pathological examinations, can assist clinicians in developing individualized treatment strategies to enhance patient prognosis.

Post-Transplant Lymphoproliferative Disorder Presenting as a Gastrointestinal Fistulous Tract in a Heart Transplant Recipient: Case Report and Literature Review

We present a challenging case of Epstein-Barr virus-related isolated small bowel post-transplant lymphoproliferative disorder (PTLD) in a pediatric heart transplant recipient presenting as recurrent gastrointestinal (GI) bleeding and subsequently a GI fistulous tract with associated intra-abdominal abscess. Diagnosis was not confirmed until exploratory laparoscopy was performed, with excision of the fistulous tract revealing evidence of PTLD on pathology. Early diagnosis of GI-PTLD remains a challenge, especially if isolated in the small intestine. Diagnosis may rely on positron emission tomography/ computed tomography scan (PET/CT) or invasive intervention to obtain appropriate tissue samples for pathology diagnosis.

How we treat diarrhea in pediatric transplant patients: a brief review

Diarrhea is a common problem faced by both hematopoietic and solid organ transplant recipients. The differential diagnosis is wide, ranging from infectious to non-infectious causes and from benign to emergent illness. Here we present two patients with diarrhea and discuss our approaches to the diagnostic evaluation and management of transplant recipients with diarrhea. We also include a review of the literature and discuss areas in need of further study.

Who is the patient at risk for EBV reactivation and disease: expert opinion focused on post-transplant lymphoproliferative disorders following hematopoietic stem cell transplantation

INTRODUCTION

Post-transplant lymphoproliferative disorders (PTLD) represent a diverse group of diseases. They develop as a consequence of uncontrolled proliferation of lymphoid or plasmacytic cells resulting from T-cell immunosuppression after transplantation of either hematopoietic cells (HCT) or solid organs (SOT), caused mainly by latent Epstein-Barr virus (EBV). The risk for EBV recurrence is dependent on the level of incompetency of the immune system, presented as an impairment of T-cell immunity.

AREAS COVERED

This review summarizes the data on incidence and risk factors of EBV infection in patients after HCT. The median rate of EBV infection in HCT recipients was estimated at 30% after allogeneic and<1% after autologous transplant; 5% in non-transplant hematological malignancies; 30% in SOT recipients. The median rate of PTLD after HCT is estimated at 3%. The most frequently reported risk factors for EBV infection and disease include: donor EBV-seropositivity, use of T-cell depletion, especially with ATG; reduced-intensity conditioning; mismatched family or unrelated donor transplants; and acute or chronic graft-versus-host-disease.

EXPERT OPINION

The major risk factors for EBV infection and EBV-PTLD can be easily identified: EBV-seropositive donor, depletion of T-cells, and the use of immunosuppressive therapy. Strategies for avoiding risk factors include elimination EBV from the graft and improving T-cell function.