Post-transplant lymphoproliferative disorder of the ileum diagnosed by double-balloon enteroscopy
27 November 2013 (online)
Post-transplant lymphoproliferative disorder (PTLD) is a common life-threatening complication after solid-organ transplantation that is mostly related to Epstein–Barr virus (EBV) infection . PTLD occurs in 6.2 % of lung transplants, 5.2 % of kidney and pancreas transplants, 2 % of heart transplants, and 1.4 % of liver transplants . Although around 15 % of patients present as an emergency with intestinal perforation , there are only a few reports of cases in which PTLD lesions in the small intestine have been observed endoscopically. We report a case of PTLD involving the ileum that occurred 11 months after heart transplantation and was detected during double-balloon enteroscopy (DBE).
A 49-year-old man who had undergone a heart transplant 11 months previously and was receiving 10 mg tacrolimus, 2.5 mg everolimus, and 5 mg prednisolone per day was admitted to our hospital because of high fever and passage of a tarry stool. Esophagogastroduodenoscopy (EGD) showed an ulcer in the posterior wall of the stomach ([Fig. 1 a]), which was later shown on pathological examination to contain a nonspecific inflammatory infiltrate. Further examination with DBE revealed multiple ulcers in the ileum ([Fig. 1 b]), which were later shown to be positive on fluorodeoxyglucose-positron emission tomography (FDG-PET).
Treatment was started with fasting and total parenteral nutrition, but his condition remained unchanged. After a month, he complained of sudden severe abdominal pain, which was caused by perforation of the ileal ulcers, and he underwent emergent segmental ileal resection. Pathological examination of the resection specimen revealed a diagnosis of diffuse large B-cell lymphoma caused by PTLD ([Fig. 2 a]) and staining for EBV-encoded RNA (EBER) was positive ([Fig. 2 b]). He therefore received treatment with rituximab, and a subsequent FDG-PET scan showed that the FDG-avid stomach lesion had disappeared.
There have been few reported cases of PTLD-related ileal lesions being diagnosed by endoscopy. Nevertheless, the possibility of PTLD must be considered when multiple ileal ulcers are observed after organ transplantation.
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