Endoscopy 2013; 45(S 02): E380-E381
DOI: 10.1055/s-0033-1344828
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Post-transplant lymphoproliferative disorder of the ileum diagnosed by double-balloon enteroscopy

Seiichi Tawara
Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Osaka, Japan
,
Shinichiro Shinzaki
Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Osaka, Japan
,
Tsutomu Nishida
Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Osaka, Japan
,
Motohiko Kato
Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Osaka, Japan
,
Satoshi Hiyama
Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Osaka, Japan
,
Takahiro Inoue
Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Osaka, Japan
,
Hideki Iijima
Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Osaka, Japan
,
Masahiko Tsujii
Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Osaka, Japan
,
Tetsuo Takehara
Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Osaka, Japan
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Publikationsverlauf

Publikationsdatum:
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 [1]. 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 [2]. Although around 15 % of patients present as an emergency with intestinal perforation [3], 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).

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Fig. 1 Endoscopic images showing: a an ulcer seen during esophagogastroduodenoscopy on the posterior wall of the stomach (later histological diagnosis was nonspecific); b multiple ulcers detected in the ileum by double-balloon enteroscopy (DBE).
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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.

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Fig. 2 Pathological appearance of the resected ileum showing: a diffuse large B-cell lymphoma caused by post-transplant lymphoproliferative disorder (PTLD); b positivity (brown staining) for EBV-encoded RNA (EBER).
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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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