Isolated pleural PTLD after cardiac transplantation.
PREAMBLE: Epstein-Barr virus infection (EBV) and immunosuppression promote emergence of posttransplant lymphoproliferative disorders (PTLD) in patients undergoing organ transplantation.


OBJECTIVE
We report a case of PTLD confined to the pleura.


RESULTS
The patient was a 62-year-old male who had undergone cardiac transplant in 1993 for ischemic heart disease. Seven years later, he presented with dyspnea and bilateral pleural effusions. The CT scan revealed left sided pleural base thickening. The cytology of the pleural fluid and fine needle aspirate of the pleura was both suggestive of PTLD. However, the tissue submitted for ancillary studies did not contain the diagnostic material. A clinical decision was made to withdraw immunosuppressive therapy and start rituximab. His clinical course was complicated by Pneumocystis carinii pneumonia and he died 4 months after the diagnosis of PTLD. Autopsy revealed bilateral pleural effusions with pleural nodules involving the visceral and parietal pleura of both lungs. Immunohistochemistry demonstrated B cell lineage with kappa/lambda ratio of 1. PCR studies done on the pleural nodules (postmortem specimen) revealed the presence of EBV DNA and absence of human herpes virus 8 (HHV8) DNA. In situ hybridization revealed positive staining for EBV RNA within the neoplasm.


CONCLUSIONS
Pleural-based PTLD is rare. Cytology in conjunction with immunophenotyping and molecular studies can be useful for a definitive diagnosis. In our case, cytology sample was suggestive of PTLD. PCR studies performed on the antemortem specimen confirmed the presence of monoclonal IgH gene rearrangement, while the postmortem specimen revealed oligoclonal IgH gene rearrangement. The change from monoclonal to oligoclonal IgH gene rearrangement suggests reversion of monoclonal to polyclonal PTLD following rituximab and CHOP therapy. We also demonstrated EBV DNA and RNA in the tumor nodules, supporting EBV-induced PTLD.
Lamba
Manisha
M
Department of Pathology and Laboratory Medicine, Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada. mlamba@ottawahospital.on.ca
Jabi
Maha
M
Padmore
Ruth
R
Sengar
Dharmendra P S
DP
Veinot
John P
JP
D017931:DNA Primers / Q000737:chemistry; D004279:DNA, Viral / Q000032:analysis; D020031:Epstein-Barr Virus Infections / Q000150:complications / Q000473:pathology; D017809:Fatal Outcome; D015326:Gene Rearrangement, B-Lymphocyte, Heavy Chain / Q000235:genetics; D016027:Heart Transplantation / Q000009:adverse effects*; D004854:Herpesvirus 4, Human / Q000235:genetics / Q000302:isolation & purification; D006801:Humans; D016867:Immunocompromised Host; D007124:Immunoenzyme Techniques; D017403:In Situ Hybridization; D008232:Lymphoproliferative Disorders / Q000235:genetics / Q000473:pathology* / Q000821:virology; D008297:Male; D008875:Middle Aged; D010995:Pleural Diseases / Q000000981:diagnostic imaging / Q000473:pathology* / Q000821:virology; D010996:Pleural Effusion / Q000473:pathology / Q000821:virology; D011183:Postoperative Complications / Q000473:pathology*; D012367:RNA, Viral / Q000032:analysis; D014057:Tomography, X-Ray Computed
D017931:DNA Primers; D004279:DNA, Viral; D012367:RNA, Viral