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Weekly Chest CasesArchive of Old Cases

Case No : 510 Date 2007-08-06

  • Courtesy of Eun Ah Park, MD. / Seoul National University Hospital, Korea.
  • Age/Sex 16 / F
  • Chief ComplaintLFT abnormality. Incidentally detected lung nodules on abdomen CT. No respiratory symptom. Phx: Liver transplantation due to Wilson disease 2 years ago. Bone marrow transplantation due to secondary aplastic anemia a year ago.
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Diagnosis With Brief Discussion

Diagnosis
Posttransplant lymphoproliferative disorder
Radiologic Findings
Chest CT scans shows multiple nodules in both lower lobes.
The patient underwent wedge resection of left lower lobe.
A Pathologic report revealed polymorphic posttransplant lymphoproliferative disorder.
The result of EBV in situ hybridization was positive.
Brief Review
Posttransplantation lymphoproliferative disorder (PTLD) is defined as an abnormal proliferation of lymphocytes, usually of B-cell origin, occurring in patients receiving immunosuppressants following organ or bone marrow transplantation. The disorder is strongly associated with Epstein-Barr virus infection. The estimated prevalence of PTLD in pediatric transplant recipients (4%) is higher than that in adults (0.8%). Under current immunotherapy regimens, PTLD may develop as early as 1 month after transplantation, but the median time from transplantation to diagnosis was reported as 4.4 months.
The Epstein-Barr virus infects B lymphocytes and stimulates their proliferation. The cytotoxic T lymphocytes that control B-cell proliferation in the healthy host are suppressed in the transplant recipient by agents such as cyclosporine-A, FK-506, and muromonab-CD3. This pathogenetic sequence undergirds the rationale for PTLD treatment, which is resection of tumor bulk and reduction of immunosuppression.
The histologic characteristics and immunocytochemistry of PTLD help guide therapy and gauge prognosis. Polymorphous, polyclonal tumors tend to regress spontaneously after immunosuppression has been reduced, but monomorphous, monoclonal tumors are more apt to behave like typical non-Hodgkin lymphoma and may require specific chemotherapy. Widely disseminated PTLD usually portends a fatal outcome. Treatment with acyclovir is directed toward the Epstein-Barr viral infection. Use of anti-B-cell monoclonal antibodies may be effective in selected patients.
The imaging features are similar to other lymphomas. CT may reveal retroperitoneal, mesenteric, mediastinal, or peripheral adenopathy or masses. Nodules in the liver, spleen, or kidneys are characteristically homogeneous and well-defined. Lung parenchymal involvement typically consists of discrete pulmonary nodules. Gastrointestinal involvement tends to produce ulcerative lesions leading to perforation and pneumoperitoneum.
References
Bowen et al. Cases of the Day. RadioGraphics 1992;12(2):393-395
Keywords
Lung, Lymphproliferative disorder,

No. of Applicants : 49

▶ Correct Answer : 23/49,  46.9%
  • - Korea Dae Yun Kim
  • - Registrar in Radiology, UHL NHS Trust, UK A. Donuru
  • - Ondokuz Mayis University, Samsun Turkey Cetin Celenk
  • - Pohang Naval Hospital, Korea Jinoo Kim
  • - Jiangsu Province Official Hospital, Nanjing, Jiangsu Province, China Dong Sheng Jin
  • - CHR Annecy, France Segall Olivier
  • - Saint-etienne, France Antoine Marie
  • - Annecy hospital, France Gilles Genin
  • - E-Da Hospital, Taiwan Yu-Feng Wei
  • - Osaka University, Japan Osamu Honda
  • - Armed Forces Chun Cheon Hospital, Korea Lim Chae Hun
  • - Hospital Sotiria, Athens, Greece Vasilios Tzilas
  • - University of Colorado, Denver, CO, USA Seth Kligerman
  • - NUH, nottingham, UK Rohit Kochhar
  • - National Taiwan University Hospital, Taipei, Taiwan Chin Chung Shu
  • - Regional Imaging Riverina, Australia Rashid Hashmi
  • - Asan Medical Center, Korea Eun Jin Chae
  • - EKH-Berlin, Germany Michael Weber
  • - IRSA, La Rochelle, France Denis Chabassiere
  • - Jackson Memorial Hospital, Miami, Florida, USA N.B.S. Mani
  • - CHRU Lille hopital calmette, France Toledano Manuel
  • - Pittwater Radiology, Australia Julie Arora
  • - Armidale Radiology, Australia Saurabh Khandelwal
▶ Correct Answer as Differential Diagnosis : 15/49,  30.6%
  • - Dept of radiology, Inje University Ilsan Paik Hospital, Korea Bae Geun Oh
  • - Mumbai , India Rahul B Deshmukh
  • - Bavi Thera
  • - Balabhai Nanavati hospital, mumbai, India Susheel Kumar
  • - Dept. of Radiodiagnosis and Imaging, PGIMER, Chandigarh, India Ram Prakash Galwa
  • - Vital imaging centre, Mumbai, India Ganesh Agrawal
  • - KAUMS, Kashan, Iran Ebrahim Razi
  • - Homs National Hospital, Homs - Syria Rami Abou Zalaf
  • - Mackay Memorial Hospital, Taipei, Taiwan Chia-Fu Tsai
  • - CHU Nord St Etienne , France Romain Malezieux
  • - Polyclinique de Savoie, France Gay Depassier, Annemasse
  • - Yongsan Hospital, College of Medicine Chung-Ang University, Korea Jae Seung Seo
  • - China Medical University Hospital, Taiwan Jun-Jun Yeh
  • - Max Hospital, New Delhi, India Vickrant Malhotra
  • - IRSA La Rochelle, France Jean-Luc BIGOT
▶ Semi-Correct Answer : 1/49,  2.0%
  • - Hangang Sacred Heart Hospital, Korea Eil Seong Lee
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