Case Studies
Case 7.1 Epstein-Barr virus-induced lymphoma in a transplant recipient
A 65-year-old insulin-dependent diabetic man underwent cadaveric renal transplantation for end-stage renal failure. The immediate postoperative course was complicated by acute rejection which was successfully reversed by antithymocyte globulin. He was discharged from hospital 2 weeks later on insulin, prednisolone, azathioprine and cyclosporin (to prevent transplant rejection), co-trimoxazole (to prevent Pneumocystis infection), erythropoietin and ranitidine. Five months later, he developed progressive dyspnoea, fever and fatigue. Clinical examination revealed bilateral lung crackles and hepatosplenomegaly. Bilateral diffuse interstitial shadowing was noted on chest X-ray. The differential diagnosis is summarized in Table C7.1. His haemoglobin was 84g/l and he was severely leucopenic at 1.0 x 109/l. Blood cultures were sterile and a bone marrow biopsy showed normal myeloid and erythroid maturation with no acid-fast bacilli or fungi evident on special stains. A transbronchial biopsy showed no histological abnormality; special stains for acid-fast bacilli, Pneumocystis and cytomegalovirus were negative. Open lung biopsy showed fibrinous pneumonia with obstructive bronchiolitis associated with a dense cellular infiltrate of highly atypical lymphoid cells containing pleiomorphic nuclei. The lymphoid cells expressed B-cell markers (CD20, CD79) and stained positively for a number of Epstein-Barr virus (EBV) gene products (EBV nuclear antigens, EBV latent membrane proteins).
The lung biopsy results were diagnostic of a B-cell lymphoma secondary to EBV. Following the diagnosis, his immunosuppressive medication was stopped but the patient died 2 weeks later from progressive respiratory failure.
Table C7.1 Differential diagnosis of fever and lung shadows in a renal transplant recipient.
- Bacterial pneumonia (unlikely at 5 months post-transplant)
- Reactivation of tuberculosis
- Fungal infection (Aspergillus, Pneumocystis)
- Viral infection (cytomegalovirus)
- Epstein-Barr-virus-induced lymphoproliferative disease
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