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Antithymocyte-globulin Post-transplant lymphoproliferative disorder and Epstein-Barr virus infection: case report

A 57-year-old man developed post-transplant lymphoproliferative disorder (PTLD) and Epstein-Barr virus infection during treatment with antithymocyte globulin. The man presented with progressively plum colored per-rectal bleeding for 24 hours along with decreased haemoglobin level. He had a significant history of unrelated donor allogenic haematopoietic stem cell transplantation and was receiving conditioning regimen with antithymocyte globulin [route and dosage not stated] for six months prior to the current presentation. Following the transplantation, he was discharged on prednisolone and ciclosporin for cutaneous graft-versus-host disease. At the current presentation, CT angiogram showed contrast extravasation into the lumen of the jejunum along with thickening of the jejunal wall. Additionally, superior mesenteric angiography was carried out, but subselective embolisation was not possible. Enteroscopy demonstrated small superficial nonbleeding ulcers in the 3rd and 4th parts of the duodenum and the jejunum, but views were obscured due to the presence of altered blood and clots. The man required blood transfusions and he developed melaena after seven days. Enteroscopy showed multiple malignant appearing ulcerations along with active oozing, raised margins, amorphous surface, and exposed vascularity. Due to the bleeding risk and active oozing, biopsies were not performed. The entire site was treated with haemospray. On the next day, he experienced increasing abdominal pain. An CT scan demonstrated perforation at the site of the small bowel disease. Hence, he underwent laparotomy with excision of 1.3m of jejunum because of multiple perforations from tumour infiltration. Microscopic examination revealed extensive infiltration of bowel wall by a B-cell lymphoma, extending into the subserosal fat and staining was positive for Epstein-Barr virus RNA. His finding were consistent with post-transplant lymphoproliferative disorder [duration of treatment to reactions onsets and outcomes not stated]. Young E, et al. An Unexpected Cause of Gastrointestinal Bleeding after Stem Cell Transplantation. Gastroenterology 159: 443-445, No. 2, Aug 2020. Available from: URL: 803500841 http://doi.org/10.1053/j.gastro.2020.03.035

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Reactions 12 Sep 2020 No. 1821