Immunosuppressants
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Epstein-Barr virus associated post transplant lymphoproliferative disorder in the gastrointestinal tract: case report A 28-year-old man developed Epstein-Barr virus associated post transplant lymphoproliferative disorder (EBV-PTLD) in the gastrointestinal tract following immunosuppressive therapy with everolimus, methylprednisolone, mycophenolate-mofetil, prednisone and tacrolimus [routes and dosages not stated]. The man, who had been hemodialysed since September 2012 due to tubulointerstitial nephritis, underwent a kidney transplant in July 2013. He then started receiving immunosuppressive therapy with tacrolimus, mycophenolate mofetil and prednisone. After the transplant, he developed recurrent urinary tract infections caused by multi-resistant strains [details not stated], for which he received meropenem, imipenem and cilastatin. He also experienced repeated relapses of Clostridium difficile infection, for which he received metronidazole, vancomycin and fidaxomicin. In view of the high risk of Cytomegalovirus (CMV) infection, he received valganciclovir prophylaxis and mycophenolate mofetil was replaced by everolimus. Methylprednisolone was also added. In March 2014, he was hospitalised for pain in the abdomen and diarrhoea. Physical examination showed tenderness in the area of the cecum. Investigations revealed the following: haemoglobin 11.2 g/dL, WBC 4390 /µL, creatinine 138 µmol/L and lactate dehydrogenase increased up to 1002 U/L. Hybridisation study in situ for EBV infection showed numerous positive cells. Colonoscopy revealed ulcerations in the large intestine and polymorphic lymphoma was found in the collected samples. To assess the stage of the disease, positron emission tomography-computed tomography (PET-CT) was performed, which demonstrated metabolically active areas within the large intestine and especially in the rectum in the form of thickening of the posterior and rightsided wall up to 25mm in the area of 38×21×90mm. PTLD stage IVA, according to the Ann Arbor classification, was determined. Because of the diagnosis of PTLD, the existing immunosuppressive treatment was modified by gradually reducing tacrolimus (to a blood concentration of 3–4 ng/mL) and then discontinuing it, while everolimus (concentrations from 5.4–10.2 ng/mL) and methyloprednisolone were continued. He received rituximab according to the protocol of the Polish Lymphoma Research Group. After a few weeks of the treatment, a complete remission in the PTLD was achieved. He was carefully followed up under the following schedule: every 3 months for 1 year, every 6 months for 2 years, and then once a year. A repeat CT scan and colonoscopy confirmed complete remission of the disease. More than 5 years from the onset of PTLD symptoms, he was in full remission with a very good general condition and he was receiving the following treatment: everolimus 2mg twice daily, methyloprednisolone 4mg once daily, potassium chloride, betaxolol, atorvastatin, pyridoxine [vitamin B6], magnesium and fosfomycin (fosfomycin to prevent urinary tract in
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