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Lymphoproliferative disorder presenting as pulmonary nodules after bone marrow transplantation

Bone Marrow Transplantation volume 28, pages 808–810 (2001)Cite this article

Lymphoproliferative disorder after bone marrow transplantation (BMT) usually occurs in lymph nodes of the pharynx, mediastinum and retroperitoneum. We describe three patients who developed post-transplant lymphoproliferative disorder (PTLD) presenting as pulmonary nodules. Epstein–Barr virus (EBV)-associated lymphoproliferative disorder is a potentially fatal complication of BMT. Acquired immunodeficiency after BMT results in impaired T cell immunity, which contributes to expansion of B cells infected with EBV. Risk factors for BMT-associated PTLD include HLA mismatch, T cell depletion, donor cytomegalovirus (CMV) disease, antithymocyte globulin (ATG) administration, and primary EBV infection after BMT.1,2

We report three cases of high-grade PTLD presenting as pulmonary parenchymal lesions in patients after allogeneic BMT. Histopathologic evaluation of biopsy specimens with immunophenotyping, EBV PCR, and EBV clonality assessment by Southern blotting define these EBV-driven malignancies.3 Although not routine, in the immunocompromised host, EBV viral load testing by quantitative DNA amplification is more reliable than EBV serology as an early marker of lymphoproliferation and potentially useful for monitoring therapy response in PTLD patients.4 The reduction of immunosuppressive medications may cure some anatomically limited lymphoproliferative lesions.5 Unmanipulated donor-derived lymphocyte infusions and anti-CD20 monoclonal antibody rituximab have also been used to treat EBV-associated PTLD.6 In patients who do not respond to these therapies, durable complete responses have been achieved with chemotherapy. Adoptive transfer of EBV-specific cytotoxic T cells has been effective in selected patients.7 In our patients, we observed durable remissions in two patients treated with DLI alone or with DLI and chemotherapy. In the third patient, the lymphoma progressed despite aggressive chemotherapy, illustrating the variable clinical behavior of these malignancies. In summary, these cases demonstrate that consideration of PTLD in the differential diagnosis of pulmonary nodules is important, since PTLD is a potentially treatable complication of BMT. As both lower respiratory infection and PTLD can result from immunosuppression after BMT and both can present with fever and cough, early diagnosis can be difficult. The cases we present indicate the need for early aggressive strategies to diagnose patients with pulmonary nodules of unclear etiology.

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Authors and Affiliations

  1. Department of Pediatric Hematology/Oncology/Blood and Marrow Transplantation, University of Minnesota, 420 Delaware Street SE, Minneapolis, 55406, MN, USA

    J Tolar, NKC Ramsay, C Peters & SM Davies

  2. Department of Laboratory Medicine and Pathology, University of Minnesota, 420 Delaware Street SE, Minneapolis, 55406, MN, USA

    JE Coad

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  1. J Tolar
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Tolar, J., Coad, J., Ramsay, N. et al. Lymphoproliferative disorder presenting as pulmonary nodules after bone marrow transplantation. Bone Marrow Transplant 28, 808–810 (2001). https://doi.org/10.1038/sj.bmt.1703249

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