Post-transplantation lymphoproliferative disorder with gastrointestinal involvement

Post-Transplant Lymphoproliferative Disorder at the Porta Hepatis Causing Hepatic Artery Stenosis and Cholestasis

BACKGROUND Post-transplant lymphoproliferative disorder (PTLD) encompasses a group of disorders ranging from hyperplastic to malignant lymphoid proliferations in the post-transplant period owing to immunosuppression, often in the setting of EBV transformation. PTLD is a rare complication of immunosuppression that, like lymphomas, can have a variable presentation based on disease localization. We report a case of PTLD mass effect at the porta hepatis for the first time in the literature, resulting in hepatic artery stenosis (HAS) and common hepatic duct obstruction. CASE REPORT A 54-year-old woman presented with cholestasis 4 months after receiving a deceased donor liver transplant. MRCP revealed a mass at the porta hepatis causing biliary compression, which resolved with subsequent biliary stenting. The woman presented again 3 weeks later with a similar presentation. CT revealed that the mass had enlarged, causing HAS, which resolved with subsequent hepatic artery stenting. The biopsy revealed PTLD, and the patient was successfully managed with rituximab and a reduction of her immunosuppressive regimen. CONCLUSIONS This case report describes a rare occurrence of PTLD, which particularly impacting the porta hepatis, resulting in HAS and compression of the bile duct. PTLD should be considered in the differential diagnosis for obstructive jaundice and hepatic artery compression, even in the early post-transplant months, when these symptoms are often attributed to surgical factors.

A pediatric case series of catastrophic gastrointestinal complications of posttransplant lymphoproliferative disease with increasing incidence, high association with coronavirus disease 2019, higher mortality, and a plea for early endoscopy to prevent late fatal outcome

BACKGROUND

Posttransplant lymphoproliferative disorder is one of the most severe complications after transplantation, caused by uncontrolled proliferation of Epstein-Barr virus-positive B-cells in the setting of chronic immunosuppression. As one of the biggest transplant centers worldwide, we observed a potential increase in the number of patients with posttransplant lymphoproliferative disorder presenting with gastrointestinal symptoms in 1 year, during the coronavirus disease 2019 pandemic. There is limited information about dysregulation of the immune system following coronavirus disease 2019 infection, which may lead to Epstein-Barr virus reactivation in Epstein-Barr virus-positive B-cells and development of posttransplant lymphoproliferative disorder. Furthermore, there is no consensus in literature on a modality that can help in early diagnosis of posttransplant lymphoproliferative disorder with nonspecific gastrointestinal presentations before late and fatal complications occur.

CASE PRESENTATION

Our case series includes five Iranian (Persian) patients, three female (2, 2.5, and 5 years old) and two male (2 and 2.5 years old), who developed gastrointestinal posttransplant lymphoproliferative disorder after liver transplantation. All of our patients were on a similar immunosuppressant regimen and had similar Epstein-Barr virus serologic status (seronegative at time of transplantation but seropositive at time of posttransplant lymphoproliferative disorder diagnosis). Four patients had either a positive coronavirus disease 2019 polymerase chain reaction test or exposure within the family. Although all of our patients presented with nonspecific gastrointestinal symptoms, four patients developed late posttransplant lymphoproliferative disorder complications such as bowel perforation and obstruction. All five patients with gastrointestinal posttransplant lymphoproliferative disorder received chemotherapy, but only two survived and currently are continuing the therapy. In one of the surviving patients, prompt endoscopic investigation resulted in early diagnosis of posttransplant lymphoproliferative disorder and a better outcome.

CONCLUSION

Since 80% of our patients had exposure to coronavirus, a potential relationship might be suggested between the two. Furthermore, as we witnessed in one case, urgent endoscopic investigation in immunocompromised patients presenting with gastrointestinal symptoms can improve the clinical outcomes and therefore should be considered for early diagnosis of posttransplant lymphoproliferative disorder.

Emerging roles of a chemoattractant receptor GPR15 and ligands in pathophysiology

Chemokine receptors play a central role in the maintenance of immune homeostasis and development of inflammation by directing leukocyte migration to tissues. GPR15 is a G protein-coupled receptor (GPCR) that was initially known as a co-receptor for human immunodeficiency virus (HIV) and simian immunodeficiency virus (SIV), with structural similarity to other members of the chemoattractant receptor family. Since the discovery of its novel function as a colon-homing receptor of T cells in mice a decade ago, GPR15 has been rapidly gaining attention for its involvement in a variety of inflammatory and immune disorders. The recent identification of its natural ligand C10orf99, a chemokine-like polypeptide strongly expressed in gastrointestinal tissues, has established that GPR15-C10orf99 is a novel signaling axis that controls intestinal homeostasis and inflammation through the migration of immune cells. In addition, it has been demonstrated that C10orf99-independent functions of GPR15 and GPR15-independent activities of C10orf99 also play significant roles in the pathophysiology. Therefore, GPR15 and its ligands are potential therapeutic targets. To provide a basis for the future development of GPR15- or GPR15 ligand-targeted therapeutics, we have summarized the latest advances in the role of GPR15 and its ligands in human diseases as well as the molecular mechanisms that regulate GPR15 expression and functions.

Recurrent bleeding duodenal and colonic ulcers due to post-transplant lymphoproliferative disorder

Post-transplant lymphoproliferative disorder (PTLD) is a rare complication of solid organ transplantation as the result of immunosuppressant medications. Epstein-Barr virus (EBV) has been implicated in most of these cases, specifically with B-cell predominant lymphoma. This case report describes a 24-year-old female who presented with recurrent GI bleed within 6 months post-orthostatic heart transplant. Endoscopic evaluations including video capsule study, push enteroscopy, and colonoscopy revealed multiple ulcerated lesions in duodenum, jejunum, and colon secondary to Epstein-Barr Virus-associated monomorphic PTLD. Despite continuation of rituximab after discharge, she returned to the hospital for recurrent GI bleed requiring additional endoscopic intervention. PTLD is a devastating disease of the post-transplant population. Due to a high risk of recurrent GI bleeding, patients with PTLD may benefit from careful monitoring by gastroenterology as an outpatient with a low threshold for repeat endoscopic evaluation despite being on immunotherapy or chemotherapy.

Isolated Colonic Histoplasmosis in Patients Undergoing Immunomodulator Therapy: A Systematic Review

Gastrointestinal histoplasmosis remains an inconspicuous clinicopathologic entity. It is predominantly considered a protean manifestation of disseminated disease. We hereby delineate a unique case of biopsy-proven isolated colonic histoplasmosis in a patient undergoing methotrexate therapy. Furthermore, we present the first systematic review of the MEDLINE, Google Scholar, Embase, and Scopus databases regarding isolated colonic histoplasmosis in adult patients receiving immunomodulator therapy (IMT). A total of 13 case reports (level of clinical evidence: IV) were identified. The mean age was 55.6 ± 11.1 years, with 9 (69.2%) cases reported in women. Patients with subclinical disease (5, 38.5%) were often incidentally diagnosed by screening colonoscopy. Symptomatic individuals predominantly presented with diarrhea (4, 30.8%), weight loss (3, 23.1%), and/or abdominal pain (3, 23.1%). IMT was mainly administered for liver transplant (4, 30.8%), renal transplant (4, 30.8%), and ulcerative colitis (2, 15.4%). Common colonoscopy features included colonic ulcerations (7, 53.8%), polyps or pseudopolyps (3, 23.1%), and/or mass-like lesions (3, 23.1%). Diagnosis was made by histology of colonic biopsy in 11 (84.6%) and resected specimens in 2 (15.4%) patients. Treatment consisted of a combination of amphotericin B with oral itraconazole in 6 (46.2%), oral itraconazole alone in 5 (38.5%), and amphotericin B alone in 2 (15.4%) patients. Complete clinical recovery was achieved in all patients. This article illustrates that isolated colonic involvement can be the only clinical presentation of histoplasmosis. It may masquerade as other bowel disorders, presenting diagnostic and therapeutic conundrums. Gastroenterologists should rule out colonic histoplasmosis in IMT recipients who develop unexplained colitis symptoms.

Recent Advances in Digestive Tract Tumors: Updates From the 5th Edition of the World Health Organization "Blue Book"

CONTEXT.—

The World Health Organization Classification of Tumours: Digestive System Tumors, 5th edition, was published in 2019 and shows several impactful changes as compared with the 4th edition published in 2010. Changes include a revised nomenclature of serrated lesions and revamping the classification of neuroendocrine neoplasms. Appendiceal goblet cell adenocarcinoma is heavily revised, and intrahepatic cholangiocarcinoma is split into 2 subtypes. New subtypes of colorectal carcinoma and hepatocellular carcinoma are described. Precursor lesions are emphasized with their own entries, and both dysplastic and invasive lesions are generally recommended to be graded using a 2-tier system. Hematolymphoid tumors, mesenchymal tumors, and genetic tumor syndromes each have their own sections in the 5th edition. New hematolymphoid lesions include monomorphic epitheliotropic intestinal T-cell lymphoma; duodenal-type follicular lymphoma; intestinal T-cell lymphoma, not otherwise specified; and indolent T-cell lymphoproliferative disorder of the gastrointestinal tract. This paper will provide an in-depth look at the changes in the 5th edition as compared with the 4th edition.

OBJECTIVE.—

To provide a comprehensive, in-depth update on the World Health Organization classification of digestive tumors, including changes to nomenclature, updated diagnostic criteria, and newly described entities.

DATA SOURCES.—

The 5th edition of the World Health Organization Classification of Tumours: Digestive System Tumours, as well as the 4th edition.

CONCLUSIONS.—

The World Health Organization has made many key changes in its newest update on tumors of the digestive system. Pathologists should be aware of these changes and incorporate them into their practice as able or necessary.

Overview of Gastrointestinal Lymphoproliferative disorders✰

Lymphoproliferative processes which occur in the gastrointestinal tract range from benign reactive processes such as follicular hyperplasia (rectal tonsil) to high grade malignant lymphomas and histiocytic sarcoma. The WHO Classification of Tumors: Digestive System Tumors, 5th Edition was published in 2019 and shows several impactful changes as compared to the 4th Edition published in 2010. WHO Classification of Tumors of Hematopoietic and Lymphoid Tissues 2017 also included detailed changes in hematopoietic neoplasms within the gastrointestinal tract. New entities or renamed hematolymphoid lesions include monomorphic epitheliotropic intestinal T-cell lymphoma, duodenal-type follicular lymphoma, intestinal T-cell lymphoma, NOS and indolent T-cell lymphoproliferative disorder of the gastrointestinal tract. A brief overview of WHO classification of digestive tumors and WHO classification of tumors of hematopoietic and lymphoid tissue is discussed focusing on the changes in the most recent WHO texts. In depth discussions will be presented in other papers in this series.

Early Onset Post-transplant Lymphoproliferative Disorder Presenting with Diarrhea Post-orthotopic Liver Transplant Treated Successfully with Single Rituximab Agent

Post-transplant lymphoproliferative disorder (PTLD) is a rare complication seen in hematologic stem cell (HSC) and solid organ transplantation that results from immune suppressant medications needed to prevent allograft rejection. Epstein-Barr virus (EBV) has been implicated in a majority of these cases, specifically with B-cell-predominant lymphomas. We present a 57-year-old female who underwent an orthotopic liver transplant and presented with diarrhea and weight loss. At the time of transplantation, the patient's quantitative EBV titers were negative; however, repeat titers during her admission were positive. Infectious etiologies for diarrhea were negative so a colonoscopy was pursued which revealed large ulcerated areas and biopsies consistent with monomorphic, diffuse large B-cell lymphoma, plus EBV. Imaging revealed multiple areas below the diaphragm of lymphadenopathy. The patient was started on rituximab and antivirals, and immune suppressive medications were decreased with a resolution of her symptoms. PTLD after any transplantation can be difficult to diagnose, given the wide range of presenting symptoms. Identifying patients who are at high risk for developing PTLD may lead to a more timely diagnosis to initiate treatment and decrease mortality risk.