| BackgroundPosttransplant lymphoproliferative disorder (PTLD) is a group of lymphoid tissue tumors following solid organ transplantation (SOT) and allogeneic hematopoietic stem cell transplantation (HSCT), which mainly has four pathological subtypes, including early lesions, monoPTLD, polyPTLD and classical Hodgkin’s lymphoma PTLD. It usually happened in patients who needed to use immunosuppressive drugs to avoid rejection after transplantation. Diffuse large B cell lymphoma (DLBCL) is the most common disorder of monoPTLD subtype. Most of PTLD originate from B cells and are associated with EBV infection. Of patients with EBV negative expression, cytomegalovirus (CMV) infection is a pathogenesis related with high risk. Virus infection could result in proto-oncogenes’s accumulation and deletion, mutation, rearrangement, amplification and abnormal methylation epi genetic change of suppressor genes. DLBCL is the most common malignant lymphoid tumor, accounting for31%of non-Hodgkin’s lymphoma. Nowadays the immunochemotherapy regimen, rituximab combined with CHOP (R-CHOP), is its standard treatment. The incident rate of hepatitis C virus (HCV) is about3%in the world and about35,000new cases appears annually. It has been reported that hepatitis C has a certain relationship with lymphoma. The main treatment agents for viral hepatitis C are interferon and ribavirin. Case summaryThe patient was a59-year-old woman. She had been with intermittent fever for three months and discovered cervical lump over twenty days. Three months ago, she felt intermittent fever without any cause. The temperature was about38℃. Pneumonia, antibiotic curative effect was poor. Twenty days ago, she found bilateral cervical lymph nodes enlargement. Multiple enlarged lymph nodes with toughness, poor mobility and absence of tenderness could be touched in bilateral neck, and some had been mutual fusion conglobation, about4cm x3cm on the left side and2cm x1.5cm on the right side. Respiratory sounds in right lung were weak. A small amount of rhonchus and moist rales could be heard. She also presented with arrhythmia and pulse deficit, metallic opening snap and diastolic rumbling murmur could be heard. Bilateral lower extremities were moderate edema.The patient had been performed renal transplantation. DLBCL was diagnosed through biopsy of cervical lymph node. It may be related to posttransplant lymphoproliferative disorder. Diagnosis:(1)PTLD-DLBCL with non GCB subtype, stage ⅢB, invading bilateral cervical, mediastinum, left armpit, abdominal and retroperitoneal, left groin lymph nodes, with hydrothorax and ascites, IPI3score, intermediate-high risk (aaIPI3score, high risk);(2)Rheumatic heart disease with heart valve replacement, atrial fibrillation, NYHA stage Ⅱ;(3)Chronic viral hepatitis C;(4)Cytomegalovirus infection;(5)Pneumonia. After comprehensive analysis, we reduced immunosuppressant first and used6cycles of R-CVP regimen. Treatment with anti-virus and anti-infection were applied and immunological rejection, protection of heart function was taken more noticed of, quantity value of virus was monitored closely. Efficacy evaluation was uncertain complete response (CRu) after the whole treatment and toxicity could be controlled. Another two cycles of rituximab were performed to consolidate the efficacy. She got better out of the hospital.Conclusions1. Rituximab combined with chemotherapy can be used as PTLD patients’ treatment, and curative effect is certain.2. For with HCV and cytomegalovirus infection, cardiac insufficiency, pneumo- nia and other complications of lymphoma patients, although the treatment is difficult, successful experience is worthy of summarizing.3. HCV infection has certain influence on the immunochemotherapy, we need to observe quantity value of HCV RNA and function of liver.4. PTLD has low incidence, poor prognosis. Treatment should be taken to improve the prognosis of patients and prolong survival period. |
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