Abstract: TH-PO1029
Epstein-Barr Virus (EBV)-Positive Post-Transplant Lymphoproliferative Disorder (PTLD) Transforming to Diffuse Large B-Cell Lymphoma with Central Nervous System (CNS) Involvement in an EBV-Seronegative Kidney Transplant Donor-Recipient Pair
Session Information
- Transplantation: Clinical - Outcomes, Malignancy, and Pathology
October 22, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Hih, Nouraldin, Mansoura University Faculty of Medicine, Mansoura, Dakahlia Governorate, Egypt
- Soliman, Abdelsalam Karim, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Randhawa, Parmjeet S., University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Puttarajappa, Chethan M., University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Cruz Peralta, Massiel Penelope, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Tevar, Amit D., University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Wright, Susan Guthrie, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Shah, Nirav A., University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Soliman, Karim, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
Introduction
PTLD is a life-threatening complication of solid organ transplantation, most commonly driven by EBV reactivation or primary infection in seronegative recipients. PTLD arising in an EBV D-/R- pair represents an uncommon and poorly understood phenomenon, challenging the assumption that EBV seronegativity confers lower risk.
Case Description
Case Presentation: A 48-year-old female with ESKD secondary to polycystic kidney disease underwent deceased donor kidney transplantation in March 2025 (KDPI 66%, CIT 804 minutes, CPRA 99%, EBV D-/R-). Induction included thymoglobulin with standard maintenance immunosuppression of tacrolimus, mycophenolate mofetil, and steroids. The early course was complicated by AKI with biopsy-proven acute tubular injury, bacteremia, and obstructive nephropathy requiring nephrostomy placement.
Disease Course and Pathology: Eight months post-transplant, a renal allograft biopsy (Fig. 1) demonstrated EBV-positive PTLD with foci of large atypical lymphoid cells in a markedly necrotic background. CD20 was strongly positive in viable foci with EBER positivity by in situ hybridisation. Subclassification was limited by necrosis and crush artefact; MUM-1 was positive in a subset, BCL6 was weakly positive, and Ki-67 was not evaluable. Concurrent mesenteric lymph node excision showed preserved architecture with scattered EBV-positive small-to-intermediate cells and low Ki-67, reviewed at Hematopathology consensus conference. Rituximab followed by two cycles of R-CHOP was initiated. PET-CT in March 2026 demonstrated progressive allograft thickening, enlarging pulmonary nodules, and a new brain abnormality. Tacrolimus was discontinued. Excisional biopsy on 4/14/2026 confirmed EBV-positive DLBCL consistent with PTLD transformation. CAR-T cell therapy and focused radiation are planned.
Discussion
This case demonstrates aggressive PTLD transformation to EBV-positive DLBCL with CNS involvement within one year of transplantation despite an EBV D-/R- serologic profile conventionally regarded as low risk. It challenges current EBV-based risk stratification paradigms, highlights the diagnostic difficulty of necrotic allograft biopsies in PTLD, and reinforces the importance of early repeat biopsy when initial tissue is inadequate. Clinicians should maintain high vigilance for PTLD regardless of pre-transplant EBV serostatus.
Acknowledgment
The authors would like to acknowledge all clinicians and pathology teams involved in the care of this patient.