Infectious complications during immunochemotherapy of post-transplantation lymphoproliferative disease–can we decrease the risk? Two case reports and review of literature

BACKGROUND: Post-transplant lymphoproliferative disease (PTLD) is a heterogeneous group of diseases that develop after solid organ and hematopoietic stem cells transplantation related to intensive immunosuppression regimen, T-cell depletion and Epstein-Barr virus infection. Despite the improvement in the management of PTLD, the prognosis remains poor. Here we report the management of two transplanted patients with PTLD and infections during immunochemotherapy (ICTH). CASE SUMMARY: Of 65-year-old woman 11 years after kidney transplantation (first case) presented with diffuse large B-cell lymphoma (DLBCL) CS III and started ICHT according to R-CHOP protocol. Despite the secondary prevention of neutropenic fever, the patient developed grade 4 neutropenia with urinary and pulmonary tract infections after the fifth cycle. ICTH was continued in reduced doses up to 7 cycles followed by involved-field radiation therapy of the residual disease. The second case presents a 49-year-old man, 8 years after liver transplantation due to cirrhosis in the course of chronic hepatitis B, who started ICTH for DLBCL Burkitt-like CS IV. The patient received four cycles of ICTH according to R-CODOX/R-IVAC protocol, with reduced doses. In both cases initially undertaken reduction of immunosuppression was ineffective to prevent infectious complications. Despite one incomplete ICHT treatment due to recurrent infections, both our patients remain in complete remission. CONCLUSION: Reduction of immunosuppression and the doses of chemotherapeutics may be insufficient to prevent infectious complications during ICTH in PTLD patients.