Epstein-Barr virus-associated Hodgkin's disease following renal transplantation
A 41-year-old man received a kidney transplant 116 months previously for chronic renal failure of unknown origin. The post-transplant immunosuppressive agents consisted of cyclosporine, mycophenolate mofetil, and prednisone. He remained well with stable renal function for almost 10 years, maintaining a serum creatinine level in the range of 2 mg/dL.\nIn April 2004, he was admitted to the hospital because of right cervical lymphadenopathy and a 6 kg weight loss over the previous 2 months. There was no history of fever or night sweats. Laboratory findings showed a hemoglobin level of 9.1 g/dL, white blood cell count 8.4×109/L, platelet count 445×109/L, creatinine 2.5 mg/dL, lactic dehydrogenase 229 U/L, and an erythrocyte sedimentation rate of 50 mm/hr. Liver function tests were normal. Estimated glomerularfiltration rate was 37.0 mL/min/1.73 m2. Serologic tests for EBV were negative for EBV (VCA) IgM, positive for EBV IgG and positive for EBNA. Magnetic resonance imaging (MRI) of the neck showed multiple lymph nodes ranging from 1~3 cm in the right cervical level II to V, and a single lymph node on the left at level II. There were no abnormal findings on plane film chest X-ray, abdominal computerized tomography or bone marrow biopsy. The patient was clinically stage IIB. The right cervical lymph node at level III was excised and microscopically revealed mixed cellularity Hodgkin's disease with typical Reed-Sternberg cells. Immunohistochemical staining was positive for CD30 and EBV-latent membrane protein-1 (LMP-1) in the Reed-Sternberg cells (), but CD15 staining was negative. CD20, CD79a (B cell markers) and CD3 were positive for reactive lymphocytes and CD56 was negative. The doses of immunosuppressive agents were reduced (mycophenolate mofetil was discontinued, cyclosporine dose reduced from 200 mg to 150 mg and prednisone continued 5 mg) and the patient received 2 cycles of adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD). Neck ultrasonography following the second course of chemotherapy revealed a marked decrease in the size of the cervical lymph nodes. Radiation therapy (3600 cGy) was then administered to both cervical fields. Whole body positron emission tomography CT (PET-CT) performed 3 months following completion of radiotherapy showed no abnormal fluorodeoxyglucose (FDG) uptake in the neck. Based on a follow up ultrasonography study 8 months after completion of therapy, he was in complete remission and his creatinine level remained stable at 2.5 mg/dL.