Primary gastric T-cell lymphoma without human T-lymphotropic virus type 1: report of a case

Although primary gastric malignant lymphoma accounts for slightly more than 10% of all lymphomas at extranodular sites, it is relatively rare clinically, representing only 1% of all malignant diseases of the stomach. In addition, most such diseases tend to be B-cell lymphoma, while T-cell lymphoma is extremely rare. We encountered a patient with primary gastric T-cell malignant lymphoma who, although demonstrating a very rare phenomenon, was negative for antihuman T-lymphotropic virus type 1 antibody. A 73-year-old man was admitted to the hospital with the chief complaint of upper abdominal pain. The primary lesion was a type 3 tumor located at the cardia to the posterior wall of the upper body of the stomach, which had invaded the tail of the pancreas and a part of the transverse colon. A total gastrectomy, pancreatosplenectomy, and partial resection of the transverse colon were performed. The surgical section contained a giant ulcerative lesion with its bank cleaved, and a histological examination revealed a diffuse, small cell (Lymphoma Study Group classification) malignant lymphoma. An immunohistochemical analysis of the surgical specimen was positive for LCA/CD45, UCLH-1/CD45RO, and Leu-4/CD3, and negative for L-26/CD20, and it was diagnosed to be primary gastric T-cell malignant lymphoma. Received: June 28, 2001 / Accepted: November 20, 2001     

Atypical mycobacterium infection with dermatological manifestation in a renal transplant recipient

In April 1997, a 58-year-old renal transplant recipient presented with abscess-like nodules in his left calf and on his right foot. Furuncular disease was suspected and the patient was treated with flucloxacillin. However, the lesions increased in size and became ulcerative. In the following 3 months, cultures of punctuated material, blood, and urine remained negative and gram stains did not reveal micro-organisms. In June 1997, acid-fast stains were positive. A diagnosis of a nontuberculous mycobacterium (NTM) infection was made and empirical antimycobacterial therapy was started. The combination of relatively minor symptoms with enlarged purulent lesions, causing severe morbidity, raises the possibility of NTM infection in the immunocompromised patient. Received: 24 March 1998 Received after revision: 28 July 1998 Accepted: 23 September 1998     

Orthostatic acute renal failure in a renal transplant

Complications due to ureteric obstruction are an occasional cause for renal transplant dysfunction. Here we report an unusual case of orthostatic renal failure in a renal transplant recipient. Our patient had the previously reported predisposing risk factors including: female sex, obesity, and lax abdominal musculature. It is important to recognize this unusual complication of renal transplantation early in order to preserve long-term graft function. Received: 23 December 1996 Received after revision: 6 May 1997 Accepted: 13 May 1997     

Do noninherited maternal antigens (NIMA) enhance renal graft survival?

To test the hypothesis that noninherited maternal antigens (NIMA) can modulate the alloreactivity of infant cells and provide protection for renal transplant recipients, a study of renal transplantations performed between 1980 and 1991 was undertaken. The survival rate of grafts with a mismatched antigen identical to the NIMA was compared to that of grafts in which the mismatched antigen was not identical to the NIMA. In the case of HLA-A mismatches, graft survival rates were significantly better for NIMA-mismatched transplants: 94 % and 83 % at 1 and 3 years, respectively, for single NIMA HLA-A mismatched transplants, and 83 % and 67 % when both HLA-A antigens were mismatched, compared to 76 % and 68 % (one non-NIMA HLA-A mismatch) and 67 % and 45 % (two non-NIMA HLA-A mismatches). Our results suggest that some class I NIMA-mismatched antigens are not harmful to renal transplant recipients. Received: 16 May 1997 Received after revision: 8 October 1997 Accepted: 19 November 1997     

Renal Responses to exercise in heart and kidney transplant patients

There is a lack of information about renal responses in heart and kidney transplant patients after intense physical exercise. Eleven heart and ten kidney transplant recipients, as well as two control groups of healthy subjects, were given a maximum exercise test on a bicycle ergometer. One control group was also given a moderate load corresponding to the peak load of the kidney transplant group. Blood and urine samples were collected before and after exercise and assayed for lactate, creatinine, total protein, and albumin. The glomerular filtration rate remained stable at the end of exercise in the transplant patients, while there was a slight (17 %) decrease in the control group. Albumin excretion rates after maximum exercise attained a mean of 237 μg · min^–1in the control group and a mean of 45 and 16 μg · min^–1, respectively, in the heart and kidney groups. Postexercise proteinuria seemed to be related to the absolute intensity of the event, but kidney transplant patients showed a reduced effect as compared to heart transplant patients. We conclude that short-term, maximum exercise in heart and kidney transplant recipients is not detrimental to kidney function. Received: 21 November 1996 Received after revision: 4 March 1997 Accepted: 18 March 1997     

T-cell malignant lymphoma of the ileum causing ileac fistulas: report of a case

We herein present a rare case of three fistulas caused by a recurrence of T-cell lymphoma of the ileum. A 67-year-old man presented at a local hospital with left lower abdominal pain in May 1997. Upper and lower gastrointestinal examinations did not reveal any abnormal findings, but an abdominal aortic aneurysm was diagnosed by computed tomography, and thus was determined to be the source of the pain. The patient was referred to our hospital to undergo a grafting operation; however, a laparotomy performed in July 1997 revealed an unexpected small intestinal tumor, and therefore a partial ileectomy between 15 and 70 cm in an oral direction from the terminal ileum was carried out instead. Histopathological and genetic examinations demonstrated diffuse small malignant lymphocytic T-cell lymphomas of the ileum invading all layers. Metastasis of the facial skin and local recurrence were recognized 5 months later, and chemotherapy with THP-COP and ESHAP only resulted in progressive disease. An ileac fistula was found to have formed between the intestine and abdominal wall in March 1998, and the patient died in May 1998. An autopsy revealed three fistulas caused by metastatic tumors, one of which communicated with the duodenum from the ileum, one with the skin from the ileum, and one to the transverse colon from the ileum. Received: February 16, 2001 / Accepted: July 17, 2001     

Is cytomegalovirus a cause of ureteral stricture in renal transplant recipients?

Cytomegalovirus (CMV) is regarded as a predominant infectious agent in solid organ transplants. CMV disease has highly protean clinical manifestations. Nevertheless, urinary tract involvement seems to be very rare during CMV infection. We report two cases of renal transplant recipients in whom ureteral stricture developed in the course of CMV disease. Histologic data were available for them and were consistent with CMV infection. We discuss previous case reports and propose physiopathologic mechanisms. Received: 3 October 1996 Received after revision: 13 February 1997 Accepted: 17 February 1997     

Post Transplant T-Cell Lymphoma: A Case Series of Four Patients from a Single Unit and Review of the Literature

Post-transplant lymphoproliferative disorders (PTLDs) occur in approximately 1% of renal graft recipients. Of these, up to 15 percent are of the T-cell type. In this study, we present four cases of T-cell lymphoma from our renal transplant population, each of whom presented with non-specific symptoms, pancytopenia and/or liver dysfunction, with no obvious lymphadenopathy. They were all diagnosed with rare subsets of T-cell PTLD that included hepato-splenic T-cell lymphoma and anaplastic large cell lymphoma (ALCL). At the time of presentation, the patients were too ill for treatment to be initiated and succumbed to their illness. Increased awareness of this condition may allow for earlier diagnosis and improve its prognosis.     

Two grams daily of oral acyclovir reduces the incidence of cytomegalovirus disease in CMV-seropositive liver transplant recipients

Our objective in this study was to determine the efficacy of 2 grams a day of oral acyclovir administered for 16 weeks after transplantation for the prevention of cytomegalovirus (CMV) infection and disease in CMV-seropositive liver transplant recipients. Seventy-three adult liver transplant recipients, seropositive for CMV, were randomized to receive either 2 grams a day of oral acyclovir for 16 weeks after transplantation or no prophylaxis. The incidence of CMV disease was significantly lower in the acyclovir group (5 %) than in the control group (27 %; P < 0.05). By log-rank analysis, the differences in the probability of presenting CMV disease over the first 16 weeks and over the 1st year were also significant (P < 0.05). We conclude that 2 grams a day of oral acyclovir provides effective prophylaxis against CMV disease in CMV-seropositive liver transplant recipients. Received: 14 March 1997 Received after revision: 30 May 1997 Accepted: 9 June 1997     

Acute renal failure in a patient with hemophagocytic syndrome

Acute renal failure (ARF) occurred in a 47-year-old man with hemophagocytic syndrome. Histological findings of the kidney revealed diffuse infiltration of interstitium by phagocytosing cells mixed with atypical lymphoid cells of varying size. The cytological features of the lymphoid population in liver and spleen were consistent with a diagnosis of peripheral T-cell lymphoma. We believe that this ARF could have been exacerbated by the interstitial infiltration of phagocytosing cells, reactive lymphoid cells, and T-cell lymphoma cells. Received: September 25, 1998 / Accepted: July 22, 1999     

Long-term follow-up of renal transplant recipients treated with losartan for post-transplant erythrosis

Post-transplant erythrosis (PTE) develops in 9 %–22 % of all renal transplant recipients. Defined as a persistently elevated hematocrit (> 0.51), it occurs most commonly during the first 2 years post-transplantation in hypertensive males with excellent allograft function. Several studies have focused on a major role for angiotensin II in PTE pathogenesis, and some case reports have suggested that losartan is an effective treatment for PTE. Nevertheless, its long-term safety and efficiency have not been reported in renal transplant recipients suffering from PTE. We describe four patients successfully treated with losartan for PTE. Hematocrit remained normal for 21, 18, 15, and 15 months, respectively, after the beginning of losartan therapy. Mean erythropoietin concentration was not modified by treatment (17 ± 3.7 mU/ml vs 17 ± 3.8 mU/ml) and serum creatinine concentration remained stable. We conclude that losartan is a safe and effective long-term treatment for PTE. Received: 18 December 1997 Received after revision: 6 March 1998 Accepted: 16 March 1998     

Cytomegalovirus pneumonitis after kidney transplantation is not caused by plugging of cytomegalic endothelial cells only

In addition to life-threatening pneumonia, cytomegalovirus (CMV) may also cause subclinical pulmonary dysfunction after kidney transplantation. To investigate the role of plugging of cytomegalic endothelial cells in the pulmonary capillary bed, we prospectively determined specific carbon monoxide diffusion capacity (KCOc) and its components: the pulmonary diffusing membrane factor (Dm) and pulmonary capillary blood volume (Vcap) before and during CMV infection in 13 kidney transplant recipients and 13 controls. During CMV infection, mean KCOc decreased significantly by 28 % of the initial value (mean KCOc 79 vs 109; P < 0.005 ) due to a decrease in both Vcap and Dm. The KCOc in controls showed a significantly smaller decrease due to a slightly lower Vcap. We conclude that kidney transplant recipients with CMV infection have significant pulmonary diffusion disturbances due to a combination of lower Vcap and lower Dm. The most likely explanation for this phenomenon is a local inflammatory process due to CMV and not plugging of cytomegalic endothelial cells only. Received: 25 February 1998 Received after revision: 26 June 1998 Accepted: 22 September 1998     

Successful treatment of disseminated cryptococcosis in a liver transplant recipient with fluconazole and flucytosine, an all oral regimen

Amphotericin B, with or without 5-flucytosine, is currently the therapy of choice for cryptococcal infections. However, amphotericin B, is nephrotoxic and requires long-term venous access for parenteral administration. The combination of fluconazole and flucytosine is synergistic in vitro against Cryptococcus. To date, however, the efficacy of fluconazole and flucytosine for cryptococcosis in liver transplant recipients has never been reported. We report a 66-year-old liver transplant recipient with disseminated invasive cryptococcus (presenting as cryptococcal subcutaneous abscess, osteomyelitis, and serum cryptococcal antigen titer of 1:32). The administration of amphotericin B for 3 weeks led to nephrotoxicity without any clinical response (persistent abscess without change in serum cryptococcal antigen titer). Fluconazole, at a dosage equivalent to 800 mg/day administered orally, and flucytosine, also given orally, led to a clinical response and a steady decline in serum cryptococcal antigen titer, which became negative at 6 weeks of therapy. The patient remains well 18 months after therapy. No adverse effects have been attributed to fluconazole or flucytosine. This combination obviates the nephrotoxicity and the need for parenteral access required for amphotericin B infusion, and it can be administered orally. The combination of fluconazole and flucytosine warrants future controlled trials for the treatment of cryptococcal infection in liver transplant recipients. Received: 11 March 1997 Received after revision: 11 June 1997 Accepted: 19 August 1997     

EBV‐Associated Leukoencephalopathy with Late Onset of Central Nervous System Lymphoma in a Kidney Transplant Recipient

Central nervous system (CNS) lymphoma is a rare posttransplant lymphoproliferative disorder (PTLD), which usually has a poor outcome. To date, no specific conditions predisposing to this complication have been identified. We here describe the case of a renal transplant patient who was initially diagnosed as having Epstein‐Barr virus (EBV)‐associated leukoencephalopathy and ultimately developed EBV‐positive CNS lymphoma. The patient was a young lady who, 2 years after transplantation, presented with focal neurological and electroencephalographic abnormalities and diffuse white matter lesions on brain magnetic resonance imaging. EBV‐DNA was detected in the cerebrospinal fluid (CSF) by polymerase chain reaction. After acyclovir therapy and immunosuppressive drug tapering, the symptoms and electroencephalographic abnormalities subsided, and EBV‐DNA disappeared from the CSF. Ten years later, a bulky cerebral mass was found. After excision, a diagnosis of EBV‐positive, Hodgkin‐like monomorphic B‐cell PTLD was made. This case illustrates the potential pathophysiological relationships between EBV infection, leukoencephalopathy and CNS lymphoma; although a long time elapsed from the initial neurological illness to CNS lymphoma, a link between these two conditions cannot be excluded. Therefore, a careful long‐term follow‐up of EBV‐related encephalopathy is advisable.     

Neoral induction in pediatric renal transplantation

Neoral was instituted in pediatric renal transplant patients with the hypothesis it would have more predictable kinetics than Sandimmun. However, significant questions have arisen concerning potential toxicity and dosing interval related to its rapid absorption with subsequent high initial peak. This is compounded by the fact that children appear to metabolize cyclosporine at a greater rate than adults. This combination of a rapid peak and rapid absorption may then result in lower trough levels at 12 h. We compared the trough cyclosporine levels of nine children who received Neoral with nine who received Sandimmun at the time of initial transplantation. More frequent dosing (every 8 h) was required in the Neoral population compared with the Sandimmun population for the 1st month in order to obtain comparable trough levels. Beyond the initial 4–6 weeks, trough levels were similar for Neoral and Sandimmun. Whereas 1-month creatinine levels and blood pressures were similar, the number of blood pressure medications was significantly higher in the Neoral group. At 5.5 ± 1.1 months’ followup, a single patient in the current Neoral group and in the retrospective Sandimmun group each experienced a single OKT3 allograft-treated rejection. We suggest that the area under the curve is different in Neoral than Sandimmun, and the initial dosing frequency may need to be adjusted accordingly. Received August 21, 1996; received in revised form June 27, 1997; accepted June 30, 1997     

A randomized prospective study comparing low-dose OKT3 to low-dose ATG for the treatment of acute steroid-resistant rejection episodes in kidney transplant recipients

Acute steroid-resistant rejection episodes in kidney allograft recipients require treatment with antilymphocyte antibodies. Monoclonal anti-CD3 and polyclonal antilymphocyte antibodies have been widely used but seldom compared. Recent data have suggested that these antibodies could be used at reduced doses without jeopardizing their efficacy. In this study, we randomized renal transplant recipients who encountered a first acute steroid-resistant rejection episode to low-dose ATG or low-dose OKT3 treatment. Sixty patients were enrolled in the study. They received prophylactic immunosuppression with cyclosporin, azathioprine, and prednisolone. Treatment of biopsy-proven rejection consisted of a 10-day course of either ATG (n = 31) or OKT3 (n = 29). The total ATG dose was 484 ± 110 mg, i. e., 0.75 mg/kg per day. The total OKT3 dose was 32 ± 4 mg, i. e., 0.05 mg/kg per day. We compared reversion of rejection, side effects, immunodepression, and graft function. Reversion of rejection was similar in the two groups, although we noted a trend in favor of ATG. Results were 3 % vs 10 % early graft failures, 13 % vs 23 % overall graft failures, 28 % vs 38 % 3-month actuarial incidence of rebound rejection, and 89 % vs 81 % 1-year graft survival rate in the ATG and OKT3 groups, respectively. Tolerance was worse in the OKT3 group due to the first-dose syndrome. Infections and cancers occurred with the same frequency. ATG resulted in a deeper and longer decrease in peripheral lymphocyte subsets. Graft function was similar in the two groups. We conclude that low-dose ATG and low-dose OKT3 are equally effective in reversing steroid-resistant acute rejection. Tolerance was better with ATG, which also gave a more potent and longlasting immunodepression. The use of reduced doses of ATG and OKT3 did not appear to lessen their efficacy. Received: 27 June 1997 Received after revision: 15 October 1997 Accepted: 19 November 1997     

CD30-Negative Cutaneous T-Cell Lymphomas Other than Mycosis Fungoides

Cutaneous T-cell lymphomas (CTCLs), other than mycosis fungoides/Sézary syndrome and the group of cutaneous CD30⁺ lymphoproliferative disorders, are rare. These include subcutaneous panniculitis–like T-cell lymphoma (SPTCL); extranodal natural killer/T-cell lymphoma, nasal type; primary cutaneous peripheral T-cell lymphoma, not otherwise specified (PTCL, NOS); and rare subtypes of PTCL, NOS. Apart from SPTCL and primary cutaneous CD4-positive small-medium pleomorphic T-cell lymphoma, these lymphomas have in common aggressive clinical behavior and poor prognosis. Differentiation between these different types of CTCL may be difficult and requires integration of histopathologic findings with clinical data and the results of phenotypic and often molecular genetic studies.     

Acute renal failure due to obstruction in Burkitt lymphoma

 Acute renal failure in Burkitt lymphoma is commonly the result of tumor lysis syndrome. We present a 15-year-old boy who developed hypertension, seizures, and acute renal failure due to extrinsic compression of the bladder and ureters by a large retrovesical Burkitt lymphoma. The causes of acute renal failure in Burkitt lymphoma and the incidence of acute urinary obstruction in this disease are reviewed. Received: 18 May 1998 / Revised: 30 June 1998 / Accepted: 1 July 1998     

Lipid abnormalities in stable liver transplant recipients – effects of cyclosporin, tacrolimus, and steroids

Dyslipidemia is common after liver transplantation, but the underlying mechanisms are largely unknown. We studied the lipid profile of 27 liver transplant recipients randomized to receive either cyclosporin (CyA, n = 14) or tacrolimus (n = 13) and compared them with 20 healthy, matched controls. Before transplantation, patients presented low total and low-density lipoprotein (LDL) cholesterol (as compared to controls) that increased shortly, i. e., 3 months, after transplantation. Eighteen months post-transplantation, total and LDL cholesterol levels decreased to pretransplant values but tended to remain higher in CyA-treated patients. However, at that time, prednisone treatment was more prevalent among CyA-treated than tacrolimus-treated patients and fully accounted for the difference in cholesterol levels. Indeed, regardless of therapy, patients not receiving prednisone exhibited lower cholesterol levels than prednisone-treated patients and controls. We conclude that prednisone therapy, rather than CyA or tacrolimus immunosuppression, seems to be the major determinant of increased cholesterol levels. Received: 19 June 1997 Received after revision: 24 October 1997 Accepted: 10 November 1997     

A rare case of vascular rejection in a renal transplant recipient with nephrotic range proteinuria

Abstract:  In the post-cyclosporine A era, it has been reported that acute rejection after kidney transplantation is commonly revealed as an asymptomatic increase in the serum creatinine level. Nephrotic range proteinuria is observed in patients with recurrent or de novo glomerulonephritis, or with chronic transplant nephropathy and glomerulopathy in the late phase. Acute rejection occurring with nephrotic range proteinuria without a rise of serum creatinine has been rarely reported. Here, we report a rare case of vascular rejection in a renal transplant recipient with nephrotic range proteinuria. A 34-yr-old male renal transplant recipient presented with acute vascular rejection and early-onset nephrotic syndrome. Severe nephrotic range proteinuria was detected with a minimally elevated level of serum creatinine. Biopsy showed severe glomerulitis and vasculitis, which was relieved by conversion of the immunosupressant regimen. Severe proteinuria was a sign of acute vascular rejection with severe glomerulitis and vasculitis. Careful observation to ensure maintenance of immunosuppression is necessary in such cases.