Working Diagnosis:
Epstein-Barr Virus (EBV) positive post-transplant central nervous system large B-cell lymphoma with focal seizures secondary to brain lesion.

Treatment:
The patient was treated acutely with IV dexamethasone and then started on levetiracetam as an outpatient. The brain lesion was treated surgically with a right frontal craniotomy with total resection. He was treated with four doses of weekly rituximab infusions. The post-treatment monitoring plan included a brain MRI every two months.

Outcome:
The patient was found to have no metastatic disease. He initiated physical therapy one month after surgery with persistent mild left leg weakness. Initiation of jogging and cycling is planned for 6 months post-operatively.

Author's Comments:
Immunosuppression plays a large role in the development of cancer in solid organ transplant recipients through the loss of the immunosurveillance process. Some of the most common malignancies due to immunosuppression include skin cancers and postransplant lymphoproliferative disorders. It is essential to keep this in mind when treating posttransplant patients, regardless of the specialty we are in, as patients with lymphoproliferative disorders such as this patient, can present with a complex set of symptoms.

Editor's Comments:
This case serves as an important reminder to always keep a broad differential, particularly when evaluating a patient who has an atypical presentation or a complicated medical history. Solid organ transplant recipients have an approximately twofold higher risk of colon, breast, lung and prostate cancer when compared with the general population. The risk of other less common cancers, such as Kaposi sarcoma, non-Hodgkin lymphoma, non-melanomatous skin cancers, and cancers related to viral infections, is increased as much as 20-fold. Post-transplant lymphoproliferative disorder (PTLD) is one of the most common malignancies seen after solid organ transplantation. In the setting of immunosuppression and impaired T-cell responses, EBV is able to promote B-cell proliferation in a potentially unregulated fashion. Primary central nervous system PTLD is very rare.

References:
Krisl JC, Doan VP. Chemotherapy and Transplantation: The Role of Immunosuppression in Malignancy and a Review of Antineoplastic Agents in Solid Organ Transplant Recipients. Am J Transplant. 2017;17(8):1974-1991

Cimino FM, Snyder KA. Primary Care of the Solid Organ Transplant Recipient. Am Fam Physician. 2016 Feb 1;93(3):203-10.

Crombie JL, LaCasce AS. Epstein Barr Virus Associated B-Cell Lymphomas and Iatrogenic Lymphoproliferative Disorders. Front Oncol. 2019;9:109.

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