Ratuapli et al. Journal of Medical Case Reports 2011, 5:5 http://www.jmedicalcasereports.com/content/5/1/5 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Epstein Barr Virus-positive large T-cell lymphoma presenting as acute appendicitis 17 years after cadaveric renal transplant: a case report Shiva K Ratuapli1*, Shishir Murarka1, Karen A Miller2, James C Ferraro1, Haider Zafar1 Abstract Introduction: The majority of post-transplant lymphoproliferative disorders in renal transplant patients are of the B-cell phenotype, while the T-cell phenotype is rare. We report a case of Epstein Barr Virus-positive, T-cell lymphoma in a renal transplant patient, presenting unusually as acute appendicitis. Case presentation: A 45-year-old Hispanic male renal transplant patient presented with right-side abdominal pain 17 years after transplant. The laboratory studies were unremarkable. Laparoscopic exploration showed an inflamed appendix so a laparoscopic appendectomy was performed. Pathology of the appendix showed large cells positive for CD3, CD56 and Epstein Barr Virus-encoded RNA staining, and negative for CD20 and CD30. The tissue tested positive for T-cell receptor gene rearrangement by polymerase chain reaction analysis. Treatment management involved reduction of immunosuppression and initiation of chemotherapy with cisplatin, etoposide, gemcitabine, and solumedrol followed by cyclophosphamide, hydroxydaunorubicin, vincristine and prednisone). He recovered and the allo-grafted kidney is fully functional. Conclusion: We report a rare case of post-renal transplant large T-cell lymphoma, with an unusual presentation of acute appendicitis and Epstein Barr Virus-positivity, which responded well to chemotherapy. Introduction Solid organ transplantation has been increasingly per- formed in recent years with the use of highly potent immunosuppressive agents to avoid rejection by the host. Post-transplant lymphoproliferative disorders (PTLD) are well known malignancies found in trans- plant patients, with an incidence reportedly 28 to 49 times greater than in the general population [1]. PTLD in renal transplant patients is reported to be higher in the paediatric population (10.1%) than the adult popula- tion (1.2%) [2]. PTLD in renal transplant patients was first described as a complication with azathioprine-based therapy [3], but was later described after therapy with multiple more novel immunosuppressive agents. While the majority of PTLD in renal transplant patients are of the B-cell phenotype, a few exhibit the T-cell phenotype [4]. We report a case of Epstein Barr * Correspondence: shiva.ratuapli@bannerhealth.com 1Department of Medicine, Banner Estrella Medical Center, 9201 W. Thomas Road, Phoenix, AZ 85037, USA Full list of author information is available at the end of the article Virus (EBV)-positive T-cell lymphoma in a patient, who underwent cadaveric renal transplant 17 years ago and was on chronic multi-drug immunosuppression. Our patient presented unusually with abdominal pain and acute appendicitis. Case presentation A 45-year-old Hispanic male who underwent cadaveric renal transplant in the right lower quadrant 17 years earlier, presented to the hospital with a three-month history of generalized abdominal pain with localization to the right side for two weeks. He was on chronic immunosuppression with tacrolimus, azathioprine, siro- limus and prednisone. The pain was more pronounced in the right upper quadrant, and the ultrasound imaging of the abdomen was suggestive of cholecystitis. Labora- tory studies did not reveal any abnormalities. He could not confirm if he had had any problems or surgeries on his gall bladder. Hence, he underwent laparoscopic exploration of the gall bladder fossa. During surgery, adhesions of the omentum were found in the gall © 2011 Ratuapli et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.