Ratuapli et al. Journal of Medical Case Reports 2011, 5:5 http://www.jmedicalcasereports.com/content/5/1/5 Page 4 of 8 Figure 4 Appendiceal infiltrate showing scattered Epstein Barr Virus-positive cells (100 X). etoposide 40 mg/m2 and solumedrol 250 mg adminis- tered on days one, two and three, and gemcitabine (Gemzar) 1000 mg/m2 on day one (ongoing Phase II trial SWOG 0350). Our patient had a positive and rapid clinical response to this regimen. Thus, the chemother- apy was changed to a standard CHOP regimen (cyclo- phosphamide, doxorubicin [Adriamycin], vincristine, prednisone). His gastric outlet obstruction was sup- ported with total parenteral nutrition (TPN) for a few weeks, after which the patient was able to eat well. A repeat PET scan after the second cycle of CHOP showed a significant response. The main complications during the therapy were pan- cytopenia, febrile neutropenia and pneumonia. These were managed successfully. He recovered well and is presently receiving treatment as an outpatient. His allo- grafted kidney is also fully functional. Restaging is planned after a total of six cycles of CHOP with a PET scan and EGD. Discussion Our case is interesting due to the latency of PTLD development, the lack of hematological abnormalities and the EBV-positivity, even though the lymphoma was of T-cell origin. The diagnosis became apparent when an appendectomy was performed for abdominal pain. The cytopathology of our patient shows all the typical features of a peripheral T-cell variant of PTLD, where the T-cell lineage of the lymphoma was confirmed by TCR gene rearrangement studies. While presenting symptoms in the majority of patients are non-specific such as fever and weight loss, approxi- mately 15% of cases present as an emergency with intest- inal perforation [5]. Similar to other reports on T-cell type PTLD, which generally occurred more than five years after transplant, this case occurred 17 years after the renal transplant. The high levels of immunosuppres- sion were due to two episodes of graft rejection in the preceding four years.