Bilateral Conjunctival Mucosa-Associated Lymphoid Tissue Type Lymphoma in a Kidney Transplant Recipient

Abstract

Lymphoproliferative disorder in a posttransplant setting has emerged as a difficult problem in kidney transplantation (KT).Lymphoma involving adnexa of the eye has rarely been reported due to scarcity of lymphoreticular tissue in the ocular area. This report presents a case of a 37-year-old KT recipient who was diagnosed with conjunctival mucosa-associated lymphoid tissue lymphoma with a chief complaint of seeing black spots. Unlike other post-transplant lymphoproliferative diseases associated with the Epstein-Barr virus (EBV) reactivation via immunosuppression, the lesion was not related to the virus. The patient received radiotherapy with concomitant conversion from the tacrolimus to the sirolimus. Overall, the results presented herein indicate lymphoma may be an important differential diagnosis when KT recipients complain of ocular discomfort. Case Report INTRODUCTIONKidney transplantation (KT) is an emerging option for renal replacement therapy that improves the quality of life, as compared to dialysis. However, immunosuppressive therapy for the prevention of rejection can lead to lymphoproliferative disease after KT up to 1% to 20%(1). The extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) type that belonged to the indolent B-cell lymphomas which is mainly an observed gastric mucosa and it is associated with the Helicobacter pylori infection(2-5), has been rarely reported as originating from other sites. We herein report a case of a KT recipient who is diagnosed with extranodal marginal zone lymphoma involving both conjunctivae. CASE REPORTA 37-year-old woman with end-stage renal disease due to lupus nephritis received a living-donor KT after 5 years of peritoneal dialysis. The donor was her mother, and the human leukocyte antigen mismatch number was 2. She underwent induction therapy by using basiliximab, and thereafter maintained immunosuppression with tacrolimus, mycophenolic acid, and deflazacort. The trough level of tacrolimus has been maintained between 4∼5 ng/mL. The allograft function was kept stable with an estimated glomerular filtration rate of 60 mL/min/1.73 m Cytomegalovirus and Epstein-Barr virus (EBV) were not detected in the real-time polymerase chain reaction test. In the ophthalmic examination, multiple cystic nodules located in both lower conjunctivae were found. The cystic nodules were biopsied and diagnosed with extranodal marginal zone lymphoma of MALT type (Fig. 1). During the staging workup for lymphoma, orbital magnetic resonance imaging and positron emission tomography computed tomography (PET-CT) showed hypertrophic changes in the lower conjunctivae of both eyes and tonsils (Fig. 2). The bone marrow finding was normal, and the chromosome analysis of hematology/oncology showed no atypical clone. The stain for EBV was negative. The patient also underwent esophagogastroduodenoscopy with a negative result of H. pylori It is generally known that MALT lymphoma most frequently develops in the stomach due to the H. pylori infection(12). Only rare nongastric MA...