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PTLD Initial Management — SCE Infectious Diseases MCQ

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ModerateImmunocompromised HostPTLD Initial ManagementSCE Infectious Diseases

A 50-year-old renal transplant recipient on Tacrolimus develops post-transplant lymphoproliferative disorder (PTLD). EBV viral load is extremely high. CT shows widespread lymphadenopathy. Biopsy confirms EBV-positive diffuse large B-cell lymphoma. What is the initial management step?

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Correct answer: B — Reduction of immunosuppression (reduce Tacrolimus and stop Mycophenolate if possible) — this is the first-line intervention for PTLD

Reduction of immunosuppression (RIS) is the mandatory first step in PTLD management. Approximately 30–50% of PTLD (particularly early/polymorphic forms) responds to RIS alone. The rationale is to restore EBV-specific T-cell immunity. The degree of immunosuppression reduction must balance PTLD response against rejection risk (typically: stop Mycophenolate/Azathioprine, halve Tacrolimus/Ciclosporin). If no response to RIS within 2–4 weeks, Rituximab (anti-CD20) ± chemotherapy (R-CHOP) is added. Antivirals (Aciclovir, Ganciclovir) are NOT effective against PTLD as EBV is in latent form.

Reference: NICE NG37 2016 – SOT; BSH 2023 – PTLD; ECIL-7 2019 – EBV-PTLD