Antiviral therapy with IV acyclovir or ganciclovir has been used to inhibit EBV

replication in an effort to treat PTLD. Response is variable and may depend on the

type and extent of PTLD. A.L. already has received ganciclovir for 4 weeks during

which time she presented with PTLD. Surgery, radiation therapy, and chemotherapy

are used to treat PTLD depending on the situation. Interferon and immunoglobulin

have been effective in a few cases that appeared unresponsive to other therapies.

Monoclonal or immunoblastic, disseminated, rapidly progressive PTLD responds

poorly to traditional therapy and has a mortality rate as high as 70%. Rituximab (an

anti-B-cell, anti-CD20 antibody) is considered first-line therapy for CD20-postive

B-cell PTLD along with reduction or withdrawal of immunosuppression if possible.

Patients usually get 375 mg/m2 weekly for 4 weeks; some groups have used

prolonged therapy. Patients may have relapse or disease progression that may

respond to chemotherapy regimens such as cyclophosphamide, adriamycin,

vincristine, prednisone, or dexamethasone (CHOP); CHOP plus rituximab (CHOPR); and cyclophosphamide, doxorubicin, etopside, prednisone, cytarabine,

bleomycin, vincristine, and methotrexate (PROMACE-cytaBOM).

p. 744

p. 745

Transplant recipients have a higher risk of myelotoxic side effects, depending on

their maintenance immunosuppression. A.L.’s prognosis is poor given the type and

extent of her PTLD, which would have been more responsive to therapy if it had been

diagnosed early. Polyclonal PTLD responds well to reduction or discontinuation of

immunosuppression and high-dose acyclovir or ganciclovir therapy for several

weeks to months. The roles of prophylactic antivirals, immunoglobulins, and EBV

PCR monitoring in the prevention of PTLD are currently controversial, with mixed

results in current literature.

99

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