Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
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Case Report

Volume 000, Number 000, October 2025, pages 000-000

Refractory Epstein-Barr Virus-Negative Diffuse Large B-Cell Lymphoma Post-Transplant Lymphoproliferative Disorder in a Renal Transplant Patient Treated With Bispecific Antibody Therapy

Figures

Figure 1.
Figure 1. At time of initial presentation, CT abdomen and pelvis showing increase in size of the abdominal and pelvic lymph nodes (arrows) suspicious for post-transplant lymphoproliferative disorder. CT: computed tomography.
Figure 2.
Figure 2. Gastric biopsy showing sheets of small round blue tumor cells (a, H&E, × 200) that stained diffusely positive with B-cell markers CD20 (b, CD20 immunohistochemistry, × 100) and PAX5 (c, PAX5 immunohistochemistry, × 100). H&E: hematoxylin and eosin.
Figure 3.
Figure 3. (a) PET showing metabolic activity of right sided pelvic lymph nodes/nodal masses (arrows) at 3 months from initial presentation. (b) PET conducted 4 months after initial presentation with diffuse terminal ileum/ascending colon thickened wall uptake and increase in size and metabolic activity of right-sided pelvic lymph nodes/nodal masses (arrows), consistent with persistent lymphoma. PET: positron emission tomography.
Figure 4.
Figure 4. PET scan with diffuse disease progression (arrows) 14 months after initial presentation. PET: positron emission tomography.
Figure 5.
Figure 5. A timeline showing the different lines of therapies used to treat this case. R-CHOP: rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone; R-GemOx: rituximab, gemcitabine, oxaliplatin. Created in BioRender by A. Frisch (2025). https://BioRender.com/9hy92es

Table

Table 1. Patient’s Complicated Clinical Course and Treatment History
 
TimelineClinical events and findingsManagementOutcome
“M” represents months in the timeline. “W” represents weeks in the timeline. The table begins with the patient’s kidney transplant and early symptoms then arriving “day 0” with our inpatient team’s first encounter. The following rows detail her treatment course and disease progression. CAR: chimeric antigen receptor; CMV: cytomegalovirus; CRS: cytokine release syndrome; CT: computed tomography; DLBCL: diffuse large B-cell lymphoma; EBV: Epstein-Barr virus; EGD: esophagogastroduodenoscopy; ESRD: end-stage renal disease; GI: gastrointestinal; ICU: intensive care unit; PET: positron emission tomography; PTLD: post-transplant lymphoproliferative disorder; R-CHOP: rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone; R-GemOx: rituximab, gemcitabine, oxaliplatin.
30 M prior to initial presentationDeceased donor kidney transplant for ESRD (hypertensive nephrosclerosis).Immunosuppression with tacrolimus, mycophenolate, prednisone.Stable graft function post-transplant.
6 M prior to initial presentationProgressive abdominal discomfort, early satiety, unintentional weight loss.Symptom monitoring.Worsening symptoms over months.
Initial presentation, “day 0”Abdominal pain and fatigue. CT abdomen and pelvis showing increase in size of the abdominal and pelvic lymph nodes suspicious for post-transplant lymphoproliferative disorder (Fig. 2).Retroperitoneal lymph node biopsy.Diagnosed with EBV-negative DLBCL, germinal center B-cell subtype PTLD.
2 W after presentationInitiated first cycle of R-CHOP.Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone.Mild neutropenia, partial radiographic response after two cycles.
4 M after presentationDisease progression post six cycles of R-CHOP. PET: new pelvic nodes, bowel lesions (Fig. 3).Biopsy of right pelvic node: residual DLBCL with necrosis, high Ki-67, GC phenotype.Confirmed refractory disease.
8 M after presentationStarted on rituximab + polatuzumab vedotin (delayed due to hospitalizations).Chemotherapy initiated.Admitted to ICU with septic shock post-cycle.
8 - 9 M after presentationEGD/colonoscopy: gastric ulcer (DLBCL), CMV colitis.Multidisciplinary discussion; suppressive antibiotics.Decision to continue therapy.
9 - 11 M after presentationFour cycles of R-GemOx.Tolerated treatment initially.CT in October: disease progression with worsening abdominal pain.
12 M after presentationBridging therapy initiated: obinutuzumab + glofitamab for CAR T-cell consideration.Admitted for CRS monitoring after first dose.Discharged, tolerated initial treatment.
13 - 14 M after presentationPolatuzumab added. Recurrent admissions for GI toxicity (C. difficile colitis, pain).Supportive care, pain control.CT: tumor progression (up to 11.9 cm mass), new ascites.
14 - 15 M after presentationPET scan confirms disease progression (Fig. 4).Started glofitamab + loncastuximab tesirine-lpyl (LOTIS-7 trial).Admitted soon after first dose with pain, fevers.
15 M after presentationEmotional distress, ongoing symptoms. Imaging: no new disease.Goals-of-care discussion. Transitioned to hospice care.Patient chose to stop treatment.