The clinical presentation of PTLD can vary from a nonspecific
viral illness to a malignant lymphoma. Symptoms may include fever,
malaise, weight loss, sore throat, lymphadenopathy, diarrhea or
gastrointestinal bleeding, headache, and allograft dysfunction.
Physical examination may reveal tonsillar enlargement, asymmetry,
ulceration, lymphadenopathy, splenomegaly, and/or graft
tenderness and enlargement. The transplant graft is often involved
in the presentation of PTLD. Identification of EBV viremia by PCR
in the clinical setting of graft dysfunction, or nonspecific viral
illness strongly suggests the diagnosis of PTLD. The diagnostic
evaluation for PTLD should include a complete blood count (CBC)
with differential, electrolytes, lactate dehydrogenase, calcium,
and uric acid. Assessment of liver function and renal function should
be included, as well as measurement of EBV serologies and PCR. Imaging
studies should include CT scan of chest, abdomen, and pelvis specifically
looking for nodal or extra-nodal disease, and nodular or infiltrative
changes in the allograft. Mesenteric adenopathy or bowel wall thickening
are additional gastrointestinal manifestations of PTLD. A biopsy of
any suspicious lesions should be obtained. In the absence of other
specific radiographic findings, endoscopy with biopsy may be able
to demonstrate nonbulky PTLD or mucosal ulceration. A transplant
graft biopsy should also be done to rule out involvement with PTLD.