Concomitant Kaposi sarcoma and multicentric Castleman’s disease in a heart transplant recipient Ami Patel, MD * , Eliahu Bishburg, MD, Mark Zucker, MD, Patricia Tsang, MD, Sandhya Nagarakanti, MD, Indu Sabnani, MD Newark Beth Israel Medical Center, 201 Lyons Avenue, Newark, NJ 07112, USA article info Article history: Received 27 May 2014 Received in revised form 22 July 2014 Accepted 22 July 2014 Available online 29 August 2014 Keywords: HHV-8 Heart transplant KS MCD abstract Post-transplant human herpes virus -8 (HHV-8)/Kaposi sarcoma herpes virus (KSHV) infection is asso- ciated with neoplastic and non-neoplastic diseases. Kaposi sarcoma (KS), multicentric Castleman’s dis- ease (MCD), and primary effusion lymphomas (PEL) are the most common HHV-8-associated neoplastic complications described in solid organ transplant (SOT) patients. Concurrent KS and MCD have been previously described after transplantation only twice e once after liver transplantation and once after renal transplantation. We describe a unique heart transplant patient who also developed concurrent KS and MCD. To our knowledge this is the first documented case of a heart transplant recipient presenting with these two HHV-8-mediated complications at the same time. Ó 2014 Elsevier Inc. All rights reserved. Introduction HHV-8/KSHV is a g e herpes virus that has been associated with neoplastic and non-neoplastic post-transplantation (PT) compli- cations. 1 The most common neoplastic complications associated with the virus are Kaposi sarcoma (KS), multicentric Castleman’s disease (MCD), and primary effusion lymphomas (PEL). 1e3 PT-KS develops in up to 1% of SOT and is more commonly seen in renal transplant recipients. PT-MCD is likewise observed infrequently in <1% of SOT. In addition to renal transplant recipients, it is also seen in liver transplant recipients. A few cases of combined KS and MCD cases have been described in AIDS patients and other immuno- suppressed patients, but rarely in SOT patients. Case report The patient, a 72 year-old Caucasian male was admitted with fever and chills of three days duration. Past medical history was remarkable for coronary artery disease and severe left ventricular dysfunction. He underwent orthotropic heart transplantation (OHT) 18 months prior to the current hospitalization. The donor and the recipient were cytomegalovirus (CMV) negative. The pa- tient was maintained on oral tacrolimus 3.5 mg twice daily, mycophenolate mofetil 500 mg twice daily which was tapered off over 6 weeks duration, prednisone 20 mg daily which was also tapered off over 6 week period and valganciclovir 450 mg daily for one year post transplantation. Two months prior to the admission, the patient presented with generalized lymphadenopathy for which he underwent a right inguinal lymph node biopsy at his local hospital. Pathological ex- amination of the node showed a vascular nodule composed of atypical plump spindle cells that formed slit-like vascular spaces containing red blood cells. Immunostains revealed the spindle cells were CD34 positive, smooth muscle antibody (SMA) positive, P16 focally faintly positive, HHV-8 focally positive, collagen IV positive, A- AT focally positive, cytokeratin (CK) 7 negative, CK18 negative, and tumor associated glycoprotein (TAG) 72 (B72.3) negative. Pe- riodic acid Schiff (PAS) stains revealed scattered hyaline globules. The overall findings were compatible with a diagnosis of KS (Fig. 1). Bone marrow biopsy did not reveal lymphoma. Quantitative PCR performed on a blood sample demonstrated an EpsteineBarr viral (EBV) load of 105 copies/ml, and CMV viral load of <500 copies/ml. The tacrolimus level upon presentation was 6.6 ng/mL (target range 8e10 ng/mL). Due to the persistence of diffuse lymphadenopathy, a second lymph node biopsy was performed. Pathological evaluation of the axillary lymph node revealed multiple lymphoid follicles Abbreviations: SOT, solid organ transplant; PT, post-transplant; LANA, latency associated nuclear antigen; CNI, calcineurin inhibitors. Disclosures: no conflict of interest for all the authors. * Corresponding author. Tel.: þ1 347 610 0219. E-mail address: dramikpatel@hotmail.com (A. Patel). Contents lists available at ScienceDirect Heart & Lung journal homepage: www.heartandlung.org 0147-9563/$ e see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2014.07.005 Heart & Lung 43 (2014) 506e509