Immunohistological study of a pediatric patient with plasma cell-rich acute rejection

We report here the case of a girl who developed plasma cell-rich acute rejection (PCAR), a condition characterized by the presence of mature plasma cells infiltrating a renal allograft. The patient's creatinine level increased sharply to 4.3 mg/dL from 0.9 mg/dL at 19 months post-renal transplantation. She showed no response to methylprednisolone pulse therapy at a dose of 500 mg for three d but did show an immediate clinical and histopathological response to muromonab-CD3 (OKT3) administration. She had two episodes of PCAR recurrence and subsequently lost her graft. She had no evidences of antibody-mediated rejection including C4d deposition in peritubular capillaries and donor-specific antibodies during the entire follow-up period. To elucidate the pathogenesis of PCAR, immunohistological examination of infiltrating cells was performed. CD3-positive cells infiltration seemed to be associated with the CD138-positive cells infiltration, and the number of CD3-positive cells was increased preceding PCAR recurrence. Additionally, a rapid decrease in the number of CD138-positive cells and CD3-positive cells following the OKT3 administration was observed. This case suggests that T-cell mediated immune mechanisms might play a role in the development of PCAR.