Post-transplant lymphoproliferative disorder presenting as large bowel obstruction leading to distributive shock

A woman in her 70s with a history of liver transplantation presented with constipation and leucocytosis. Imaging demonstrated a large obstructing sigmoid mass. She underwent a colonoscopy that showed narrowing but no luminal mass. She underwent an interventional radiology guided biopsy of the mass. Post-procedurally, she developed tachycardia and hypotension. She was taken to the operating room and was found to be haemorrhaging from the biopsy sites. The haemorrhage was controlled, and she underwent a diverting transverse loop colostomy. Postoperatively, she developed distributive shock that progressed despite resuscitative efforts. Her pathology returned as Epstein-Barr virus positive monomorphic post-transplant lymphoproliferative disorder (PTLD) of diffuse large B-cell lymphoma type. The distributive shock was from massive cytokine release secondary to her lymphoma, so she was started on an urgent chemotherapy regimen. Despite this, she never recovered haemodynamically, and she was compassionately extubated. The clinical presentation of PTLD can be variable with rapidly progressing life-threatening manifestations.