Massive pseudolymphomatous pericardial effusion in the posttransplant setting mimicking posttransplant...

We report an unusual case of massive pseudolymphomatous pericardial effusion in a cardiac transplant recipient. The near-coincidental development of the lymphocytic effusion and an EBV-associated tonsillar lymphoproliferative disorder suggested that the effusion was a manifestation of a posttransplant B cell lymphoproliferative disorder (PTLD). Although benign pericardial effusion is frequently seen in the post-cardiac transplant setting, EBV-related PTLD may also present as a malignant lymphocytic effusion. We present detailed histologic, virologic, and immunophenotypic data that proved useful in distinguishing between these 2 processes. Whereas the tonsillar process was a potentially malignant EBV-positive B cell predominant process requiring immunosuppressant withdrawal, the pericardial effusion was a benign EBV-negative T cell predominant process that, given its association with rejection, might require the diametrically opposite therapy of increased immunosuppression. Our approach to the proper diagnostic distinction between these 2 different post-cardiac transplant processes should prove useful to cardiac transplant teams.