Predictors of Posttransplant Lymphoproliferative Disease in Pediatric Patients.

Objective: Posttransplant lymphoproliferative disorder (PTLD) is a complication of pediatric solid organ transplantation. Benign adenotonsillar lymphoid hyperplasia confounds the ability to diagnose PTLD. Our aim was to identify factors that predict the presence of PTLD to inform decision-making regarding adenotonsillectomy.

Methods: The electronic medical records at a quaternary children's hospital were queried over a 23-year period (2000-2023) for solid organ transplant patients that underwent tonsillectomy and/or adenoidectomy. Demographics, clinical presentation, and EBV serologies were analyzed to determine factors associated with presence of PTLD on final pathology.

Results: A total of 114 patients met inclusion criteria for analysis. Thirty-two of the 114 patients (28.1%) who underwent tonsillectomy and/or adenoidectomy had PTLD. Age at transplant, age at biopsy, sex, race, and type of organ transplanted were not found to be associated with development of PTLD. Patients with PTLD were more likely to have smaller tonsils, sore throat, fever, and tonsillar exudate; they were less likely to experience sleep disordered breathing. The immunosuppression agent used for induction and the number of maintenance immunosuppressive medications were not associated with the development of PTLD. Increased Epstein-Barr Virus (EBV) PCR copy number correlated to increased risk of developing PTLD (p < 0.003).

Conclusion: Tonsillar hypertrophy and sleep disordered breathing are not necessarily indicative of the presence of PTLD. Suspicion for adenotonsillar PTLD should be based on symptomatology, clinical exam, EBV serologies, and degree of EBV PCR positivity. Sore throat, fever, tonsillar exudates, and significant elevation in EBV PCR copy number are particularly concerning for PTLD.

Level of evidence: 3 Laryngoscope, 2025.