You correctly identified the fact that the high EBV PCR was very suggestive of solid-organ post-transplant Lymphoproliferative Disorder.

This is a rare presentation of PTLD, presenting as it does with pancytopenia as the predominant feature. This is occasionally seen and the point of this case was to highlight the differentials for haematological dysfunction in solid organ trasnplant recipients.

The patient is investigated with a bone marrow aspirate and trephine and PET CT. The marrow confirms the clinical suspicion of EBV driven PTLD (monomorphic type DLBCL) and the PET shows widespread marrow involvement, multiple lesions in the liver and 2-3 cm nodes in the groin, thorax and pelvis (stage 4B disease).

What are the treatment steps we should consider in PTLD?