SESSION TYPE: Airway Cases II
PRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Obstructive sleep apnea (OSA) is often associated with obesity. Infrequently in adults, isolated lesions of the upper airways can produce OSA . We report a post-transplant patient with tonsillar lymphoma and OSA.
CASE PRESENTATION: A 45 year old man with history of kidney transplant, hypertension and hyperlipidemia presented with 6 months history of loud snoring, daytime hypersomnolence and recurrent sore throat. He had undergone kidney transplant 18 months prior and reported progressive weight gain since then. His BMI was 30.7 and neck circumference was 43 cm. Examination of the oropharynx revealed grade 4 tonsillar enlargement. Epworth Sleepiness score was 19. His AHI was 59.1/hr and CPAP therapy was initiated. In view of the marked tonsillar enlargement he was subjected for tonsillectomy and uvulopharyngoplasty. Postoperative histopathology showed a low grade B cell Lymphoma. EBV IgG serology was positive. Bone marrow studies were negative for malignant lymphoma. CT Thorax and Abdomen was normal. Chemotherapy was not started and the lymphoma remained in remission at one year follow-up. A repeat PSG 6 months after surgery showed a residual AHI of 25/hr and patient was continued on CPAP therapy.
DISCUSSION: Upper airway obstruction due to tonsillar hypertrophy superimposed on a narrow oropharynx had produced increasing symptoms in this patient. Surgery improved the apnoeic episodes by 42% however post-surgical AHI of 25/hr suggests a multifactorial cause of OSA. This case of tonsilar lymphoma presenting as OSA in a typical patient description emphasizes the importance of a careful clinical examination of the upper airway in patients with features of sleep apnea. This patient has post-transplant lymphoproliferative disorder (PTLD). PTLD is a well known complication of solid organ transplantation however isolated tonsillar PTLD in the adult population is rare . PTLD is often associated with Epstein-Barr virus infection as evident in this patient. Reduction in immunosupression is often sufficient for treatment .
CONCLUSIONS: This case highlights the importance of clinical upper airway assessment in the evaluation of patients with OSA. Even when the patient’s body habitus is typical, upper airway pathology can still be a contributing factor to the occurrence of OSA.
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2) Williams MD, Brown HM. The adequacy of gross pathological examination of routine tonsils and adenoids in patients 21 years old and youger. Human Pathology.2003;10:1053-7.
3) Rami T. Bustami et al. Immunosuppression and the Risk of Post-Transplant Malignancy Among Cadaveric First Kidney Transplant Recipients. American Journal of Transplantation. 2004;1.
DISCLOSURE: The following authors have nothing to disclose: Lalitha Pereirasamy, Ong Thun How
No Product/Research Disclosure InformationDepartment of Respiratory Medicine, Penang General Hospital, Georgetown, Malaysia