CLINICAL PEARLS AND PITFALLS PTLD is a spectrum of neoplastic diseases that can occur in children after solid organ transplant PTLD is often associated with EBV infection Children may be asymptomatic, or have nonspecific symptoms such as malaise and fever Diagnosis rarely occurs in the ED, yet clinicians must have a high level of suspicion Goals of Treatment PTLD represents a spectrum of lymphoproliferative diseases that occur in patients post transplant Diagnosis of PTLD in the ED is rare, but it is important for emergency clinicians to recognize the common symptoms, which include malaise, fever, chronic gastrointestinal symptoms, and/or pulmonary symptoms A high clinical suspicion of PTLD warrants admission for further diagnostic testing Current Evidence EBV is a ubiquitous virus and, similar to CMV, is associated with hepatitis as well as a more systemic illness EBV infection commonly occurs in the first year following transplantation when immunosuppression levels are higher, but can present anytime following transplantation EBV infection is more common in children and can reflect primary disease or reactivation of disease Between 60% and 80% of pediatric transplant recipients are EBV seronegative at the time of transplantation and high levels of immunosuppression increase the risk of developing symptomatic disease Acute EBV infection presents as a mononucleosis-like syndrome with diffuse B-cell hyperplasia Of particular concern with EBV infection is the risk of subsequent development of PTLD PTLD refers to a spectrum of lymphoproliferative disorders that ranges from Bcell hyperplasia to monoclonal lymphoma In many cases, development of PTLD results from EBV activation and mutation of lymphocytes in the immunosuppressed host PTLD is the most common neoplastic disorder in children following transplantation In addition to EBV infection post transplant, significant risk factors for development of PTLD include younger age at transplant and prolonged, intense immunosuppression, such as may occur post treatment of serial rejection episodes or after many years of chronic immunosuppression Serial monitoring of EBV viral load has allowed for earlier