diagnosis of primary EBV infection which has reduced the risk of PTLD to less than 3% in the liver transplant population, and less than 10% in the heart transplant population Imaging via CT scan can help screen for enlarged lymph nodes, solid tumors, and other findings concerning for neoplasia If found, and if accessible, biopsy of the disease site is the diagnostic step of choice A PET-CT may help detect occult disease Treatment typically includes minimization or discontinuation of immunosuppression as a first step, to allow the body to resume control of the proliferating B cells Directed therapies with chemotherapeutic regimens including rituximab, cyclophosphamide, and prednisone may then be added If high EBV load is detected, an antiviral agent is typically added as adjunct therapy Clinical Considerations Clinical Recognition Suspicion for PTLD should arise in the setting of a child with a prior EBV infection and an increasing viral load as measured by EBV polymerase chain reaction (PCR) Other presentations include progressive and unremitting gastrointestinal findings (e.g., chronic diarrhea, bloody stool, abdominal pain, anorexia, weight loss), pulmonary symptoms (e.g., chronic cough, shortness of breath), or vague systemic malaise (e.g., fever, feeling unwell, weight loss) Children may be asymptomatic Lymphoproliferative disease can occur in any location, and screening must include the graft (though lesions are rarely intracardiac), lungs, brain, intestine, spleen, liver, lymph nodes, and bone marrow Clinical Assessment Common clinical examination findings may include fever, lymphadenopathy (especially cervical, submandibular, and axillary), sinusitis, tonsillar enlargement, and splenomegaly Initial assessments should target the primary symptomatology: if diarrhea is present, stool should be collected and sent for usual infectious pathogens plus occult (or gross) blood; if respiratory symptoms are present, chest radiograph is indicated; palpable masses or obstructive symptoms require CT imaging All of this must be performed with the advice and participation of the transplant team The diagnosis of PTLD is rarely made in the ED It usually requires a combination of imaging, analysis of tissues (e.g., lymph node, tonsil, liver) for evidence of EBV-transformed B cells and quantitative EBV PCR from blood confirming viral replication With that said, investigations can be initiated in the