Rapid tumor lysis after immunosuppressive pause in post-transplant lymphoproliferative disorder

• TLS developed after immunosuppression reduction for renal PTLD, without chemotherapy. • Kidney transplant case of TLS triggered solely by tapering immunosuppression. • EBV-positive polymorphic PTLD in an EBV-mismatched recipient led to fatal TLS. • Stresses early TLS risk assessment when reducing immunosuppression in PTLD. • Supports gradual tapering and TLS prophylaxis in high-risk transplant recipients. Post-transplant lymphoproliferative disorder (PTLD) is a well-documented complication in patients undergoing solid organ transplantation, with varying clinical presentations and progression. Tumor lysis syndrome (TLS), although typically associated with hematologic malignancies, can occur in PTLD under rare circumstances, often triggered by cytotoxic therapies. Here, we present a female in her late 50’s with a history of kidney transplantation complicated by PTLD who developed severe TLS following a temporary cessation of immunosuppressive therapy. Despite aggressive management, the patient deteriorated rapidly, culminating in respiratory failure, disseminated intravascular coagulation (DIC), and death. This case highlights the unusual presentation, rapid progression, and catastrophic outcome of TLS in the context of PTLD without cytotoxic therapy, underlining the challenges in managing these patients. Early recognition and prompt management of TLS are crucial, especially in transplant recipients where clinical manifestations may be atypical.