Fatal lactic acidosis and hypoglycemia in a patient with relapsed natural killer/T-cell lymphoma

Tumor-Associated Lactic Acidosis and Early Death in Patients With Lymphoma

BACKGROUND

Cancer is characterized by accelerated glycolysis with enhanced glucose uptake and lactate production, a phenomenon termed Warburg effect (WE). We studied the incidence and clinical impact of Warburg-driven lactic acidosis in lymphoma.

METHODS

Patients admitted with newly diagnosed or relapsed/refractory lymphoma and documented lactate levels during the first week of admission were included. Patients with lactatemia were classified as secondary (with a recognizable cause for elevated lactate) or none (WE group).

RESULTS

WE and secondary lactatemia were documented in 58 and 44 patients (15% and 12% of evaluable patients, respectively). Both WE and secondary lactatemia were associated with poor short-term survival. WE at presentation correlated with tumor burden, with most patients having aggressive disease, advanced stage, and extranodal involvement. WE was associated with high rates of early death (26% and 43% at 30- and 60-days, respectively). Higher lactate levels correlated with worse survival. Earlier initiation of chemotherapy was associated with a (nonsignificant) trend toward better outcomes, whereas steroid and/or thiamine therapy did not alter patient outcomes. Glucose administration was associated with worse survival.

CONCLUSION

WE-driven lactatemia is associated with high tumor burden and increased short-term mortality in lymphoma. Prompt initiation of anti-lymphoma therapy may improve outcomes.

Atypical Presentation of Burkitt Lymphoma With Isolated Peritoneal Involvement and Association With Refractory Type B Lactic Acidosis and Hypoglycemia Secondary to the Warburg Effect

Lactic acidosis is considered to be one of the most common causes of high anion gap metabolic acidosis in hospitalized patients. Warburg effect can present with type B lactic acidosis and is considered to be a rare but well-known complication of hematological malignancies. Here, we present the case of a 39-year-old male who had type B lactic acidosis and recurrent hypoglycemia secondary to newly diagnosed Burkitt lymphoma. This case highlights the importance of considering malignancy workup in any case of unexplained type B lactic acidosis with vague clinical presentation, which can aid in early diagnosis and management.

Type B lactic acidosis associated with diffuse large B-cell lymphoma and the Warburg effect

Type B lactic acidosis is a rare complication of non-tissue perfusion abnormalities caused by solid tumors or hematologic malignancies. Herein, we present the case of a 42-year-old man with type B lactic acidosis and hypoglycemia who was found to have a diffuse large B-cell lymphoma. The cause of lactic acidosis and/or hypoglycemia is thought to be the Warburg effect, which is when the metabolic rate of a rapidly growing malignant tumor is very high and dominated by glycolysis. Systemic damage from type B lactic acidosis can occur when the increased rate of glycolysis exceeds the normal muscle and liver lactic acid clearance rate. The Warburg effect is a rare but serious condition that needs to be recognized, not only in diffuse large B-cell lymphoma, but also in other malignancies. The prognosis of lactic acidosis in patients with malignant tumors is very poor. Currently, effective chemotherapy seems to be the only hope for survival.

Lactic Acidosis and Hypoglycemia in a Patient with Gastric Diffuse Large B-Cell Lymphoma due to the Warburg Effect

Lactic acidosis is pathophysiologically classified into type A and type B. The latter is a rare but potentially life-threatening emergency, mainly described in hematological malignancies. The association between Type B lactic acidosis and malignancy is known as the Warburg effect. Patients with the Warburg effect have a very poor prognosis. Herein, we report a case of gastric diffuse large B-cell lymphoma (DLBCL) with severe lactic acidosis and hypoglycemia owing to the Warburg effect that were effectively treated by prompt introduction of chemotherapy. A 73-year-old woman with a 2-month history of abdominal distension was referred to us for suspected peritoneal cancer. Pathological examination revealed gastric DLBCL with peritoneal dissemination. After hospitalization, blood test results revealed prolonged hypoglycemia, with a blood sugar level of 50-70 mg/dL; severe lactic acidosis with pH 7.166; lactate level 12.7 mmol/L; and base excess -21.0 mEq/L, despite continuous administration of glucose and sodium bicarbonate. The cause of lactic acidosis and/or hypoglycemia was considered to be the Warburg effect. We initiated a 50% reduced-dose CHOP (cyclophosphamide, vincristine, doxorubicin, prednisolone) chemotherapy regimen without rituximab until information on the CD20-positive status was available. During chemotherapy, acidosis, hypoglycemia, and impaired consciousness promptly improved. If lactic acidosis or hypoglycemia is present in patients with malignant tumors, it is important to suspect the possibility of the Warburg effect and to introduce cancer treatment as soon as possible.

Lymphoma and Lactic Acidosis

A 39-year-old man presented with new onset of sinus congestion, shortness of breath, and diaphoresis. His laboratory tests were notable for hypercalcemia and lactic acidosis. A CT scan of the head demonstrated mild paranasal disease. CT scan of the chest, abdomen, and pelvis demonstrated omental caking with lymphadenopathy and a thickened loop of bowel in the left upper quadrant suggestive of lymphoma. All abdominal lesions seen in the CT were intensely F-FDG avid with diffuse uptake in the bone marrow. There was markedly decreased F-FDG uptake in both the brain and liver. Histopathology was positive for Burkitt lymphoma.

A case of type B lactic acidosis as a complication of chronic myelomonocytic leukaemia: a case report and review of the literature

Introduction

Type B lactic acidosis represents a rare and often lethal complication of haematological malignancy. Here, we present a patient who developed a type B lactic acidosis presumably due to a concurrent chronic myelomonocytic leukaemia. Upon swift initiation of cytoreductive chemotherapy (doxorubicin), the lactic acidosis was rapidly brought under control. This case adds to the literature reporting other haematological malignancies that can cause a type B lactic acidosis and its successful treatment.

Case presentation

We report the case of a 77-year-old Caucasian man brought to our Accident and Emergency department following an unwitnessed collapse; he was found surrounded by coffee-ground vomit. Although haemodynamically stable on admission, he rapidly deteriorated as his lactic acid rose. An initial arterial blood gas revealed a pH of 7.27 and lactate of 18mmol/L (peaking at 21mmol/L).

Conclusions

A high degree of clinical suspicion for haematological malignancy should be held when presented with a patient with lactic acidosis in clinical practice, even without evidence of poor oxygenation or another cause. Treatment with emergency chemotherapy, in lieu of a definitive diagnosis, was rapidly successful at lowering lactate levels within 8 hours. This may suggest a causal and perhaps direct relationship between lactic acid production and the presence of leukemic cells. Veno-venous haemofiltration had no apparent effect on reducing the lactic acidosis and therefore its benefit is questioned in this setting, especially at the cost of delaying chemotherapy. In the face of a life-threatening lactic acidosis, pragmatic clinical judgement alone may justify the rapid initiation of chemotherapy.

Unexpected primary osseous lymphoma as the cause of lactic acidosis in a patient suffering from pancreatitis

A 45-year-old man was admitted due to acute pancreatitis. A severe lactic acidosis was found. Following active therapy, the signs and symptoms from pancreatitis was improved, but acidosis was exacerbated. FDG PET/CT images were acquired to investigate the etiology of lactic acidosis and/or other unknown pathology. The images showed widespread abnormal FDG activity in the bone marrows throughout the body, suggestive of hematologic malignancy, which was confirmed as primary osseous non-Hodgkin lymphoma following a histopathological examination of the bone marrow. Chemotherapy against lymphoma was initiated and status of the lactic acidosis was rapidly corrected.

Severe lactic acidosis in a patient with B-cell lymphoma: a case report and review of the literature

Lactic acidosis is commonly observed in clinical situations such as shock and sepsis, as a result of tissue hypoperfusion and hypoxia. Lymphoma and leukemia are among other clinical situations where lactic acidosis has been reported. We present a case of a 59-year-old female with lactic acidosis who was found to have aggressive B-cell lymphoma. There have been 29 cases of lymphoma induced lactic acidosis reported thus far; however all reported cases have abnormal vital signs or concomitant medical conditions that may lead to lactic acidosis. The pathogenesis of malignancy-induced lactic acidosis is not well understood; however associated factors include increased glycolysis, increased lactate production by cancer cells, and decreased hepatic clearance of lactate. When it occurs, lactic acidosis is a poor prognostic sign in these patients. Prompt diagnosis and treatment of underlying lymphoma or leukemia remains the only way to achieve complete resolution of lactic acidosis in these patients.

Lactic acidosis and hypoglycemia with ALL relapse following engrafted bone marrow transplant

Lactic acidosis together with hypoglycemia in the face of hematologic malignancy is a grave development. A 7-year-old male with pre-B-cell ALL following hematopoietic cell transplant was admitted to our hospital in his second relapse. On hospital days 4 and 5, he developed refractory hypoglycemia, lactic acidosis, central respiratory failure, and acute renal failure. Bicarbonate infusion, B vitamins, and hemodialysis were not effective. Care was withdrawn on hospital day 9. Further understanding of the mechanisms that cause the combined onset of lactic acidosis and hypoglycemia will help clinicians in implementing timely therapies that may reduce mortality.

A leukemic change as an initial manifestation of the common variant type of ALK-positive anaplastic large cell lymphoma in a patient with lung adenocarcinoma

We report an 81-year-old man who had leukemic presentation of ALK-positive anaplastic large cell lymphoma (ALCL) as an initial manifestation. He had been well after chemotherapy and irradiation for the advanced lung adenocarcinoma, but suddenly suffered from severe lactic acidosis and hypotension. The peripheral blood smear and bone marrow aspiration revealed the infiltration of atypical large cells with horseshoe-shaped or lobulated nuclei. The detection of CD30 expression and the t (2;5) (p23;q35) translocation in these cells was confirmatory of a diagnosis of common variant ALK-positive ALCL in a leukemic phase. He deteriorated rapidly and died before administration of the chemotherapy. An adequate, prompt diagnosis is necessary for this rare disease status in oncologic emergency to improve the disease management.