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Not All Tumor Lysis Syndromes Are Due to Malignancy FREE TO VIEW

Dereddi Raja Reddy, MD; Pramod Guru, MBBS; Shihab Sugeir, MD; Vivek Iyer, MD
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Mayo Clinic, Rochester, MN

Chest. 2014;146(4_MeetingAbstracts):181A. doi:10.1378/chest.1992331
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SESSION TITLE: Infectious Disease Student/Resident Case Report Posters III

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Tumor lysis syndrome (TLS) is commonly seen in hematologic and solid tumor malignancies in association with chemotherapy and sometimes spontaneously. Infection associated TLS has never been described to our knowledge.

CASE PRESENTATION: A previously healthy young 29 year old male with h/o polysubstance abuse initially evaluated for intermittent chest pain, shortness of breath and ten pound weight loss in a span of one week. He was referred to our facility after detection of anterior mediastinal mass with significant lymphadenopathy on CT chest & abdomen. Physical examination at presentation was unremarkable. His laboratory examination showed hyperuricemia (13.9), hyperphosphatemia (9.8), hypocalcemia (7.2) along with elevated BUN (52) and Creatinine (4.0). Other remarkable findings were leucocytosis (39,000) with left shift, EKG evidence of pericarditis and tamponade physiology on echocardiogram. Toxicology screen, HIV and work up (endoscopy) for abnormalities of upper aerodigestive tract were negative. Initial suspicion for malignancy was excluded after multiple negative biopsies. Analysis of the pericardial fluid and the mediastinal abscess were positive for polymicrobial infection due to Actinomyces odontolyticus, Streptococcus group C and Parvimonas micra. Patient’s hospital course was complicated by multiorgan failure requiring life supporting therapies in the form of mechanical ventilation, inotropes, dialysis and antibiotics. Initially he underwent percutaneous pericardial fluid drainage followed by pericardial stripping and mediastinal washout via open thoracotomy. After 3 weeks of hospital stay and multiple antimicrobial therapies, patient recovered and was discharged home.

DISCUSSION: TLS is an oncologic emergency due to release of intracellular contents into the extracellular space leading to overwhelming homeostatic mechanisms1. TLS occurs most commonly following treatment of a malignancy; however, it can occur spontaneously2. While our patient fulfills the laboratory and clinical definition criteria for TLS and was treated with rasburicase, he does not have the risk factors for its development. To our knowledge, this is the first case of TLS associated with polymicrobial mediastinal abscess. The exact etiopathology in our patient is not clear, as we didn’t have any evidence to suggest recent toxic substance abuse, fall or seizure. Our best hypothesis is that he had a small esophageal perforation that allowed seeding of his mediastinal space and pericardium.

CONCLUSIONS: This case describes that TLS can be from an infectious etiology and not just malignancy or its associated therapies.

Reference #1: Tumor Lysis Syndrome F. Perry Wilson and Jeffrey S. Berns Clin J Am Soc Nephrol 7: 1730-1739, 2012.

Reference #2: Spontaneous tumour lysis syndrome Natasha Kekre MD, Bojana Djordjevic MD, Claire Touchie MD CMAJ 2012, 184(8)

DISCLOSURE: The following authors have nothing to disclose: Dereddi Raja Reddy, Pramod Guru, Shihab Sugeir, Vivek Iyer

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