SESSION TITLE: Critical Care Student/Resident Case Report Posters I
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: Lactic acidosis is a common cause of an anion gap metabolic acidosis .The most frequent cause of lactic acidosis is impaired tissue perfusion, which is induced by various shock states causing tissue hypoxia. Rarely lymphomas and leukemias are known to cause lactic acidosis with hypoglycemia.
CASE PRESENTATION: A 52 year old male presented with a painless left groin swelling for 1 month duration. He denied any fever, loss of appetite or loss of weight. His past medical history was significant for HIV and was on treatment which he discontinued 1 month ago. Physical examination revealed enlarged left inguinal lymph node which was not tender. Other lymph nodes were not palpable and other system examination was unrevealing. His complete blood count was normal. Chemistry on admission showed an anion gap metabolic acidosis and further testing showed a significantly elevated lactic acid of 100.4 mg/dl (4-14.4) which was refractory to hydration. There was no evidence of sepsis or tissue hypoperfusion and the cause of lacticemia remained obscure. His CD4 count was 532 cell/ul with a viral load of 3885. During his hospital stay he had multiple episodes of non-fasting symptomatic hypoglycemia with lowest recorded glucose of 35mg/dl. The Differential diagnoses for type B lactic acidosis with hypoglycemia are islet cell tumor, adrenal insufficiency, and hypothyroidism. On further workup his Insulin, c-peptide, IGF-1, cortisol and TSH were normal. Although ARVT can cause lactic acidosis he was not on his medications for more than a month. A computed tomography of abdomen and pelvis showed 4.5 cm soft tissue mass at the left inguinal canal, bilateral groin and external iliac lymphadenopathy with large mesenteric lymphadenopathy. Patient had a left inguinal lymph node biopsy and it showed Burkitt's lymphoma. The patient was treated with RCHOP and his lactic acidosis and hypoglycemia resolved. However he succumbed to death after 6 months of diagnosis due to severe sepsis.
DISCUSSION: Lactic acidosis is commonly used in sepsis patients as a marker of severity of sepsis. Tissue hypoperfusion causes type A lactic acidosis whereas type B lactic acidosis occurs in the absence of systemic hypoperfusion. Malignancy induced lactic acidosis is a type B lactic acidosis and the mechanism is poorly understood. The “Warburg” effect in which neoplastic cells undergo aerobic glycolysis and produce lactate in excess amounts is one of the suggested pathogenesis. Lactic acidosis with refractory hypoglycemia is a rare finding in patients with Burkitt’s lymphoma with only two reported cases.
CONCLUSIONS: Lactic acidosis with hypoglycaemia is not always due to sepsis and consideration of underlying hematological malignancies will prompt for early diagnosis and initiation of treatment
Reference #1: Glasheen JJ1, Sorensen MD. Burkitt's lymphoma presenting with lactic acidosis and hypoglycemia - a case presentation. Leuk Lymphoma. 2005 Feb;46(2):281-3.
DISCLOSURE: The following authors have nothing to disclose: BHRADEEV SIVASAMBU, Meera Yogarajah
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