Critical Care: Student/Resident Case Report Poster - Critical Care II |

Type B Lactic Acidosis as a Severe Metabolic Complication of Waldenström Macroglobulinemia Mistaken for Sepsis FREE TO VIEW

Chung Sang Tse, MD; Kannan Ramar, MBBS
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Mayo Clinic, Rochester, MN

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):394A. doi:10.1016/j.chest.2016.08.407
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Waldenström macroglobulinemia is a rare, slow-growing hematologic malignancy with bone marrow lymphoplasmacytic lymphoma and circulating monoclonal IgM. We present the first reported case of type B lactic acidosis in Waldenström macroglobulinemia, whose initial presentation resembled septic shock.

CASE PRESENTATION: A 74-year old man with a five-year history of Waldenström’s macroglobulinemia was admitted to our intensive care unit (ICU) with melena 17 days after fludarabine initiation, his fourth chemotherapy regimen. He was hemodynamically stable, afebrile, and had no other focal complaints. Pertinent laboratory data showed pancytopenia with lactate of 11.7 mmol/L (normal 0.6-2.3 mmol/L), anion gap 33.4 mg/dL, arterial pH 7.40, pCO2 20 mmHg, IgM 2030 mg/dL (normal 50-300 mg/dL), and LDH 2350 U/L (normal 122-222 U/L). Initially suspecting septic shock due to his immunosuppressed state and lactic acidosis, broad spectrum antibiotics were initiated with vancomycin, piperacillin-tazobactam, and caspofungin. Blood (bacterial and fungal) and urine cultures returned negative as part of an extensive workup for infection. Computerized Tomography of his abdomen showed no signs of ischemic bowel. Over the next two days, lactate rose to 17.7 mmol/L and pH downtrended to 7.06 (Fig 1). Non-fluid responsive hypotension developed, prompting initiation of vasopressor support. He was intubated due to respiratory distress. Comfort care was initiated on Hospital Day 3, and the patient expired the following day.

DISCUSSION: Patients with hematologic malignancies may present to the ICU with severe and progressive lactic acidosis without signs of infection, hypoxia, ischemia, ketosis, or severe liver dysfunction. Hematologic-malignancy associated type B (non-ischemic) lactic acidosis has been reported with high fatality in myeloma, leukemia, and lymphoma, where rapid clinical deterioration led to death within a few days of presentation [1-3]. Proposed mechanisms for elevated lactate production include anaerobic glycolysis driven by low oxygen levels within dense clusters of tumor cells, and aerobic glycolysis with neoplastic cells shifting primarily to lactic acid fermentation (fast glycolysis), known as the “Warburg” effect [2], rather than normal pyruvate oxidation (slow glycolysis). Clinicians should be aware of this phenomenon particularly in patients with hematologic malignancies presenting to the ICU as they can be mistakenly treated for septic shock.

CONCLUSIONS: Though type B lactic acidosis is reported in other types of hematologic malignancies, this is the first case reported in Waldenström macroglobulinemia. Suspicion of type B lactic acidosis should be raised in patients with hematologic malignancy who present with elevated lactate and acidemia in the absence of signs of ischemia or sepsis.

Reference #1: PMID 17632264

Reference #2: PMID 23478115

Reference #3: PMID 12613530

DISCLOSURE: The following authors have nothing to disclose: Chung Sang Tse, Kannan Ramar

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