COMMON LAB ABNORMALITIES FROM AN UNCOMMON SOURCE: A CASE REPORT

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Diffuse large B cell lymphoma (DLBCL) is an aggressive form of non-Hodgkin lymphoma (NHL) of B cells. Although its genesis is typically in the lymph nodes, it can form in extra-nodal sites such as the gastrointestinal tract and central nervous system. This disease usually presents with lymphadenopathy, fever, weight loss or fatigue. On occasion, this condition can also present with refractory hypoglycemia and lactic acidosis. CASE PRESENTATION: This is a case of a 66 year old female with a history of diabetes and DLBCL successfully treated with rituximab who presented with lethargy. Initial labs were remarkable for severe hypoglycemia and lactic acidosis of unknown origin. The patient was subsequently intubated, started on broad spectrum antibiotics and admitted to the intensive care unit. Her hypoglycemia was suspected to be secondary to glimepiride toxicity in the setting of acute renal failure and she was started on octreotide. However, her hypoglycemia was refractory to treatment. Her lactic acid continued to rise despite adequate fluid resuscitation and vasopressor support. Exploratory laparotomy was performed out of concern for mesenteric ischemia and revealed a necrotic appendix that was subsequently removed. Surgical pathology was consistent with recurrent DLBCL. Salvage chemotherapy was attempted with improvement in hypoglycemia and lactic acidosis; however, the patient ultimately succumbed to her illness several days later. DISCUSSION: DLBCL typically presents with nodal symptoms, fever, or night sweats. However, there have been a few documented cases of patients initially presenting with refractory hypoglycemia and worsening lactic acidosis despite adequate fluid resuscitation and vasopressor support. These findings presenting as a single entity has been associated with the Warburg effect, meaning that the high rate of replication and glycolysis in cancer cells ultimately leads to increased lactic acid formation and glucose consumption. In the setting of NHL, this is a rare complication and is associated with rapid disease progression and poor outcomes. CONCLUSIONS: This case is an example of an atypical etiology of common lab abnormalities. The patient had both hypoglycemia and an elevated lactate that were unresponsive to traditional therapies. Although a component of the patient's refractory hypoglycemia could have been due to glimepiride, its improvement with chemotherapy is consistent with it being related to DLBCL. In patients with refractory hypoglycemia and rising lactic acidosis with a history of malignancy, relapse should be considered as part of the differential diagnosis. Reference #1: Tanios G, Aranguren IM, Goldstein JS, Patel CB. Diffuse large B-cell lymphoma: A metabolic disorder? The American journal of case reports. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3859735/. Published December 2, 2013. Accessed March 13, 2019. Reference #2: Vander Heiden MG, Cantley LC, Thompson CB. Understanding the Warburg effect: the metabolic requirements of cell proliferation. Science (New York, N.Y.). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2849637/. Published May 22, 2009. Accessed March 13, 2019. DISCLOSURES: No relevant relationships by Soorya Aggarwal, source=Web Response No relevant relationships by Robert Decker, source=Web Response No relevant relationships by Breanna Goldner, source=Web Response No relevant relationships by Alaynna Kears, source=Web Response