Malignant Lactic Acidosis in a Patient With Recurrent B Cell Lymphoma: A Case Report

Abstract

INTRODUCTION: Malignant lactic acidosis (MLA) is defined as pH of < 7.37 and a lactic acidosis level > 5mmol/L in association with malignant tumor. It is rare, and often found fatal, with 92% overall mortality. MLA is commonly associated with hematological malignancies, namely high-grade lymphoma and acute leukemia. Here we present a case of MLA associated with B cell lymphoma. CASE PRESENTATION: The patient, a 44 year old female with history of B cell lymphoma status post chemotherapy in 2007 and in remission, AIDS, not on HAART, and seizure disorder was admitted to our hospital with complaints of persistent nausea and vomiting for three weeks associated with abdominal pain and severe puritus. On admission, patient's vital signs were normal. Physical exam revealed temporal wasting, scleral icterus, and hepatomegaly six centimeters below the costal margin. Her abdomen was tender to palpation, with normal active bowel sounds. No peripheral edema or skin rash was noted. Initial blood work showed glucose of 32, BUN/Cr of 66 and 3.0, a pH of 7.2, anion gap of 19, and elevated liver function tests. Ultrasound of the abdomen revealed a thickened gallbladder with minimal pericholecystic fluid collection, and hepatomegaly with diffuse heterogeneity. Despite adequate management, patient remained hypoglycemic and metabolic acidosis worsened requiring transfer to the intensive care unit with intubation and mechanical ventilation. The patient developed lethargy, and worsened abdominal pain associated with distended abdomen and hypoactive bowel sounds. Lactic acid level was noted to peak at 25.6 and LDH was 968 (fig 1 and 2). Bowel ischemia was ruled out. Bicarbonate drip was given, and daily dialysis initiated without improvement. Recurrent lymphoma was suspected in view of persistent lactic academia, hypoglycemia, hepatomegaly and history of lymphoma. Multiple liver biopsies were done which showed diffuse large B cell lymphoma. Patient's critical illness precluded chemotherapy. The family requested hospice care in keeping with the patient's known wishes and patient succumbed on hospital day 19. DISCUSSION: This patient met the criteria for malignant lactic acidosis. She developed life threatening lactic acidosis in the setting of recurrent lymphoma. There were no signs of sepsis, and patient developed persistent hypoglycemia secondary to impaired gluconeogenesis from overwhelming liver failure and academia. CONCLUSIONS: Lactic acidosis associated with hematological malignancies is rare and often fatal. Recognition of signs and symptoms are imperative for prompt treatment, and could be live saving.