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BRIEF CASE
resulted in an exacerbation of his CHF, and he was successfully
diuresed. Treatment with prednisone for presumed COPD exacerbation was also initiated, and he was transferred to the medicine service on hospital day 9 for further evaluation of persistent
lactic acidosis (LA).
Subsequently available ascites cytology revealed a highgrade lymphoma, and rasburicase was started on hospital day
15 for tumor lysis syndrome (TLS). On hospital day 17, the
patient was transferred to the ICU because of hypotension and
altered mental status. He transiently improved with intubation, fluids, hemodialysis, vasopressors, broad-spectrum
antibiotics, and stress-dose steroids, but his hemodynamic
instability persisted. After ongoing discussion with the
patient’s family, the decision was made to pursue comfort
measures, given his poor prognosis. He died 24 days after presentation. His lab values are below.
Laboratory
values
Hospital
day 1
Hospital
day 4
Hospital
day 11
Hospital
day 15
Hospital
day 17
Potassium, 5.1
mmol/L
5.6
5.6
5.2
5.1
Calcium,
mg/dL
8.6
10.4
9
9.3
Phosphorus, 5.7
mg/dL
5.8
9.9
4.6
4.6
Uric acid,
mg/dL
NA
NA
25.5
26.4
4.5
Creatinine,
mg/dL
1.9
2.36
1.6
1.9
2.5
Lactate,
mmol/L
7.8
6.0
11.1
6.9
9.2
Lactate
dehydrogenase,
U/L
NA
1,462
1,026
NA
1,263
11
Tumor burden, proliferative rate,
and treatment sensitivity are
all risk factors for [tumor lysis
syndrome]. Lactate dehydrogenase
is a marker for high rate of
proliferation and of [tumor
lysis syndrome].
The patient’s splenic abnormality most likely represents primary splenic involvement with Burkitt’s lymphoma. In a review
of 845 cases of atraumatic splenic rupture, the most common
types were neoplastic, infectious, inflammatory, and drug-related.
Additionally, the patient’s elevated lactic acid reflected his poor
prognosis since lactic acidosis is a rare complication of hematologic malignancies and appears to be an indicator of
reduced survival.
PEARLS
■ In patients with known or suspected malignancy and
risk factors for the development of tumor lysis syndrome, it is important to implement preventive measures to mitigate harm.
■ Unexplained lactic acidosis can be a manifestation of
hematologic malignancy, either alone or in combination
with TLS, and portends a poor prognosis in such cases.
THE DIAGNOSIS
This case describes a fulminant presentation of sporadic
Burkitt’s lymphoma, a highly aggressive type of non-Hodgkin’s
lymphoma. It involves translocations in the MYC oncogene
that result in a proliferation index of nearly 100%. There is a
high propensity for TLS, which can be precipitated by corticosteroids. This reflects the extreme chemosensitivity and highgrade nature of Burkitt’s lymphoma. Tumor lysis syndrome
arises from rapid cellular proliferation and turnover causing
release of intracellular metabolites. Resultant hyperkalemia,
hyperphosphatemia, hypocalcemia, and hyperuricemia can
yield renal failure, cardiac arrhythmias, seizures, or death.
Tumor burden, proliferative rate, and treatment sensitivity are
all risk factors for TLS. Lactate dehydrogenase is a marker for
high rate of proliferation and of TLS. High-grade lymphomas,
acute leukemias, and rapidly proliferating tumors are traditionally associated with the greatest risk. Renal failure, volume
depletion, hypotension, and acidic urine also increase risk by
reducing clearance of metabolites.
CASE 5: LEPROMATOUS
LEPROSY
By Jack Chase, MD
THE PATIENT
A 34-year-old man was sent by his primary care clinician to
the San Francisco General Hospital dermatology clinic for a
progressive rash. The patient, originally from the Philippines,
had developed a puffy, darkened area of skin near his right
sideburn followed by a similar lesion on his left forearm
approximately 1 year before immigrating to the United States.
After settling in the San Francisco Bay Area, he developed
additional generalized lesions over his trunk, arms and legs.
He reported no systemic symptoms. He lived with his wife and
reported no illicit substance use, and his only medical history
was a work-related laceration repaired with skin sutures 10
years ago.
ACPHOSPITALIST January 2014 19