Abstract: FR-PO001

Serious Breakdown: A Rare Case of Spontaneous Tumor Lysis Syndrome from Aggressive Diffuse Large B-Cell Lymphoma

Session Information

Category: Nephrology Education

  • 1302 Fellows and Residents Case Reports

Authors

  • Regina, Stephen P, Methodist Health System, Dallas, Texas, United States
  • Strauss, Michael M., Methodist Dallas Medical Center, Dallas, Texas, United States
  • Collazo-Maldonado, Roberto L., Methodist Dallas Medical Center, Dallas, Texas, United States
Background

Introduction:
Tumor Lysis Syndrome (TLS) is a well-known cause of AKI classically seen in patients with high grade tumors treated with chemotherapy. However, spontaneous TLS is a rare presentation that has been described mostly in Diffuse High Grade B-cell Lymphomas.

Methods

Case Description:
This is a 67 year old woman with PMH of hypertension, hypothyroidism, and marginal cell lymphoma in remission after receiving treatment with rituximab 6 months prior to admission. She was admitted with non-oliguric Stage 3 AKI after her routine outpatient labs revealed an elevated serum creatinine of 3.5 mg/dL from a baseline of 1.0 mg/dL. She was normotensive, euvolemic, and physical exam revealed some wasting, but otherwise unremarkable. Her renal ultrasound showed bilateral hydronephrosis, but renal scan showed no obstruction. Labs were significant for WBC 20,600, Hgb 10.3 g/dL, platelets 470,000 /mm3.,, K 4.4 mmol/L, phosphate 4.8 mg/dL, calcium 10.8 mg/dL, uric acid 14.9 mg/dL, LDH 1,458 U/L, CPK was normal. A PET scan showed multiple enhancing pelvic lymph nodes as well as supra- and infra-diaphragmatic tracer uptake. Biopsy of left axillary lymph nodes revealed diffuse large B cell lymphoma (DLBCL). Patient was started on IVFs, rasburicase, and allopurinol. After tissue diagnosis was obtained, she initiated chemotherapy with R-CHOP for her aggressive DLBCL. With therapy, her creatinine improved to her baseline 1.01 mg/dL, uric acid level decreased to 1.2 mg/dL, and calcium normalized to 9.8 mg/dL by discharge.

Conclusion

Discussion:
While rare, spontaneous TLS occurring in the absence of current or prior chemotherapy have been reported mostly occurring in the context of B-cell lymphomas. Nephrologists should consider an occult malignancy in the differential diagnosis of a patient presenting with AKI and hyperuricemia. With high level of suspicion, early initiation of therapy may result in renal improvement and avoid potential complications which may increase morbidity and mortality.