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Abstract: PUB128

Battling Warburg: Type B Lactic Acidosis in a Patient with Diffuse Large B-Cell Lymphoma

Session Information

Category: Trainee Case Report

  • 902 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

  • Regina, Stephen P., Methodist Health System, Dallas, Texas, United States
  • Collazo-Maldonado, Roberto L., Dallas Nephrology Associates, Dallas, Texas, United States

Group or Team Name

  • Methodist Health System
Introduction

The Warburg effect is a rare paraneoplastic syndrome seen in patients with hematologic malignancy. The metabolism of cancerous cells converts to aerobic glycolysis and results in type B lactic acidosis.

Case Description

The patient is a 62-year-old man with diffuse large B-cell lymphoma and prior hemophagocytic syndrome (HS) diagnosed 6 months prior, on chemotherapy. He presented with several weeks of fever and respiratory symptoms. Clinical exam and diagnostics did not reveal a source of sepsis. Chest radiography and CT chest were without infiltrates. COVID-19 PCR was negative. Labs- WBC 1,500 /mm3, Hemoglobin 8.8 g/dL, Platelets 63,000 /mm3, creatinine 1.1 mg/dL, lactate 2.6 mmol/L, ferritin 417 ng/mL, serum triglycerides 349 mg/dL. Patient was placed on vancomycin and cefepime and volume expanded, but continued febrile with persistent lactic acidosis. Abdominal CT revealed splenomegaly with focal hypodensities, mild descending and sigmoid diverticulosis without diverticulitis. CT mesenteric angiography revealed moderate narrowing of celiac artery and severe narrowing of the inferior mesenteric artery origin. For suspected ischemic colitis, the patient was taken emergently for exploratory laparotomy, but findings did not support ischemia. Creatinine trended up to 2.0 mg/dL with increasing lactate of 11 mmol/L, bicarbonate 13 mmol/L, and serum pH of 7.0. At this point, without septic or ischemic processes identified, the lactate production was attributed to DLBCL, and not HS as ferritin was not substantially elevated. CRRT was initiated for anuric AKI. Lactate continued to trend up to 21.7 mmol/L with bicarbonate 6 mmol/L. Family discussions were held, and the patient was transitioned to palliative care.

Discussion

Type B lactic acidosis should be considered in the differential diagnosis in patients with increased anion gap metabolic acidosis and malignancy. One rare and potentially fatal Type B lactic acidosis is due to the Warburg effect, a rare and potentially lethal paraneoplastic syndrome of hematologic malignancies.