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Lactic Acidosis In Childhood Leukemia And Lymphoma: A Case Report And Review Of The Literature

Lactic Acidosis In Childhood Leukemia And Lymphoma: A Case Report And Review Of The Literature. Quan Zhao, M.D. Pediatric Resident. Case Report. 14 yo male 3-week h/o sore throat, myalgias, odynophagia, and neck swelling. Treated with clindamycin and prednisone for 3 days

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Lactic Acidosis In Childhood Leukemia And Lymphoma: A Case Report And Review Of The Literature

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  1. Lactic Acidosis In Childhood Leukemia And Lymphoma: A Case Report And Review Of The Literature Quan Zhao, M.D. Pediatric Resident

  2. Case Report • 14 yo male • 3-week h/o sore throat, myalgias, odynophagia, and neck swelling. • Treated with clindamycin and prednisone for 3 days • The symptoms returned after cessation of the steroids. • CT: • mediastinal mass, • free pelvic fluid • thickened gallbladder wall.

  3. Case Report • T 39.4oC, HR 114, BP 116/81. • PE: diaphoretic and mottled, multiple enlarged cervical lymph nodes, abdomen was diffusely tender , hepatosplenomegaly. • CBC: WBC 16,800, P 31%, B 21%, L 33%, M 11%, Met Hb 13 plt 39,000 • CMP: Na 129, K 4.3 , Cl 98 , Bicar 14 , BUN 10, Cr 0.78, Glu 59, anion 19, Cal 8.8, Mag 1.9, phos 1.9, uric acid 3.7 , alk 290, total bili 5.4 , conj bili 4.6, AST 242, ALT 208, LDH 570, CRP 1.4. • ABG: pH 7.19, PCO2 29 , PO2 307 , bicarb 12.8, BD 15.7

  4. Case Report • day 2: • abd severely distended with elevated intra-abdominal pressure, exploratory laparotomy, no evidence of abdominal compartment syndrome. • biltateral chest tube because pleural effusion. • anuric and refractory lactic acidemia. • initial lactic acid was 8.2. bicarbonate infusion failed to correct acidosis. • hemodialysis started. successful buffer for acidosis. • lactic acid continued to rise and peaked at 33, the maximum detectable levels. • severe hypoglycemia, required continuous glucose infusion.

  5. Case Report • A bone marrow biopsy revealed T-cell leukemia. • emergent radiation therapy to relieve SVC syndrome. • day 3: • Chemotherapy was started with VCR, DNR, Pred. lactic acid levels decreased rapidly in 24 hours and returned to normal range within 4 days. • improved mental status, and required less hemodynamic and respiratory support. • day 12: • total bilirubin 16, direct 10. The patient had devitalization progressing towards dry gangrene of all his digits including his fingers, thumbs and toes. Chemotherapy was discontinued due to concern for a serious infection and hepatitis.

  6. Case Report • day 13: • erythematous, maculopapular rash all over his body, which was determined to be leukemic cell infiltration on skin biopsy. • day 14: • his condition worsened. His lactate levels again rose continuously despite reinstitution of aggressive hemodialysis. The patient also received thiamine in an effort to correct his lactic acid level. • day 16: • Chemotherapy was resumed, but his clinical status severely deteriorated and he became hypotensive. Aggressive resuscitation was continued; however, his clinical status did not improve and he died on day 17. No autopsy was obtained.

  7. Case Report

  8. Literature Review • 16 cases of LA with childhood leukemia and lymphoma • 11 leukemia, • 4 lymphoma, • 1 case was B-cell leukemia/lymphoma. • 9 cases developed LA at the time of diagnosis, • 7 cases during relapses. • 7 cases had recorded hypoglycemia. • 10 cases had liver involvement. • 9 cases had renal involvement.

  9. Literature Review • 11 cases with LA improved/resolved. • 2 thiamine deficiency associated with TPN, • both resolved with thiamine. • 1 HIV/Burkett’s lymphoma improved with glucagons and sodium acetate infusion without chemotherapy. • 8 cases with LA improved/resolved were all under chemotherapy • 5 received thiamine administration. • 2 case had thiamine deficiency associated with TPN, • 3 cases, LA were not altered with vitamin B1 IV administration.

  10. Literature Review • 15 bicarbonate infusion. All no response to bicarbonate infusion alone, even could correct the academia in some cases. • 4 dialysis. • 1 without chemotherapy, the LA did not improve. • 3 with thermotherapy was resolved/improved. • 12 (75%) died.

  11. Summary • Refractory lactic acidosis is an extremely ominous sign • This is an an oncological emergency • The pathogenesis of the lactic acidosis is unclear • Physicians should be aware of this condition and make diagnosis quickly. Lactate and glucose level should be checked. • Only chemotherapy so far has been effective in correcting the LA. • Early implementation of chemotherapy, dialysis with bicarbonate infusion, and supplement of thiamine should be the worthwhile practice.

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