SHM Converge Scientific Abstract ePoster Gallery-From Dental Chair to Critical Care: A Malignant Cause of Refractory Lactic Acidosis

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This case describes a 57-year-old woman with a prior history of stage I breast cancer who presented to the emergency department with severe left mandibular pain, facial swelling, night sweats, fatigue, dyspnea, and recent weight loss. She was febrile, tachycardic, and hypotensive on arrival, and initial evaluation showed anemia, electrolyte abnormalities, elevated bilirubin and LDH, and imaging findings concerning for mandibular osteomyelitis and bilateral perirenal nodularity.<br /><br />Despite treatment, her condition worsened rapidly. Her lactate climbed to 16 mmol/L even without ongoing shock, and she developed hypercalcemia, hypoglycemia, worsening liver tests, extremely high LDH, and coagulopathy with concern for DIC. Biopsy of the perirenal mass revealed malignant cells, and flow cytometry confirmed a clonal B-cell population consistent with aggressive B-cell lymphoma.<br /><br />The report highlights type B lactic acidosis, a rare but often fatal complication of malignancy. Unlike type A lactic acidosis, it occurs without tissue hypoperfusion and is thought to result from the Warburg effect, impaired hepatic clearance, and cytokine-driven mitochondrial dysfunction. In this patient, the refractory lactic acidosis was a key clue to an underlying aggressive lymphoma.<br /><br />Despite escalation to intubation, continuous renal replacement therapy, and vasopressors, she progressed to multiorgan failure. After goals-of-care discussions, comfort measures were chosen, and she died shortly after compassionate extubation.<br /><br />The main lesson is to maintain a broad differential for persistent lactic acidosis, especially when lactate remains high despite adequate perfusion. Clinicians should avoid anchoring on sepsis alone and consider occult malignancy, particularly lymphoma, when lactic acidosis is refractory and accompanied by cytopenias, elevated LDH, and systemic symptoms.

Asset Subtitle

Tanzeela Shuja

Meta Tag

Author List Ekow Pinkrah, Izna Hadi, Lavanya Nagarajan, Maryna Shayuk, Mevlut Ozmen, Mina Fattah, Oluwafunmbi Fatunmbi, Preksha Shah, Siad Adam, Tanzeela Shuja, Vishal Garimella, Yuliana Kvasha

Category Clinical Vignettes

Concept Type B Lactic Acidosis

Concept Malignancy

Concept Aggressive B-cell Lymphoma

Concept Type A Lactic Acidosis

Concept Lactate

Distinguished Non-Finalist

Presenter Organization Northwestern McHenry Hospital

Presenting Author Tanzeela Shuja

Track Adult

Keywords

type B lactic acidosis

aggressive B-cell lymphoma

refractory lactic acidosis

Warburg effect

mandibular osteomyelitis

perirenal nodularity

elevated LDH

multiorgan failure

cytopenias

occult malignancy

Type B Lactic Acidosis

Malignancy

Aggressive B-cell Lymphoma

Type A Lactic Acidosis

Lactate