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
 The symptoms returned after cessation of the steroids.
 CT:
 mediastinal mass,
 free pelvic fluid
 thickened gallbladder wall.
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
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.
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.
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.
Case Report
35
30
mmol/L
25
20
15
10
5
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17
Day
Lactate
Bicabonate
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.
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.
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.
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.