Assistant Professor Texas Tech University Health Sciences Center El Paso, United States
Introduction: Hypertriglyceridemia (HTG) is a rare but known side effect of PEG-asparaginase (PEG-A) with associated pseudohyponatremia (PNa). We present the case of a 13-year-old male with Pre-B acute lymphoblastic leukemia (ALL) who developed severe HTG after PEG-A with PNa and unexpectedly pseudohyperkalemia (PK).
Description: Our patient received PEG-A and ten days later developed severe HTG (>5250) coupled with hyponatremia (nadir 128) and hyperkalemia (peak 8.8). Thus, he was admitted for cardiac monitoring and management due to high risk for thromboembolism among other complications. Initial labs were repeated several times to verify sodium (Na) and potassium (K) levels. While serum chemistry samples showed abnormally high K levels (7-8), whole blood gas samples yielded normal K levels (3-4). Lab studies also showed elevated bilirubin (5-6) and LDH (>2000) levels. Cardiac evaluation was unremarkable with normal EKG and telemetry. There were no focal neurologic deficits or evidence of pancreatitis. He was treated with dextrose and insulin (max 0.5U/kg/h) infusions, fenofibrate, and omega-3 supplements for HTG along with enoxaparin for venous thromboembolism prophylaxis. He did not warrant plasmapheresis. There was a rapid decline in triglyceride (TG) levels within first 24 hours ( < 1500) with concomitant normalization of Na and K levels on serum samples. Insulin was discontinued after 5 days, once TG levels dropped below 1000. He was discharged on fenofibrate with outpatient oncology follow up.
Discussion: There are very few reported pediatric cases of severe HTG after PEG-A administration, usually associated with acute pancreatitis and PNa. Our patient also had high serum K levels, which we believe to be PK due to methods of lab assessment in the setting of HTG. While routine serum chemistry samples require dilution with correction factors, blood gas samples use whole blood without dilution, and hence do not affect true solute levels. Our patient responded well to the therapy for HTG with insulin along with adjuncts of fenofibrate and omega-3s. He did not develop pancreatitis or thromboemboli. In this case, we highlight the importance of practitioners to be aware of possible complications, lab abnormalities, and management of severe HTG after PEG-A in pediatric oncology patients.
