Pediatric Critical Care Attending Phoenix Childrens Hospital, United States
Introduction: Aerobic glycolysis or Warburg effect (WE) is a common cause of hyperlactatemia in adults with cancer, uncommonly seen in the pediatric population. We describe an unusual case of a teen with lactic acidosis as the presenting lab abnormality, who was later diagnosed with T cell acute lymphoblastic leukemia (ALL).
Description: A 17-year-old previously healthy male presents with five days of vomiting, poor PO intake, body aches and headaches. Initial diagnostic work up was significant for anion gap metabolic acidosis secondary to hyperlactatemia, transaminitis, elevated lipase, leukocytosis with a mild bandemia and CT scan abdomen concerning for changes consistent with infection. Due to worsening lactate on the pediatric floor despite fluid resuscitation and empiric antibiotics, the patient was transferred to the Pediatric ICU. The lactate level at the time was 13meq/l with pH 7.13. Inflammatory markers were low, blood and urine cultures were negative, warranting additional work up. The history was not suggestive of ingestion or toxin exposure, with a negative drug screen. The patient continued acetate containing fluids which improved the acidosis, however hyperlactatemia remained. The lactate level peaked at 18meq/l. At this point, the patient was felt to have an unknown etiology of lactic acidosis which was concerning for a life-threatening process. Literature review of case reports in adults suggestive of hyperlactatemia in malignancy prompted the decision to obtain a CT scan chest to look for a mass. CT scan showed a heterogeneous mass in the anterior mediastinum. Biopsy confirmed the diagnosis of T cell ALL. A follow up PET scan revealed metastatic disease throughout the head and neck. Chemotherapy was initiated, with marked improvement in lactate.
Discussion: In cancer cells glucose metabolism switches from oxidative pathway to glycolytic pathway causing accumulation of lactic acid, a phenomenon called Warburg effect (WE). Type B lactic acidosis is a rare presentation of hematological malignancies, especially in children. We encourage providers to investigate all patients with unexplained lactic acidosis for an ongoing oncologic emergency. Early diagnosis and administration of chemotherapy could mean towards patient survival.
