(1676) The Warburg Effect: A Case of Severe Refractory Lactic Acidosis

Introduction: Type B lactic acidosis has been associated with hematologic malignancies and is an oncologic emergency due to the high mortality rate (>90%). The Warburg effect is a phenomenon where tumor cells consume large amounts of glucose and preferentially convert it into lactic acid (LA) through anaerobic metabolism.

Description: A 74-year-old woman with a history of non-Hodgkin’s lymphoma in remission, colorectal adenocarcinoma status-post hemicolectomy, and alcohol use presented with 4 weeks of nausea, vomiting, diarrhea, abdominal pain, and oliguria. Initial vitals were notable for fluid responsive hypotension and hypoxia requiring 2 liters oxygen. Diagnostic workup showed acute kidney injury, glucose 54 mg/dL, bicarbonate 8 mmol/L, anion gap 29, beta hydroxybutyrate 14.8 mmol/L, LA 10.2 mmol/L, venous blood gas pH 7.15, and signs of enteritis on imaging. She was admitted to the ICU for severe anion gap metabolic acidosis. She received fluids, sodium bicarbonate infusion, antibiotics, and continuous renal replacement therapy. She developed shock requiring vasopressors and stress dose steroids, and severe hypoglycemia necessitating intravenous dextrose. Infectious workup including a gastroenterology pathogen panel was unremarkable. There was no bowel ischemia found during an exploratory laparotomy. Toxic alcohol levels were negative, and LA did not improve with fomepizole. Despite treatment of other etiologies of LA, lactate increased to 30 mmol/L. CT chest revealed extensive mediastinal lymphadenopathy and complete blood count had 6.9% blasts supportive of malignancy. Although she was too unstable for a biopsy, a leukemia/lymphoma panel reported a CD5, CD19, and CD20 positive B-cell population. Her persistent lactic acidosis and hypoglycemia were deemed to be mainly driven by malignancy through the Warburg effect. Unfortunately, chemotherapy was not done due to the degree of acidosis and end organ failure. She was transitioned to comfort care measures and passed away with family present.

Discussion: Malignancy can cause type B lactic acidosis due to the Warburg effect. Chemotherapy is believed to offer the most benefit as it reduces the tumor burden. The mortality and prognosis are extremely poor; therefore, it is important to consider malignancy in cases of refractory lactic acidosis.