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Permtawee K, Tengsujaritkul M, Choed-Amphai C, Chanthong S, Mankhemthong K, Sathitsamitphong L, Natesirinilkul R, Charoenkwan P. Warburg effect mimicking inborn errors of metabolism in childhood hematologic malignancies: A case-based systematic review. World J Clin Pediatr 2023; 12:350-358. [PMID: 38178939 PMCID: PMC10762596 DOI: 10.5409/wjcp.v12.i5.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 09/09/2023] [Accepted: 09/26/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Type B lactic acidosis and hypoglycemia can occur in various pediatric conditions. In young children with a history of fasting preceding these metabolic derangements, inborn errors of metabolism should be primarily considered. However, the Warburg effect, a rare metabolic complication, can also manifest in children with hematologic malignancies. Only a few reports of this condition in children have been published in the literature. AIM To identify the clinical course, treatment strategies, and outcomes of childhood hematologic malignancies with type B lactic acidosis. METHODS We performed a comprehensive search of the PubMed, Scopus, and Cochrane databases without any time restriction but limited to English language articles. The databases were last accessed on July 1st, 2023. RESULTS A total of 20 publications were included in the analysis, all of which were case reports or case series. No higher quality evidence was available. Among children with hematologic malignancies and Warburg effect, there were 14 cases of acute lymphoblastic leukemia and 6 cases of non-Hodgkin's lymphoma including our illustrative case. Lactic acidosis occurred in 55% of newly diagnosed cases and 45% of relapsed cases. The mean age was 10.3 ± 4.5 years, and 80% of cases were male. The mean serum lactate was 16.9 ± 12.6 mmol/L, and 43.8% of the cases had concomitant hypoglycemia. Lactic acidosis initially subsided in 80% of patients receiving chemotherapy compared to 60% in the contrast group. The mortality rate of newly diagnosed cases was 45.5%, while the relapsed cases represented a 100% mortality rate. All 8 patients reported before 2001 died from disease-related complications. However, patients described in reports published between 2003 and 2023 had a 54.5% rate of complete remission. CONCLUSION This complication has historically led to fatal outcome; however, patients who received chemotherapy showed a more favorable response. Therefore, it is crucial to promptly initiate specific treatment in this context.
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Affiliation(s)
- Khanittha Permtawee
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Maliwan Tengsujaritkul
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Chane Choed-Amphai
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Supapitch Chanthong
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | | | - Lalita Sathitsamitphong
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Rungrote Natesirinilkul
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Pimlak Charoenkwan
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
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Yi HK, Yoo J, Kim SJ, Choi JY, Lee KH. Lymphoma total lesion glycolysis leads to hyperlactatemia and reduction of brain glucose utilization. Sci Rep 2022; 12:12639. [PMID: 35879392 PMCID: PMC9314436 DOI: 10.1038/s41598-022-16562-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 07/12/2022] [Indexed: 11/09/2022] Open
Abstract
Clarifying the mechanism of lymphoma-associated hyperlactatemia could help identify patients at risk. Here, 129 non-Hodgkin's lymphoma patients suspected of blood lactate elevation underwent blood measurement and 18F-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) on the same day. Blood lactate elevation was mild (1.0-2.5 mmol/L) in 60, moderate (2.5-4.0 mmol/L) in 46, and severe (≥ 4.0 mmol/L) in 23 subjects. Subjects with severe lactate elevation had higher lymphoma stage, worse IPI risk, poorer ECOG performance, and higher tumor TLG. Furthermore, there was a linear correlation between blood lactate concentration and lymphoma TLG (Spearman's r = 0.367; P < 0.0001). Brain FDG uptake was low (SUVave < 4.0) in 81 patients that were older, had greater stage and IPI risk, worse ECOG performance, and higher blood lactate. Brain SUVave showed inverse correlation with blood lactate (Spearman's r = - 0.564; P < 0.0001) and lymphoma TLG (Spearman's r = - 0.252; P = 0.0066), as well as with stage, ECOG score, and IPI risk. Multivariable regression analysis confirmed increased blood lactate and lymphoma TLG as significant explanatory variables for reduced brain SUVave (both P < 0.0001). Hence, blood lactate elevation in lymphoma patients is the result of glycolytic tumor burden. Since brain cells prefer lactate over glucose as energy source when blood lactate level is increased, this causes proportional reductions of brain FDG uptake. FDG PET/CT can therefore identify high glycolytic lymphoma burden at risk of hyperlactatemia and may provide estimates of its severity by reductions in brain uptake.
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Affiliation(s)
- Hyun Kyung Yi
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 16351, Republic of Korea
| | - Jang Yoo
- Department of Nuclear Medicine, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Seok Jin Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joon Young Choi
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 16351, Republic of Korea
| | - Kyung-Han Lee
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 16351, Republic of Korea.
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Hamada T, Kaku T, Mitsu S, Morita Y, Ohno N, Yamaguchi H. Lactic Acidosis and Hypoglycemia in a Patient with Gastric Diffuse Large B-Cell Lymphoma due to the Warburg Effect. Case Rep Oncol 2020; 13:1047-1052. [PMID: 33082747 PMCID: PMC7548916 DOI: 10.1159/000509510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 11/19/2022] Open
Abstract
Lactic acidosis is pathophysiologically classified into type A and type B. The latter is a rare but potentially life-threatening emergency, mainly described in hematological malignancies. The association between Type B lactic acidosis and malignancy is known as the Warburg effect. Patients with the Warburg effect have a very poor prognosis. Herein, we report a case of gastric diffuse large B-cell lymphoma (DLBCL) with severe lactic acidosis and hypoglycemia owing to the Warburg effect that were effectively treated by prompt introduction of chemotherapy. A 73-year-old woman with a 2-month history of abdominal distension was referred to us for suspected peritoneal cancer. Pathological examination revealed gastric DLBCL with peritoneal dissemination. After hospitalization, blood test results revealed prolonged hypoglycemia, with a blood sugar level of 50-70 mg/dL; severe lactic acidosis with pH 7.166; lactate level 12.7 mmol/L; and base excess -21.0 mEq/L, despite continuous administration of glucose and sodium bicarbonate. The cause of lactic acidosis and/or hypoglycemia was considered to be the Warburg effect. We initiated a 50% reduced-dose CHOP (cyclophosphamide, vincristine, doxorubicin, prednisolone) chemotherapy regimen without rituximab until information on the CD20-positive status was available. During chemotherapy, acidosis, hypoglycemia, and impaired consciousness promptly improved. If lactic acidosis or hypoglycemia is present in patients with malignant tumors, it is important to suspect the possibility of the Warburg effect and to introduce cancer treatment as soon as possible.
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Affiliation(s)
- Takafumi Hamada
- Department of General Internal Medicine, Kagoshima Prefectural Oshima Hospital, Kagoshima, Japan
| | - Toshinari Kaku
- Department of General Internal Medicine, Kagoshima Prefectural Oshima Hospital, Kagoshima, Japan
| | - Sumitaka Mitsu
- Department of General Internal Medicine, Kagoshima Prefectural Oshima Hospital, Kagoshima, Japan
| | - Yoshinori Morita
- Department of General Internal Medicine, Kagoshima Prefectural Oshima Hospital, Kagoshima, Japan
| | - Nobuhito Ohno
- Department of Hematology, Ikeda Hospital, Kagoshima, Japan
| | - Hironori Yamaguchi
- Department of Medical Oncology, Jichi Medical University Hospital, Tochigi, Japan
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Brault C, Zerbib Y, Delette C, Marc J, Gruson B, Marolleau JP, Maizel J. The Warburg Effect as a Type B Lactic Acidosis in a Patient With Acute Myeloid Leukemia: A Diagnostic Challenge for Clinicians. Front Oncol 2018; 8:232. [PMID: 29974036 PMCID: PMC6019439 DOI: 10.3389/fonc.2018.00232] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 06/06/2018] [Indexed: 12/25/2022] Open
Abstract
Introduction The Warburg effect (WE) is an uncommon cause of type B lactic acidosis (LA) due to a deregulation of carbohydrate metabolism in neoplastic cells where lactic fermentation predominates over oxidative phosphorylation regardless of the oxygen level. Case presentation We report the case of a 57-year-old man presenting with concomitant acute myeloid leukemia and type B LA with asymptomatic hypoglycemia. We did not find arguments for a septic state, liver dysfunction, or acute mesenteric ischemia. The WE was suspected, and chemotherapy was immediately undertaken. We observed a rapid and sustained decrease in lactate level and normalization of blood glucose. Unfortunately, we noted a relapse of acute leukemia associated with WE soon after treatment initiation and the patient died in the Intensive Care unit. Discussion Some patients may present complications directly related to an underlying hematological malignancy. The WE is one of these complications and should be suspected in patients with both hypoglycemia and LA. We propose a checklist in order to help clinicians manage this life-threatening complication. Before considering WE, clinicians should eliminate diagnoses such as septic shock or mesenteric ischemia, which require urgent and specific management. Conclusion The diagnosis of WE can be challenging for clinicians in the Hematology department and the Intensive Care unit. Prompt diagnosis and rapid, adapted chemotherapy initiation may benefit patient survival.
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Affiliation(s)
- Clément Brault
- Réanimation Médicale, CHU Amiens-Picardie, Amiens, France
| | - Yoann Zerbib
- Réanimation Médicale, CHU Amiens-Picardie, Amiens, France
| | | | - Julien Marc
- Réanimation Médicale, CHU Amiens-Picardie, Amiens, France
| | | | | | - Julien Maizel
- Réanimation Médicale, CHU Amiens-Picardie, Amiens, France
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Sayyed AH, Aleem A, Al-Katari MS, Algahtani F, Aljerian K, Aleem TA, Alsaleh K. Acute Lymphoblastic Leukemia Presenting with Liver Infiltration and Severe Lactic Acidosis. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:453-457. [PMID: 29662049 PMCID: PMC5923601 DOI: 10.12659/ajcr.907383] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Type-B lactic acidosis is a rare complication of solid tumors and hematological malignancies. It occurs secondary to Warburg effect, when glucose metabolism in cancer cells switches from the oxidative pathway to the glycolytic pathway. Malignant lactic acidosis is a life-threatening condition if not promptly diagnosed and treated urgently. CASE REPORT We report the case of a 58-year-old male patient who presented with severe chest pain, dyspnea, systemic symptoms, leukopenia, normocytic anemia, and severe lactic acidosis. He was admitted with a possible diagnosis of acute pericarditis and lactic acidosis. Sodium bicarbonate replacement did not improve the lactic acidosis. Liver biopsy was performed because of persistently elevated alkaline phosphatase and gamma-glutamyl transferase; the biopsy showed atypical lymphoblasts and bone marrow biopsy confirmed the diagnosis of precursor B acute lymphoblastic leukemia. Lactic acidosis normalized after initiation of chemotherapy. CONCLUSIONS Cancer, particularly hematological malignancy, should be considered as an etiology and differential diagnosis of type-B lactic acidosis. Prompt recognition and urgent initiation of specific therapy to control the underlying malignancy are critical to manage this serious metabolic complication.
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Affiliation(s)
- Ayman Hassan Sayyed
- Department of Medicine, Division of Hematology/Oncology, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Aamer Aleem
- Department of Medicine, Division of Hematology/Oncology, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Mohammad Sami Al-Katari
- Department of Medicine, Division of Hematology/Oncology, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Fatma Algahtani
- Division of Hematopathology, Department of Pathology, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Khaldoon Aljerian
- Division of Histopathology and Forensic Medicine, Department of Pathology, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Talha A Aleem
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Khalid Alsaleh
- Department of Medicine, Division of Hematology/Oncology, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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