A 58 year old man with a severe metabolic derangement on cancer therapy

1. Abnormalities:

Anaemia, thrombocytopaenia, macrocytosis with significant lymphocytosis consistent with T cell lymphoma and bone marrow failure

Severe hyperkalaemia

Normal CRP – Infection marker negative

Coagulation markers – No obvious DIC

Elevated uric acid, LDH, Potassium and Liver functions consistent with haemolysis

Hypocalcaemia – ?Calcium deposition as CaPO4 crystals, normal PO4 and Mg

No renal failure

2. Consistent with tumour lysis syndrome

3. Large scale destruction of tumour cells which may spontaneous or may occur as a result of chemotherapy

4. Treatment Goals

Hyperkalaemia (care with Calcium)

Fluid hydration – 4/5 litres per day

Diuresis – aim for 3 litres urine per day, ensure adequate hydration prior to diuresis and care with urinary acidification/ alkalinization (precipitates uric acid crystalization/ Ca deposition)

Reduce uric acid

Care with Calcium, only replace if symptomatic

Dialysis –

Indications for dialysis include persistent hyperkalemia or hyperphosphatemia despite treatment, volume overload, uremia, symptomatic hypocalcemia, and hyperuricemia.

5.

Tumor lysis syndrome has been reported with virtually every type of tumor. It is typically associated with acute leukemias and high-grade non-Hodgkin lymphomas,  such as Burkitt lymphoma.  The syndrome has also been reported with other hematologic malignancies and with solid tumors such as hepatoblastoma and stage IV neuroblastoma.