H.J. is a 46-year-old man diagnosed with Burkitt's lymphoma 4 months ago. He has received 3 of 6 chemotherapy courses and is seen today at his physician's office with a complaint of (C/O) malaise and fever. He is found to have splenomegaly on examination. In the office, his laboratory studies reveal WBC 51.9 thou/cmm, Hgb 8.3 g/dl, Hct 23.6%, platelets 21 thou/cmm. Differential shows neutrophils 66%, lymphocytes 16%, monocytes 15%, eosinophils 5%. He is admitted to the hospital with progres-sive disease.
On admission, further laboratory studies reveal Na 136 mmol/L, K 5.2 mmol/L, Cl 97 mmol/L, CO2 28 mmol/L, glucose 98 mg/dl, BUN 24 mg/dl, creatinine 1.7 mg/dl, Ca 11.9 units/L, phosphorus 4.5 mg/dl, uric acid 23.7 mg/dl, total bilirubin 0.8 mg/dl, alkaline phosphatase 172 units/L, aspartate transaminase (AST) 254 units/L, alanine transaminase (ALT) 72 units/L, lactate dehydrogenase (LDH) 214 IU/L. CT of the abdomen shows a large spleen with metastatic disease in the liver, spleen, and pancreas; chest x-ray (CXR) demonstrates patchy infiltrates in bilateral lower lobes, R >L.
1. H.J. is diagnosed with acute tumor lysis syndrome. Briefly describe this syndrome.
2. Which of the above labs confirm this diagnosis?
3. List common signs and symptoms (S/S) of each metabolic abnormality associated with acute tumor lysis syndrome listed below.
4. The physician orders aggressive hydration, allopurinol, and chemotherapy to be started. He also ordered rasburicase, a new drug that decreases uric acid levels. How does this drug work?
5. Identify two additional complications or emergencies for which H.J. is at risk.
6. On hospital day 5, labs are as follows: WBC 1.4 thou/cmm, Hgb 8.3 g/dl, Hct 23.8%, platelets 10 thou/cmm, Na 138 mmol/L, K 4.8 mmol/L, Cl 109 mmol/L, CO2 26 mmol/L, glucose 148 mg/dl, BUN 34 mg/dl, creatinine 1.0 mg/dl, Ca 7.3 units/L, total protein 5.4 g/dl, albumin 2.8 g/dl, phosphorus 3.8 mg/dl, uric acid less than 0.5 mg/dl, total bilirubin 1.0 mg/dl, alkaline phosphatase 96 units/L, AST 49 units/L, ALT 48 units/L, LDH 224 IU/L. Ordered chemotherapy has been completed. Comparing current laboratory data to those on admission, how has his condition changed?
7. H.J. required blood product support, including leukocyte-poor pheresed platelets and leukocyte-reduced packed RBCs (PRBCs). Acetaminophen and diphenhydramine (Benadryl) are ordered as premedication for transfusion. H.J. will be closely monitored for intravascular and extravascular hemolytic reactions; febrile, allergic, and hypervolemic reactions; transfusion-related acute lung injury (TRALI); and bacterial sepsis. Identify the S/S, usual cause, and treatment for each.