scholarly journals Confirmed Hypoglycemia Without Whipple Triad: A Rare Case of Hyper-Warburgism

2020 ◽  
Vol 5 (1) ◽  
Author(s):  
Itivrita Goyal ◽  
Christopher Ogbuah ◽  
Ajay Chaudhuri ◽  
Timothy Quinn ◽  
Rajeev Sharma
Keyword(s):  
Lactic Acidosis ◽  
Chest Wall ◽  
Warburg Effect ◽  
B Cell Lymphoma ◽  
Glucose Consumption ◽  
Fdg Uptake ◽  
Pet Ct ◽  
Wall Mass ◽  
The Brain ◽  
Chest Wall Mass

Abstract Spontaneous hypoglycemia in nondiabetic patients poses a diagnostic challenge. Hypoglycemia in malignancy has several etiologies; an extremely rare mechanism is the Warburg effect causing excess lactate production and avid glucose consumption. We describe the clinical course of a 52-year-old man admitted for chest wall mass and severe but asymptomatic hypoglycemia. Laboratory workup was obtained for insulin vs noninsulin-mediated hypoglycemia, and biopsy of the chest wall mass and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) scan were performed. D10 infusion and intravenous/oral steroids started for severe hypoglycemia. Chemotherapy was initiated after biopsy, and blood glucose (BG) and lactate levels followed with clinical response in tumor size and changes in PET/CT. Investigations were significant for venous BG in the 40s (Ademolus Classification of Hypoglycemia grade 2 hypoglycemia), plasma insulin of less than 2 µU/mL (2-20 µU/mL), C-peptide of 0.2 ng/mL (0.8-6.0 ng/mL), insulin-like growth factor 2 (IGF-2) of 113 ng/mL (333-967 ng/mL), serum lactate of 16 mmol/L (0.5-2 mmol/L), and albumin of 2.3 g/dL (3.4-5.4 g/dL). Biopsy showed diffuse large B-cell lymphoma, and PET revealed highly FDG-avid disease in the chest, abdomen, and pelvis, but no FDG uptake was seen in the brain. Hypoglycemia and lactic acidosis improved remarkably after chemotherapy. PET/CT at 4 weeks showed complete metabolic response with reappearance of physiological FDG uptake in the brain. Noninsulin-mediated hypoglycemia was likely due to the combination of profound malnutrition and rapid glucose use by cancer cells. The patient presented with exaggerated Warburg effect (hyper-Warburgism), evident by extreme glucose consumption, severe lactic acidosis, and large tumor burden on PET/CT. Absence of cognitive symptoms was probably due to use of lactate by the brain. Chemotherapy corrected these abnormalities rapidly, and must be instituted in a timely manner.

scholarly journals SAT-131 Asymptomatic Severe Hypoglycemia with Lactic Acidosis in a Case of Non-Hodgkin’s Lymphoma - an Unusual Phenomenon of Hyper-Warburgism

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Itivrita Goyal ◽  
Oday Karadsheh ◽  
Manu Raj Pandey ◽  
Rajeev Sharma ◽  
Ajay Chaudhuri
Keyword(s):  
Lactic Acidosis ◽  
Chest Wall ◽  
Warburg Effect ◽  
Severe Hypoglycemia ◽  
Glucose Consumption ◽  
Tumor Burden ◽  
Large Tumor ◽  
Wall Mass ◽  
Large Tumor Burden ◽  
Chest Wall Mass

Abstract INTRODUCTION Hypoglycemia in malignancy is well known with several etiologies; impaired liver function, insulin receptor autoantibodies, production of insulin-like substance by malignant cells or large tumor burden. Another possible mechanism is the Warburg effect where metabolism shifts towards glycolytic pathways over oxidative phosphorylation even under aerobic conditions leading to excess lactate production. This leads to glucose consumption due to shunting of glucose away from normal cells to cancer cells. Very few cases of lactic acidosis and severe hypoglycemia in Non-Hodgkin’s Lymphoma have been described in the literature. We report such an unusual case here. CASE DISCUSSION A 52-year-old, African-American male was admitted for severe malnutrition with 80 lb. weight loss, severe hypoglycemia and progressively increasing right chest wall mass. On arrival, he had no classic symptoms of hypoglycemia. Physical exam revealed persistent tachycardia, white patches on oral mucosa and posterior tongue, and an indurated mass on right chest wall with extensive swelling of right upper limb. Lab work was significant for blood glucose (BG) of 41 mg/dL (60–100), lactate 16 mmol/L (0.5 to 2), anion gap 26 mEq/L (3–10), albumin 2.3 g/dL (3.4 to 5.4) and normal renal and liver function tests. Fingerstick sugar readings were persistently in the 20s with no response to multiple boluses of dextrose and glucagon. He was started on dextrose 5% (D5) drip and intravenous solumedrol. Solumedrol was weaned off and D5 titrated down to investigate causes of hypoglycemia. BG dropped to 39 and corresponding labs showed insulin level of < 2 mcUnit/mL (2–20), C-peptide of 0.2 ng/mL (0.8–6.0) and ketone level of 0.2 mmol/L (<0.4). IGF-1 and IGF-2 were both low at 26 ng/mL (61–200) and 113 ng/mL (333–967) respectively. A CT torso with contrast showed bilateral pleural effusions, moderate pericardial effusions and a large ill-defined heterogeneous mass along anterior chest wall. He underwent ultrasound guided biopsy of the chest wall mass and diagnosed with diffuse large B-cell lymphoma. He also tested positive for HIV/AIDS and Hepatitis C. PET scan showed diffuse FDG (fluorodeoxyglucose) uptake consistent with advanced disease. He was started on chemotherapy and lactate and BG normalized soon after 1st cycle. CONCLUSION In our case; suppressed insulin, low C-peptide and IGF-2 levels indicate non-insulin mediated hypoglycemia due to rapid glucose utilization by cancer cells. Severe hypoglycemia with lack of neuroglycopenic symptoms suggests use of lactate (rather than glucose) as an alternative metabolic fuel for brain, thus preserving its function. Our patient presented with an exaggerated Warburg effect (hyper-Warburgism) as evident by extreme glucose consumption, severe lactic acidosis and large tumor burden on FDG/PET. Chemotherapy must be instituted timely to correct these abnormalities.

scholarly journals Primary diffuse large B-cell lymphoma as a chest-wall mass

Medicine ◽  
2018 ◽  
Vol 97 (47) ◽  
pp. e13291 ◽  
Author(s):  
Qianwen Zhang ◽  
Yuanrong Ju ◽  
Tao Qu ◽  
Tao Wang ◽  
Xiaoqin Liu
Keyword(s):  
B Cell ◽  
Chest Wall ◽  
Cell Lymphoma ◽  
B Cell Lymphoma ◽  
Large B Cell Lymphoma ◽  
Wall Mass ◽  
Chest Wall Mass ◽  
Large B Cell

scholarly journals Diffuse large B-cell lymphoma presenting as large anterior chest wall mass involving pleura and lung: A possible result of post-traumatic chronic inflammation

2012 ◽  
Vol 3 (1) ◽  
pp. 79-83 ◽  
Author(s):  
Fouad Atoini ◽  
Aziz Ouarssani ◽  
Moulay Ahmed Hachimi ◽  
Fatima Aitlhou ◽  
Fatima Zohra Guenoun ◽  
...  
Keyword(s):  
B Cell ◽  
Chest Wall ◽  
Cell Lymphoma ◽  
B Cell Lymphoma ◽  
Anterior Chest Wall ◽  
Large B Cell Lymphoma ◽  
Post Traumatic ◽  
Wall Mass ◽  
Chest Wall Mass ◽  
Large B Cell

scholarly journals Surgical management of a rapidly growing chest wall mass of the neonate

2021 ◽  
Vol 64 ◽  
pp. 101725
Author(s):  
Danny Lascano ◽  
Michael J. Zobel ◽  
Abigail K. Zamora ◽  
Murad Alturkustani ◽  
Shengmei Zhou ◽  
...  
Keyword(s):  
Chest Wall ◽  
Surgical Management ◽  
Wall Mass ◽  
Chest Wall Mass

scholarly journals Metastatic prostate adenocarcinoma presenting as a large right supraclavicular and anterior chest wall mass

2016 ◽  
pp. bcr2016214797
Author(s):  
Ku Hung Hsieh ◽  
Grace Tan Hwei Ching ◽  
Angela Chong Phek Yoon ◽  
Melissa Teo
Keyword(s):  
Chest Wall ◽  
Anterior Chest Wall ◽  
Prostate Adenocarcinoma ◽  
Wall Mass ◽  
Chest Wall Mass

scholarly journals An Unusual Case of Fungating Chest Wall Mass

2019 ◽  
Vol 36 (1) ◽  
pp. 211-212
Author(s):  
Divya Ragate ◽  
Charanpreet Singh ◽  
Navneet Arora ◽  
Arihant Jain ◽  
Deepesh Lad ◽  
...  
Keyword(s):  
Chest Wall ◽  
Unusual Case ◽  
Wall Mass ◽  
Chest Wall Mass

Anterior Chest Wall Mass in a 46-Year-Old Woman

CHEST Journal ◽  
2002 ◽  
Vol 121 (5) ◽  
pp. 1692-1694
Author(s):  
George S. Stoica ◽  
Harry N. Steinberg ◽  
Leonard J. Rossoff
Keyword(s):  
Chest Wall ◽  
Anterior Chest Wall ◽  
Wall Mass ◽  
Chest Wall Mass

A palpable chest wall mass in a 4-year-old boy

2021 ◽  
pp. e20200053
Author(s):  
Jakob M Domm ◽  
Joanne M Langley
Keyword(s):  
Chest Pain ◽  
Tract Infection ◽  
Respiratory Tract ◽  
Chest Wall ◽  
Respiratory Infection ◽  
Lower Respiratory Tract ◽  
Atypical Presentation ◽  
History Of ◽  
Wall Mass ◽  
Chest Wall Mass

Empyema necessitans (EN) is a rare but dangerous complication of a lower respiratory tract infection. The diagnosis can be difficult to make and therefore delayed. We describe a case of a child with an atypical presentation of EN. He was afebrile and without chest pain and presented with a palpable chest wall mass after a history of recent respiratory infection. The threshold of suspicion for EN should be low, and it must be suspected in all children with a chest wall mass and recent history of respiratory infection.

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