Diffuse large B‐cell lymphoma presenting with type B lactic acidosis and hemophagocytic syndrome

We report the case of a 51-year-old woman who was diagnosed with diffuse large B cell lymphoma presenting with hemophagocytic syndrome complicated by type B lactic acidosis. The patient came to our hospital because of an intermittent fever for 1 week. The initial laboratory findings revealed the following: white blood cell count, 3600/mL; hemoglobin, 10.1 g/dL; platelet, 28,000/mL. Her serum Creactive protein level was 47.7 mg/L, and arterial blood gas analysis showed pH 7.28, PCO2 38.1 mmHg, and HCO3 17.6 m mol/L. Her lactate level was 11.8mEq/L, sodium 135mg/dL, and chloride 104 mg/dL. A high anion gap metabolic acidosis related to lactic acidosis was noted. She had a pulse rate of 95 beats/minute, and her blood pressure was 130/75 mmHg. The bone marrow examination revealed hemophagocytosis (Fig. 1A). The patient’s computed tomography scan revealed a right adrenal gland tumor of about 6.8 cm and a liver nodule of about 4.7 cm in S6eS7 (Fig. 1B). A liver nodular biopsy revealed diffuse, large lymphoid cells containing coarse chromatin and scant-to-moderate cytoplasm (Fig. 1C), and the immunohistochemical analysis revealed that the neoplastic cells were positive for CD20 (Fig. 1D), Bcl-2, and Ki-67 (data not shown), but negative for CD3. The final diagnosis was diffuse large B-cell lymphoma complicated by type B lactic acidosis and hemophagocytic syndrome. Positron emission tomography revealed increased fluorodeoxyglucose avidity over the pelvic, liver, bilateral adrenal gland, shoulder, and right neck areas (data not shown). The patient was then treated with a systemic chemotherapy consisting of EPOCH (etoposide, epirubicin, vincristine, cyclophosphamide, and prednisolone). Because