A rapidly growing lymphoma and
tumor lysis syndrome in a toddler
Worsening abdominal distention, intermittent vomiting, a palpable mass, and decreased
activity were signs of a life-threatening malignancy in this 2-year-old boy.
Holly L. Green, PA-C; Michael E. Rytting, MD; noted, without obstruction. There was a small amount of
Charles S. Cox Jr, MD ascites. Solid masses were observed in both kidneys. A
matted mass of bowel and lymph nodes was seen in the
CASE right lower portion of the abdomen (Figure 1). CT of the
A 2-year-old boy presented to the emergency department chest showed no abnormalities above the diaphragm.
(ED) with an 8-day history of increasing abdominal pain Based on a suspected diagnosis of Burkitt’s lymphoma,
and distention, intermittent vomiting, and lower-than- the patient was transferred to a children’s cancer hospital.
usual activity. Despite a decreased appetite, the child had He was started on IV ﬂuids (5% dextrose in 0.5N saline
gained 2.5 lb over the preceding week, and swelling was with 60 mEq/L of sodium acetate) at 1.5 times the mainte-
evident in his legs. He had been recently treated for con- nance rate to alkalinize his urine and prevent precipitation
stipation; no blood was detected in the stool. His urine of uric acid crystals in the kidneys. IV allopurinol was
output was normal, and he had no signiﬁcant night sweats given to prevent uric acid nephropathy. The child was
or bruising. taken emergently to the OR for exploratory laparotomy,
On initial physical examination, the child was afebrile. tissue biopsy, and central venous catheter placement.
Vital signs included heart rate, 132 beats per minute; Opening the abdomen revealed a moderate amount of
respiratory rate, 24 breaths per minute; and BP, 119/56 ascites and a baseball-sized necrotic mass adjacent to the
mm Hg. He weighed 12.1 kg. There were no murmurs, terminal ileum. When the mass was sampled for biopsy,
rubs, or gallops on cardiac examination, and breath air was noted at the base of the biopsy cavity. The mass
sounds were normal on auscultation. His abdomen was had eroded through the wall of the small intestine, and
distended and ﬁrm. Bowel sounds were hypoactive. The removal of the biopsy sample had unroofed a contained
right lower quadrant was tender to palpation. He had col- perforation. A segmental ileal resection was necessary to
lateral veins on his abdomen, presumably resulting from remove the necrotic bowel. Because the surgeon antici-
increased intra-abdominal pressure. A rectal examination
revealed no palpable mass. Cervical and inguinal lymph
nodes were shotty and nontender. His lower extremities
demonstrated 1+ pitting edema. On the morning he pre-
sented to the ED, the patient had a palpable right lower
quadrant mass measuring 2 3 cm; by evening of the
same day, the mass measured 7 7 cm.
Pertinent laboratory test results obtained during the ﬁrst
week of evaluation and therapy are listed in Table 1. At pre-
sentation, urinalysis was normal, with a urinary pH of 7.0.
By evening on the day of presentation, the patient’s lactate
dehydrogenase (LDH) had increased from a morning level
of 542 IU/L to 1,435 IU/L. His initial uric acid level, mea-
sured in the evening, was 9.2 mg/dL.
Abdominal ultrasonography showed a mildly thickened
bowel with no evidence of intussusception. CT of the ab-
domen and pelvis showed bulky soft-tissue densities that
ﬁlled the abdomen and retroperitoneum, consistent with FIGURE 1. A mass composed of bowel and lymph nodes was
lymphadenopathy. Diffuse bowel wall thickening was seen on CT.
30 JAAPA • AUGUST 2010 • 23(8) • www.jaapa.com
CASE REPORT | Burkitt’s lymphoma
TABLE 1. Laboratory values at initial presentation and on subsequent days
Test Day 1 Day 3 Day 6 Day 7 Day 8 Reference range
BUN (mg/dL) 4 10 23 52 7-17
Calcium (mg/dL) 9.3 7.7 7.6 5.0 7.3 8.7-9.8
Creatinine (mg/dL) 0.4 0.5 0.6 0.8 0.8-1.5
Hemoglobin (g/dL) 10.4 6.7 8.9 8.7 8.1 11.5-13.5
Lactate dehydrogenase (IU/L) 542 1,755 3,605 4,529 1,959 98-192
Phosphorus (mg/dL) 5.1 7.3 9.4 12.8 3.9 3.9-6.5
Potassium (mEq/L) 4.3 5.2 5.1 5.5 3.8 3.7-5.0
Uric acid (mg/dL) 9.2 8.0 3.8 6.3 1.0 2.1-5.3
Urinalysis pH 7.0 pH 7.0 pH 7.0 pH 4.5-8.0
No crystals Occasional No crystals
WBC count ( 103/ L) 11.3 7.0 5.1 8.0 9.3 4.0-5.5
pated that the severity of the chemotherapy would put a was observed in the ICU, and a nephrologist was con-
small-bowel anastomosis at risk for leakage and ﬁstula, he sulted. The patient’s ﬂuids were increased to three times the
proceeded with a right lower quadrant ileostomy and forma- maintenance r