Case history

Case history #1

A 19-year-old man is diagnosed with an aggressive diffuse large B-cell lymphoma. The disease is bulky, involving lymph nodes (above and below the diaphragm), the spleen, and the bone marrow. Serum lactate dehydrogenase is significantly elevated but renal function and electrolytes are within normal limits. Twenty-four hours after initiation of aggressive chemotherapy he complains of nausea, vomiting, diarrhea, and lethargy. He has become oliguric and is hypertensive and tachycardic. Biochemistry reveals hyperuricemia, hyperkalemia, hyperphosphatemia, elevated blood urea nitrogen, and elevated creatinine.

Case history #2

A 69-year-old woman with a 2-year history of chronic lymphocytic leukemia presents with a white blood cell (WBC) count of 41,000/microliter. She has a past medical history of hypertension and mild renal impairment related to the use of nonsteroidal anti-inflammatory drugs for osteoarthritis. Seven days after initiation of treatment with fludarabine, she complains of fatigue and weakness. The WBC count has fallen to within normal levels but serum biochemistry reveals hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and a significant deterioration in renal function.

Other presentations

Other clinical manifestations of TLS include anorexia, hematuria, flank pain, anuria, cloudy urine, joint pain/discomfort, muscle cramps and spasms, muscle weakness, paralysis, paresthesia, tetany, syncope, chest pain, dyspnea, heart failure, cardiac dysrhythmias, bradycardia, seizures, confusion, delirium, hallucinations, laryngeal spasm (rare), and sudden death.[2][3][4]

Acute kidney injury may lead to fluid overload and peripheral or pulmonary edema.[2][5][6]

Clinical manifestations of TLS typically occur within 12 to 72 hours after initiation of cancer treatment.[2][7]​ Laboratory signs of TLS may appear as early as 6 hours after treatment initiation.[8][9][10][11]

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