Stage 1:
A 59-year-old male was admitted to the cardiovascular medicine department in our hospital on 9th Jun, 2017 (6.9th, 2017) for 2 months of chest tightness and shortness of breath without any positive signs during physical examination. Troponin (0.01ng/ml), CK-MB (6U/L) and LDH (294 U/L) levels in serum were normal. Abdominal B ultrasound showed a 2.4×1.9 cm mass in the spleen and swelled lymph nodes in hepatic hilar region. Importantly, the lung CT scan revealed the normal imaging features in the lung field and lymph nodes swelling in mediastinum (Fig.1 a, b straight arrow).
Stage 2:
Then, the patient was transferred to our department for endobronchial ultrasound guided tranbronchial needle aspiration (EBUS-TBNA) investigation of mediastinal lymph nodes with primary diagnosis of lymphoma. Thoracic and abnominal enhanced CT scan (6.14th, 2017) revealed the swelling lymph nodes in mediastinal (Fig.1 c straight arrow), hilar and retroperitoneal region, severe superior vena cava stenosis (Fig.1 c bent arrow), and low-density shadows in liver and spleen. We implanted a stent in superior vena cava with the routine dexamethasone and low molecular weight heparin usage, and the edema of face, neck and right upper limb was improved. Unexpectedly, both pathological results of right main bronchial mucosa by electronic bronchoscope (Fig.2 a-b) and mediastinal lymph nodes biopsy by EBUS-TBNA (Fig.2 c-d) showed chronic inflammation with focal necrosis (6.20th, 2017, on Friday). At that time, the left cervical lymph node was found enlargement and its resection tissue biopsy was pathologically confirmed as DLBCL with LCA +, CD20 +, CD79a +, Bcl-2 +, CD10 -, Bcl-6 +, MUM1+, Ki-67 +, c-myc +, CD3 -, CD2- (6.30th, 2017). Two days later, on 2nd Jul, chest tightness and breath shortness was suddenly worsened, accompanied by low blood oxygen saturation (85%), oliguria indicating acute renal dysfunction, and cardiogenic shock with hypotension of 75/48mmHg.
Stage 3:
Emergently, 0.9% sodium chloride and dopamine were provided against the cardiogenic shock and he was removed to RICU. Non-invasive positive pressure ventilation, furosemidum, hydrocortisone succinate followed by methylprednisolone, and dopamine (highest dose of 10μg/kg.min) subsequently combined norepinephrine (highest dose of 2.0μg/kg.min) were implemented to keep the oxygenation and stable blood pressure. Meanwhile, robustly elevated potassium (highest level 6.66 mmol/L) and phosphate levels in serum were measured (table.1). After the usage of furosemidum, calcium gluconate and sodium bicarbonate, at 4 am on 4th Jul, continuous renal replacement treatment (CRRT) was implemented. In addition, increasingly worsened hepatic and renal function dysfunction were observed and the highest levels of ALT, LDH, Cr and urea were 3483.8 U/L, 8140 U/L, 232.5μmol/L and 33.1 mmol/L, respectively (Table 1). Bedside chest X-ray revealed massive pleural effusion in the right chest cavity and significantly enlarged heart shadow consequently identified as pericardial effusion (Fig.2 e-f). The thoracic and pericardial catheterization was instantly implanted and a large amount of yellow pleural effusion and red chylous pericardial effusion were drained. We infused the antibiotics of meropenem, and in the end, streptococcus parasanguis was confirmed in pericardial effusion culture. In consideration of severe liver function failure, the two times of plasma exchange using 2500ml plasma each time was assigned on 6th Jul and 7th Jul. Under the comprehensive interventions including assistant treatments of albumin and blood products, medicine protecting liver function, nutritional support, and so on, the function of organs was obviously improved (Table.1). Vasoactive agents was also down-regulated step by step, thus, the blood pressure fluctuating at the normal level of 120/70mmHg was maintained with 2.0μg/kg.min of dopamine on 8th Jul. Simultaneously, chest radiography showed the pleural and pericardial effusion were significantly decreased (Fig.2 g), and the urine output was gradually increased (Table.2). In considering of poor prognosis if there was no further treatment to the primary disease, under advice from a chief consultant hematologist and consent of the patient and the family members, on 12th Jul, we gave him the revised mini-CHOP chemotherapy with 375 mg/m2 rituximab (d0,12th Jul), 400mg/m2 cyclophosphamide (divided into two times infusion, d1, d8), 1mg/m2 vincristine (d2), 35mg/m2 doxorubicin (divided into two times infusion, d2, d9), and dexamethasone (10mg, d1-d5). To avoid the new tremendous abnormalities of tumor cells lysis, CRRT was performed again 12 hours after cyclophosphamide infusion. Unluckily, on the next day (14th Jul), the patient got worsened again reflected by recurrent breathing difficulty, moist rales, hypotension of 75/56mmHg, and 4-8μg/kg.min dopamine and 0.3-0.6 μg/kg.min norepinephrine being needed for maintaining normal blood pressure (111/84 mmHg), although the urinal output was still in stable (Table 2). Therefore, we suspended the subsequent vincristine and doxorubicin infusion. At that time, we observed high fluid load in the last two days (table.2), which maybe contributed to the recurrent acute heart dysfunction and pulmonary edema. After we removed the excessive fluid by CRRT, plasma infusion and intermittent diuretics, the patient again reached on temporary clinical stable condition with blood pressure (102-138/68-89mmHg) with 0.7-2.2 μg/kg.min dopamine and 0.15-0.3 μg/kg.min norepinephrine. However, in the end, he got further worsened again and we observed multiple herpes zoster with fusion on the cheek and neck skin on 20th Jul. Septic shock with extremely hypotension and low fever was clinically confirmed. Even if the anti-shock treatments, anti-virus, antibiotics, fluid infusion and CRRT were used, septic shock could not been reversed. On 24th Jul, 45 days after his admission, the blood pressure could not been eventually maintained with the high dose of dopamine and norepinephrine, subsequently, the cardiac and pulmonary arrest occurred and he died at 20:00.
Table 1
Troponin and electrolytes levels (mmol/L), cardiac, hepatic and renal function indexes in serum.
Time
|
Tn
|
K+
|
P3-
|
Ca2+
|
Na+
|
ALT
|
LDH
|
Cr
|
Urea
|
ALB
|
6.10
|
0.01
|
4.1
|
1.11
|
2.39
|
135
|
20.8
|
348
|
62
|
5.4
|
40.5
|
7.2a
|
0.01
|
5.57
|
1.72
|
2.08
|
119
|
133
|
-
|
111.7
|
26.6
|
-
|
7.3
|
0.01
|
6.66
|
2.52
|
2.13
|
127.7
|
232.4
|
501
|
166
|
30.5
|
31.7
|
7.4b
|
|
5.29
|
1.73
|
2.09
|
136
|
2123
|
3063
|
197
|
33.1
|
30
|
7.5
|
|
4.94
|
1.59
|
2.19
|
136.9
|
3483.8
|
2974
|
232.5
|
20.1
|
37.4
|
7.6
|
|
4.27
|
1.07
|
2.14
|
138.7
|
1696.6
|
984
|
200
|
14.8
|
37.3
|
7.8
|
|
|
|
|
|
197.6
|
400
|
200
|
11.9
|
-
|
7.13
|
|
|
|
|
|
44.9
|
452
|
163
|
13.7
|
31.6
|
7.17
|
|
|
|
|
|
35.9
|
321
|
142
|
12.5
|
30.6
|
7.19
|
|
4.21
|
1.2
|
2.31
|
138.3
|
31.3
|
266
|
251
|
30.0
|
27.5
|
7.23
|
|
4.70
|
0.98
|
2.24
|
139.4
|
36.9
|
327
|
162
|
21.5
|
31.3
|
a,b Onset of TLS was on 2nd 7 and CRRT on 4th Jul followed by plasma exchange was implemented. The organ function was still in stable after chemotherapy. Tn, Troponin (range, 0.00-ng/ml; K+, P3-, Ca2+ , Na+ (3.5-5.3, 0.85-1.51, 2.11-2.52, 137-147mmol/L); ALT, alanine transaminase (9-50 U/L ); AST, aspertate aminotransferase (15-40 U/L); LDH, lactate dehydrogenase (120-250 U/L); CK, creatine kinase (50-310 U/L); Cr, creatinine (57-97μmol/L); Urea, urea nitrogen (3.1-8.0 mmol/L); UA, uric acid (150-420μmol/L); ALB, albumin (40-55 g/L). |
Table 2
Intaking and output liquid levels inclusive of ultrafiltration liquid by CRRT
Fluids (ml)
|
7.09
|
7.11
|
7.12a
|
7.13
|
7.14
|
7.18
|
7.19
|
7.20
|
7.21
|
Total In-taking
|
3220
|
6184
|
8231
|
3734
|
4765
|
3240
|
2968
|
2068
|
5979
|
Total output
|
3262
|
8069
|
6628
|
2231
|
7428
|
2539
|
2500
|
2068
|
6919
|
Pleural effusion
|
550
|
330
|
300
|
350
|
320
|
400
|
200
|
400
|
250
|
Pericardial effusion
|
130
|
35
|
100
|
100
|
75
|
200
|
100
|
30
|
-
|
Urine output
|
75
|
135
|
80
|
110
|
120
|
1240
|
1600
|
1160
|
950
|
Ultrafiltration
|
2427
|
7429
|
5948
|
1301
|
6863
|
-
|
-
|
-
|
4869
|
a On 12th Jul, the revised mini-CHOP chemotherapy was adopted. In our CRRT system, sodium bicarbonate was directly infused into the vein as the buffer solution of hemofiltration substitution fluid, thus the infused sodium bicarbonate during CRRT was incorporated into the total in-taking. |