P2A293: T-cell Acute Lymphoblastic Leukemia Presenting as Gout and Acute Renal Failure Requiring Dialysis in Setting of Spontaneous Tumor Lysis Syndrome

Introduction: Acute renal failure (ARF) and hyperuricemia secondary to leukemia are common but usually result from rapid lysis of tumor cells after beginning treatment with chemotherapeutic agents. Spontaneous tumor lysis syndrome (STLS) can occur, albeit rarely, and is more commonly associated with non-Hodgkin lymphomas such as Burkitt and T-cell lymphoblastic lymphoma or T-cell acute lymphoblastic leukemia (ALL). Additionally, gout is not common in childhood leukemia, seen more often in adults with chronic leukemia. We present a severe pediatric case of ARF and hyperuricemia manifesting as gout requiring emergent dialysis with delayed diagnosis of T-cell ALL with additional dialysis needed upon initiation of chemotherapy.

Case Description: A 16 year old female presented with fever, chills, and back and abdominal pain treated as a UTI. However, upon development of debilitating left toe pain, further workup revealed a uric acid of 57.6 with signs of ARF including K: 6.1, HCO3: 15, BUN: 116, Cr: 20.79, and Ph: 15.5. CBC was normal besides thrombocytopenia of 118. She was admitted to the PICU and was started on hemodialysis with oncology consult. The peripheral flow cytometry was negative at that time. She improved with hemodialysis and was discharged on gout treatment including allopurinol and prednisone. After discharge she developed cervical lymphadenopathy and was treated for cat scratch disease. She followed with nephrology with creatinine normalizing to 0.87. Due to continued fatigue and body aches, two months later, another peripheral flow cytometry was performed showing 1% blasts followed by a bone marrow biopsy consistent with T-cell ALL. She began chemotherapy and developed TLS symptoms, again requiring hemodialysis.

Discussion: Hyperuricemia in pediatrics can be due to both acute and chronic causes, most commonly due to gastroenteritis and dehydration. Malignancies such as leukemia and lymphoma are also frequent causes but are related to large tumor burden or occur once treatment starts. However, a few reports have shown an association of STLS with T-cell ALL and acute renal failure, even in cases of low tumor burden. This is the first case of T-cell ALL STLS found in the literature with such severe hyperuricemia manifesting as gout coinciding with severe ARF necessitating hemodialysis with insidious progression in the setting of a very low tumor burden.

Conclusion: While STLS is rare for pediatric patients, it should be considered in clinical cases of acute renal failure and gout especially when there is no other reason for hyperuricemia. Clinicians should have a high index of suspicion for malignancy and consider repeat peripheral flow cytometry or bone marrow investigation, even with non-concerning initial peripheral blood testing to facilitate timely diagnosis. Additionally, this case highlights the risk of brisk TLS progression upon treatment in the setting of known renal dysfunction even when the tumor burden itself predicts a lower risk profile.