Bulky extranodal diffuse large B-cell lymphoma complicating with venous thromboembolisms and fatal spontaneous tumor lysis syndrome

Ria T Hendrayani; Kartika W. Taroeno-Hariadi; Yunia Artha P. Putro; Amri W. Pribadi; Ery K. Dwianingsih

doi:10.22146/inajbcs.v57i3.Supplement.24276

Ria T Hendrayani Specialty Program in Internal Medicine, Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University/Dr. Sardjito Central general Hospital, Yogyakarta, Indonesia
Kartika W. Taroeno-Hariadi Internist, Hematology and Medical Oncology Division, Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Gajah Mada University/Dr. Sardjito Central general Hospital, Yogyakarta, Indonesia
Yunia Artha P. Putro Orthopedic Surgeon, Orthopaedic and Traumatology Division, Department of Surgery, Faculty of Medicine, Public Health and Nursing, Gajah Mada University/Dr. Sardjito Central general Hospital, Yogyakarta, Indonesia
Amri W. Pribadi Radiologist, Radiology Medical Imaging Musculoskeletal Division, Department of Radiology, Faculty of Medicine, Public Health and Nursing, Gajah Mada University/Dr. Sardjito Central general Hospital, Yogyakarta, Indonesia
Ery K. Dwianingsih Pathologist, Department of Anatomical Pathology, Faculty of Medicine, Public Health and Nursing, Gajah Mada University/Dr. Sardjito Central general Hospital, Yogyakarta, Indonesia

DOI: https://doi.org/10.22146/inajbcs.v57i3.Supplement.24276

Keywords: Bulky Extranodal Diffuse Large B Cell Lymphoma, Venous Thromboembolisms, Spontaneous Tumor Lysis Syndrome

Abstract

Diffuse Large B-Cell Lymphoma (DLBCL) is the most common subtype of non- Hodgkin lymphoma, often presenting with nodal or extranodal involvement. Bulky disease and extranodal presentation are associated with increased risks of complications, particularly venous thromboembolism (VTE) and tumor lysis syndrome (TLS). While TLS typically occurs after cytotoxic therapy, spontaneous TLS can rarely develop, especially in patients with a high tumor burden and aggressive disease. A 55-year-old female was diagnosed with bulky extranodal DLBCL involving the right shoulder and extending to the scapular region. Diagnosis was confirmed through histopathological analysis with immunohistochemical staining and plain chest radiography. Due to the patient’s condition, MSCT scanning was not performed. She presented with progressive dyspnea and right lower limb edema. Imaging revealed a large mass with destruction of the right scapula and an impending thrombus in the right lower extremity vein. Anticoagulation therapy (heparin and rivaroxaban) was initiated for VTE and the high risk of pulmonary embolism. Despite not receiving chemotherapy, the patient rapidly deteriorated, displaying laboratory abnormalities consistent with spontaneous TLS: hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and acute kidney injury. Despite intensive supportive care, she developed multiorgan failure and died within 24 hours. Bulky extranodal DLBCL carries a high risk of vascular complications due to tumor mass effect and hypercoagulability. High tumor burden predisposes to spontaneous TLS, a rare but life-threatening emergency. Anticoagulant use in TLS must be approached with caution, particularly in the context of renal dysfunction, due to risks of bleeding and drug accumulation. TLS-related metabolic disturbances can impair coagulation, increasing hemorrhagic risk, and may trigger disseminated intravascular coagulation (DIC). Early recognition, close metabolic monitoring, and prophylactic TLS management in high-risk patients are essential to improve outcomes and prevent fatal complications in aggressive lymphoma cases.