Case Presentation: A 57-year-old woman with a history of stage I breast cancer (status post bilateral mastectomy in 2021), anxiety, PTSD, PCOS, and recent dental crown placement in January 2025 presented with one week of severe shock-like left mandibular pain, facial swelling, progressive fatigue, dyspnea, night sweats, anorexia, and 4–5 lbs weight loss.Given above symptoms patient alerted her oncologist who advised radiological imaging. Initial workup included CT head and MRI brain, both unrevealing. She underwent a dental evaluation and root canal with transient improvement but developed recurrence of severe pain accompanied by facial numbness and progressive constitutional symptoms, which prompted ED visit. In the ED, she was febrile (102.8°F), tachycardic, and hypotensive.Blood work revealed Hb 8.8, sodium 129, potassium 2.9, magnesium 1.3, Total bilirubin 2.6 , LDH 765, blood smear showed Normocytic anemia with monocytosis, without schistocytes. CT face showed inflammatory soft-tissue changes with cortical erosion of the left mandible, concerning for osteomyelitis/phlegmon. CT abdomen/pelvis revealed new bilateral perirenal nodularity, highly suspicious for lymphoma or metastatic disease. Broad-spectrum IV antibiotics were initiated and transferred to ICU step-down. Patient underwent biopsy of the perinephirc nodularities. During hospitalization, she developed worsening lactic acidosis without hypotension (lactate 8.8 mmol/L, eventually as high as >16mmol/L) despite aggressive hydration, raising concern for type B lactic acidosis. Additional complications included progressive leukocytosis with leukoerythroblastic picture on blood smear, hypercalcemia requiring zoledronic acid, hypoglycemia, LDH >12,000 U/L,rapidly worsening transaminitis, coagulopathy (INR 7.4) with concerns for DIC. Biopsy of the perirenal mass revealed malignant cells. Flow cytometry demonstrated a clonal B-cell population consistent with aggressive B-cell lymphoma.Despite escalation of care which included intubation, CRRT, and vasopressors, the patient continued to decline and developed multi-organ failure. Following goals-of-care discussions, comfort measures were initiated, and she passed away shortly after compassionate extubation.
Discussion: This case illustrates a rapidly progressive aggressive B-cell lymphoma that initially presented as isolated mandibular pain and swelling, ultimately revealing itself through type B lactic acidosis, hypercalcemia, cytopenias, and multiorgan failure. Type B lactic acidosis is a rare but life-threatening metabolic complication caused by malignant cell overproduction of lactate (Warburg effect), impaired hepatic clearance, and cytokine-mediated mitochondrial dysfunction. It is most often associated with high-grade lymphomas and carries extremely high mortality even with prompt treatment.Early identification of type B lactic acidosis and underlying hematologic malignancy is essential, as delays significantly worsen outcomes.
Conclusions: This case emphasizes the importance of maintaining a broad differential diagnosis for persistent lactic acidosis and systemic decompensation, particularly when clinical findings do not suggest typical sepsis physiology. Early recognition of type B lactic acidosis and underlying hematologic malignancy may allow earlier initiation of definitive therapy. Providers should avoid diagnostic anchoring, identify metabolic red flags, and coordinate timely multidisciplinary evaluation.
.png)