by Charles Sorbie, MB, ChB, FRCS(E), FRCS(C)
High-dose steroid treatment given for acute brain and spinal cord injuries needs careful consideration of its risks. A case described by Tsao et al (Lancet. 2009; 374[9688]:500) had only one warning signal for risk, mild anemia. A 37-year-old woman was admitted with a whiplash injury after a motor vehical accident. Magnetic resonance imaging showed an incomplete spinal cord injury. She was given a bolus dose of steroid intravenously, 30 mg/k over 15 minutes and maintained on 5.4 mg/k every hour for 23 hours (NASCIS protocol). Sixteen hours after treatment began, she became unresponsive, went into ventricular fibrillation, and needed defibrillation. Several metabolic changes associated with renal failure ensued. Blood urea 4.3 mmol/L rose to 18.2, creatinine 0.08 to 0.20, phosphate 1.16 to 4.59, potassium 4.2 to 8.1, uric acid 422.5 µmol/L to 1000.6. Calcium fell from 2.28 mmol/L to 1.70. Lactate dehydrogenase was high at 854 U/L. Sheets of uric acid crystals were dectected in the urine. Five sessions of hemodialysis produced a good diuresis and returned her to a more stable state.
The steroid treatment had induced acute tumor lysis syndrome and the search for an occult malignancy revealed intravascular diffuse large B-cell lymphoma. The acute tumor lysis syndrome is a constellation of metabolic crises that results from massive tumour cell destruction especially with hematological malignancies. It can lead to renal failure on top of the provoked metabolic upsets in patients carrying a large tumor burden.
In addition to conventional therapy, eg, dialysis, recombinant urate oxidase (eg, rasburicase) that converts uric acid to allantoin, can help in the treatment.
This case reminds one of the need to be aware of the immediate risks of high-dose corticosteroid therapy. The only heads-up this patient gave was mild anemia.
doi: 10.3928/01477447-20090818-03
Blue Notes Editor:
Charles Sorbie, MB, ChB, FRCS(E), FRCS(C)
Dr. Charles Sorbie is Professor of Surgery at Queen’s University and a member of the Attending Staff at the General and Hotel Dieu Hospitals in Kingston, Ontario.A former chairman of the Department of Surgery at Queen’s University, Dr. Sorbie has been President of the Canadian Orthopaedic Research Society, the Canadian Orthopaedic Association, and the Societé Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT).