Refractory Lactic Acidosis and Hypoglycemia in a Patient With Metastatic Esophageal Cancer Due to the Warburg Effect

The Warburg effect describes a phenomenon in which tumor cells switch their metabolic machinery towards a glycolytic state even in the presence of normal oxygen concentration, resulting in excess lactate production. Lactic acidosis due to the Warburg effect in malignancy is a rare but potentially life-threatening emergency mainly described in hematological malignancies but can occur in non-hematological solid malignancies. To our knowledge, we present the first reported case of lactic acidosis due to the Warburg effect in metastatic esophageal cancer. A 44-year-old male was found to have an esophageal mass and likely hepatic metastases during his hospitalization for altered mental status due to severe hypercalcemia. He was re-admitted two days after discharge for persistent vomiting and an inability to tolerate an oral diet. The lab revealed elevated lactate levels (5.2 mmol/L), metabolic acidosis (pH 7.23), and hypoglycemia (48 mg/dL), all of which were persistent throughout hospitalization despite treatment with intravenous (IV) infusions of dextrose in sodium bicarbonate, IV boluses of dextrose, and IV thiamine. An esophagogastroduodenoscopy with a biopsy of the esophageal mass revealed squamous cell carcinoma of the esophagus. Given the presence of stage IV disease and poor functional status, the patient opted for in-patient hospice, where he passed away. Since prompt diagnosis and initiation of chemotherapy, if possible, are the only effective interventions for this potentially fatal complication, it is important to increase awareness of this underrecognized metabolic and oncologic emergency among physicians.