Lactic acidosis is an extremely rare paraneoplastic manifestation of hematological malignancies, and often carries an extremely poor prognosis. Mantle cell lymphoma is an aggressive and rare form of non-Hodgkin lymphoma. To the best of our knowledge, it is extremely rare to have severe lactic acidosis in patients with mantle cell lymphoma. In this article, we are reporting a rare case of mantle cell lymphoma diagnosed with typical cluster differentiation (CD markers) in bone marrow examination with persistent lactic acidosis refractory to intravenous hydration that responded well to chemotherapy. Malignant lactic acidosis is a medical emergency that needs rapid evaluation and identification that shows improved prognosis after the introduction of chemotherapy.

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INTRODUCTION: Emphysematous pyelonephritis (EPN) is an uncommon acute severe necrotizing infection of the renal parenchyma and its surrounding tissues that results in the presence of gas in the renal parenchyma, collecting system, or perinephric tissue. The clinical course of EPN can be life threatening if not managed astutely. The primary organisms responsible include Escherichia coli and Klebsiella Pneumoniae. We present a rare and uncommon case of severe EPN that was managed conservatively with good outcome. CASE PRESENTATION:A 63-year-old Hispanic female with a past medical history of uncontrolled diabetes and hypertension presented with a four-day history of abdominal pain, nausea, vomiting and diarrhea. Vital signs showed T 38.2 C, HR 99, BP 103/ 58 mmHg and saturating 100% on RA. Palpation and percussion of the left flank region elicited pain. Lab findings were significant for hyponatremia (132), hypochloremia (95), elevated BUN and Creatinine (43/2.4), hyperglycemia (264), elevated CRP 36.5. Initial lactic acid was found to be 2.8. Urinalysis showed findings suggestive of a UTI. Patient also was incidentally found to have COVID-19 Ag and PCR positive. Chest X-ray showed mild interstitial prominence. Emergent renal ultrasound reported scattered foci of air in the left renal upper pole calyces and proximal ureter. CT Abdomen Pelvis with contrast showed air in the bladder and left ureter and kidney. Despite adequate initial resuscitation with IV fluids and IV piperacillin-tazobactam, her lactic acid increased peaking at 8.5 and she was promptly moved to MICU for hemodynamic monitoring. With a working diagnosis of EPN and SARS-CoV-2 infection, she was switched to Meropenem, placed on IV fluids and her pain was managed supportively. Urology was consulted who recommended close monitoring and plan for emergent intervention if condition worsened. However, since patient started to recover, she did not undergo intervention. Antibiotics were de-escalated to Ceftriaxone after blood cultures grew sensitive Escherichia coli. Patient's condition improved and she was discharged with outpatient follow-up with urology.DISCUSSION: Based on CT findings, emphysematous UTI's are characterized into Class I to IV with increasing mortality associated as you move towards class IV. Our patient initially presented with Class I and as a result was promptly started on antibiotics. If EPN had progressed anymore, she would have needed a percutaneous drainage, or even nephrectomy in refractory cases, in addition to antibiotic therapy. However, due to prompt care and aggressive monitoring provided to her, she was able to improve without further interventions. The rarity of the condition and the decision-making involved while managing the disease makes this case unique.CONCLUSIONS: Emphysematous pyelonephritis is an uncommon severe infection of the renal parenchyma, which with early diagnosis can be managed conservatively.