2026 Clinician Corner - Severe lactic acidosis and hypoglycemia as paraneoplastic manifestations of diffuse large B-cell lymphoma: a case-based review of hyper-Warburgism

Abstract 

Profound lactic acidosis and refractory hypoglycemia are rare but critical indicators of underlying malignancy. We report a case of diffuse large B-cell lymphoma presenting with the aforementioned metabolic derangements consistent with the Warburg effect and its extreme form, hyper-Warburgism. This phenomenon reflects aggressive tumor metabolism driven by aerobic glycolysis leading to excess lactate and glucose consumption. A comprehensive workup excluded infectious, ischemic, and metabolic causes, and the diagnosis was eventually confirmed via biopsy. Despite treatment, the disease rapidly progressed, leading to multiorgan failure. This case emphasizes the importance of recognizing atypical metabolic presentations as signs of aggressive malignancy because early identification of hyper-Warburgism can expedite oncologic evaluation, guide management, and potentially improve outcomes. 

Keywords:  Diffuse large B-cell lymphoma; hyper-Warburgism; hypoglycemia; lactic acidosis; Warburg effect

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Faculty credentials/disclosure 

The planners and faculty for this activity have no relevant financial relationships to disclose. The authors report no funding. Attempts were made to obtain consent from next of kin but they were unsuccessful. The IRB declined comment. Patient information is deidentified. 

Process

Click the "add to cart/begin" button, pay any relevant fee, take the quiz, complete the evaluation, and claim your CME credit.  You must achieve 100% on the quiz with unlimited attempts available.

  • By completing this process, you are attesting that you have read the journal article.

Expiration date:

Credit eligibility for this article is set to expire on July 1, 2027.

Learning Objectives

After completing the article, the learner should be able to:

  • Recognize the clinical presentation and biochemical profile of malignancy-associated type B lactic acidosis and hypoglycemia. 

  • Apply evidence-based diagnostic and management strategies for patients with lymphoma presenting with metabolic derangements related to the Warburg effect. 

  • Explain the underlying mechanisms of the Warburg effect and its exaggerated form, hyper-Warburgism, in hematologic malignancies. 

Key Points 

  • Severe lactic acidosis with refractory hypoglycemia may represent a paraneoplastic metabolic syndrome, particularly in aggressive hematologic malignancies. 

  • Failure of lactate levels to improve with standard resuscitation should prompt early oncologic evaluation, as delayed recognition of malignancy-associated type B lactic acidosis is associated with high mortality.  

  • Hyper-Warburgism is an extreme manifestation of the Warburg effect, characterized by uncontrolled aerobic glycolysis leading to persistent lactate overproduction and rapid glucose consumption despite adequate oxygenation and dextrose supplementation.  

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Course summary
Available credit: 
  • 1.00 American Board of Internal Medicine (ABIM) MOC Part 2
    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.00 MOC points in the American Board of Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.
  • 1.00 American Board of Surgery (ABS) Accredited CME

    Successful completion of this CME activity enables the learner to earn credit toward the CME requirement of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

  • 1.00 AMA PRA Category 1 Credit™
    The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
  • 1.00 Attendance
Course opens: 
07/01/2026
Course expires: 
07/01/2027
Cost:
$25.00

Vishnu Vandana Dubakula, DO1, Shayan Salehi-Hajivandi, MD1, Namratha Gangidi, MBBS2, Blake Oliaro, MD1, Jadvinder Goraya, MD3, and Kevin Alexander Zamora, MD1 

 

1 Department of Internal Medicine, Baylor Scott & White Medical Center –Round Rock, Round Rock, Texas, USA  

2 Kamineni Academy of Medical Sciences and Research Centre, Hyderabad, India 

3 Pulmonary and Critical Care Department, Baylor Scott & White Medical Center –Round Rock, Round Rock, Texas, USA 

 

Corresponding author: Vishnu Vandana Dubakula, DO, Department of Internal Medicine, Baylor Scott & White Medical Center –Round Rock, 300 University Blvd., Round Rock, TX 78665 (e-mail: [email protected]) 

Accreditation

The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Designation

AMA PRA Category 1 Credit™

The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABS CC

Successful completion of this CME activity enables the learner to earn credit toward the CME requirement of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

ABIM MOC

 Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

Available Credit

  • 1.00 American Board of Internal Medicine (ABIM) MOC Part 2
    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.00 MOC points in the American Board of Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.
  • 1.00 American Board of Surgery (ABS) Accredited CME

    Successful completion of this CME activity enables the learner to earn credit toward the CME requirement of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

  • 1.00 AMA PRA Category 1 Credit™
    The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
  • 1.00 Attendance

Price

Cost:
$25.00
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