Tumor lysis syndrome differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohamad Alkateb, MBBCh [2]

Overview

Tumor lysis syndrome must be differentiated from other diseases that cause hyperuricemia, hyperkalemia, and hyperphosphatemia, such as acute kidney injury. The common conditions are hereditary hyperuricemia, Insulin resistance, Hypertension, Obesity, Gout, Alcoholism and renal insufficiency. Patients taking ACE inhibitor, NSAIDs and Antibiotics such as trimethoprim are more prone to hyperkalemia. Hyperphosphatemia is usually seen in Acute kidney injury, Hypoparathyroidism, vitamin D supplementation and also in sarcoidos.

Differentiating tumor lysis syndrome from other Diseases

Tumor lysis syndrome must be differentiated from other diseases that cause electrolytes disturbance.

• Hyperuricemia:

• Hereditary hyperuricemia
• Insulin resistance
• Hypertension
• Obesity
• Gout
• Alcoholism
• Renal insufficiency
• Medications:

• Diuretics
• Salicylates
• Pyrazinamide
• Ethambutol
• Nicotinic acid
• Ciclosporin

• Hyperkalemia:

• Renal insufficiency
• Medications

• ACE inhibitor
• angiotensin receptor blockers
• Potassium-sparing diuretics such asamiloride and spironolactone
• NSAIDs such as ibuprofen and naproxen
• Ciclosporin
• Tacrolimus
• Antibiotics such as trimethoprim
• Antiparasitic drugs such as pentamidine

• Mineralocorticoid deficiency or resistance:

• Addison's disease
• Aldosterone deficiency
• Some forms of congenital adrenal hyperplasia
• Type IV renal tubular acidosis

• Gordon's syndrome (pseudohypoaldosteronism type II)

• Hyperphosphatemia

• Acute kidney injury
• Hypoparathyroidism
• Vitamin D
• vitamin A intoxication
• Sarcoidosis
• Immobilization
• Osteolytic metastases
• Milk-alkali syndrome
• Severe hypermagnesemia or hypomagnesemia
• Pseudohypoparathyroidism
• Acromegaly
• Extensive cellular injury or necrosis:

• Crush injury
• Rhabdomyolysis
• Hyperthermia
• Fulminant hepatitis
• Severe hemolytic anemia

• Transcellular phosphate shifts:

• Metabolic acidosis
• Respiratory acidosis

Differentiating tumor lysis syndrome based on hyperkalemia:

Organ system Conditions Distinguishing features Additional findings Symptoms Signs Labs Tissue break down Tumor lysis syndrome Fever, weight loss, symptoms related to underlying malignancy Altered mental status, lymphadenopathy, muscle weakness Hyperkalemia, hyperphosphatemia, hypocalcemia History of underlying malignancy Rhabdomyolysis Myalgia, fatigue Altered mental status, hypotension Hyperkalemia, increased muscle enzymes (CK, aldolase) History of seizure, drug overdose, or trauma Renal Acute kidney injury Nausea, vomiting, decreased urine output, fatigue, dyspnea, edema Tremor, confusion, edema Hyperkalemia, increased BUN and Cr, metabolic acidosis Recently developed symptoms Chronic kidney disease Nausea, vomiting, decreased urine output, fatigue, dyspnea, edema Tremor, confusion, edema Hyperkalemia, increased BUN and Cr, metabolic acidosis, hypocalcemia, hyperphosphatemia Chronic underlying disease (DM, HTN), duration of symptoms ≥ 3 months Renal tubular acidosis type-4 Usually asyptomatic Signs of underlying disease Hyperkalemia, normal anion gap metabolic acidosis, urine PH< 5.5 History of diabetes mellitus Endocrine DKA Change in mental status, abdominal pain Decreased skin turgor, dry oral mucosa, tachycardia Hyperglycemia, increased anion gap metabolic acidosis, ketonemia Rapidly developing polyuria, polydipsia, and weight loss HHS Change in mental status, abdominal pain Decreased skin turgor, dry oral mucosa, tachycardia Severe hyperglycemia, normal anion gap, increased serum osmolality Polyuria, polydipsia, and weight loss develop more insidious Congenital adrenal hyperplasia (CAH) Poor feeding, failure to thrive, precocious puberty, short statue, hirsutism, weight loss Ambiguous genitalia, hypotension Hyperkalemia, increased 17 hydroxyprogestrone, hyponatremia Salt wasting Addison's disease Skin hyperpigmentation, fatigue, salt craving, nausea and vomiting, amenorrhea, depression Hyperpigmentation, hypotension, pubic and axillary hair loss Hyperkalemia, decreased serum cortisol level Diagnosis by cosyntropin test