Ixazomib-associated tumor lysis syndrome in multiple myeloma A case report

Rationale: Tumor lysis syndrome (TLS) is an oncologic emergency, but its incidence in MM is rare. To our knowledge, ixazomib has not been associated with TLS in MM. Patient concerns: The patient developed TLS after 10 days of treatment with ixazomib, accompanied by renal failure of hyperuricemia, hyperkalemia, and hyperphosphatemia. Diagnoses: MM (type IgG lambda) was diagnosed according to the diagnostic criteria established by the International Myeloma Working Group and classified stage IIA by the International Staging System. TLS was diagnosed after the patient met all three criteria of the Cairo-Bishop TLS scoring system. Interventions: From April 8, 2017, the patient was treated with 3 courses of bortezomib, cyclophosphamide, and dexamethasone chemotherapy. From August 18, she received five courses of bortezomib combined with DCEP chemotherapy. On May 21, 2018 treatment was switched to lenalidomide, bortezomib, and dexamethasone for four courses. Ixazomib was started on October 10, 2018 with cyclophosphamide and dexamethasone. On October 19, 2018 vigorous intravenous hydration with sodium bicarbonate was initiated and peroral febuxostat was administered. Outcomes: On October 19, changes in hematological indicators raised concern for TLS worsening kidney function and decreasing urine output. She refused renal replacement treatment for TLS-induced acute kidney injury. On October 26th, the patient died of respiratory failure. Lessons: This case highlights the need to vigilant for the occurrence of TLS in patients undergoing MM treatment with ixazomib. Higher baseline uric acid or creatinine, rapidly progressive anemia, and raised lactate dehydrogenase (LDH) and beta 2-microglobulin may be surrogate markers of TLS.