Background 
Diffuse large B cell lymphoma (DLBCL) is a common subtype of non-Hodgkin lymphoma. Rarely, it presents with lactic acidosis, a paraneoplastic phenomenon associated with high mortality. Lactic acidosis is caused by the Warburg effect, resulting in lactate production even in the presence of oxygen. Few cases of lactic acidosis in DLBCL have been reported. Prompt diagnosis and management are crucial. Treatment with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) chemo-immunotherapy is standard for DLBCL. We present a case of lactic acidosis in a 60-year-old female with DLBCL, emphasizing the importance of timely recognition and treatment of this condition in hematologic malignancies due to its poor prognosis. 

Case Presentation 
We present the case of a 60-year-old woman with a complex medical history, including obesity, hypothyroidism, chronic low back pain, adrenal insufficiency, anemia, thrombocytopenia, hyponatremia, and psychogenic polydipsia. She was admitted due to confusion, gait imbalance, dyspnea, leg edema, and hypotension. Elevated lactate levels indicated potential metabolic issues related to her comorbidities. Multiple specialties were consulted. Diagnostic procedures included laparoscopy, negative AAT stool results, liver and bone marrow biopsies, and discontinuation of antibiotics after negative cultures. Despite continuous monitoring, her lactate level remained elevated. Abnormal light chain ratio and albumin-predominant proteinuria suggested amyloidosis. Imaging revealed lung abnormalities, and a thoracentesis showed lymphocytic exudates. A biopsy of the abdominal fat pad confirmed diffuse large B cell lymphoma (DLBCL). Kidney function worsened, requiring pressure support. Treatment with Rituxan and Rasburicase, followed by R-CHOP chemotherapy, was initiated. This case underscores the challenges in managing a patient with multiple comorbidities, leading to metabolic abnormalities, lung findings, and a diagnosis of DLBCL. Prompt treatment initiation was vital. 

Discussion 
Lactic acidosis, an uncommon manifestation of hematologic malignancies, is associated with poor prognosis. Lactic acidosis occurs when there is an imbalance between lactic acid production and hepatic metabolism. It is classified into types A, B, and D based on the underlying causes. Type B lactic acidosis is linked to malignancies, including hematologic cancers, where tumor cells rely on glycolysis for energy production. The Warburg effect explains this phenomenon, where tumor cells preferentially metabolize glucose to lactate even in the presence of oxygen. Treatment involves addressing the underlying malignancy, while supportive measures like hemodialysis and thiamine supplementation may be used. Malignancy-associated lactic acidosis is a grave prognostic marker. 


Lactic Acidosis Unveiled: A Hidden Clue to Diffuse Large B Cell Lymphoma

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