A case report of anaphylaxis caused by initial administration of rasburicase resulting in death just before the treatment of diffuse large B cell lymphoma

Abstract Background: Rasburicase has potent efficacy in controlling uric acid and is widely used to prevent tumor lysis syndrome in high-risk patients owing to its low toxicity profile. However, the safety of rasburicase re-administration has not been established due to the risk of anaphylaxis mediated by antibody production. However, reports of such reactions upon the initial administration of rasburicase are scarce. Case presentation: A 71-year-old Japanese female who had been diagnosed with diffuse large B cell lymphoma with a large tumor burden experienced anaphylactic shock leading to death that occurred upon initial administration of rasburicase just before the chemotherapy. The patient had several unfavorable characteristics that resulted in a fatal outcome, including a predisposition to allergies. Moreover, there was a large tumor in the posterior mediastinum that, although it would not cause a significant issue under normal circumstances, could severely impact hemodynamics if the patient entered into a state of shock. Chest compressions during cardiopulmonary resuscitation resulted in crushing of the tumor. The pre-and postmortem examination revealed that the cause of death was a cascade of events starting with anaphylaxis-induced distributive shock leading to obstructive shock due to collapse of the heart, which was compressed by the tumor. This was further compounded by massive bleeding from the tumor and tension hemothorax, resulting in circulatory collapse. Conclusions: Anaphylaxis can lead to lethal outcomes when unfavorable conditions overlap. Clinicians need to carefully assess the indication for rasburicase, considering both the risk of tumor lysis syndrome and the patient’s background risks simultaneously.