Oncology Case Study: A Dog with Epistaxis

I will post the answers to the first questions below, so that we can move on to the next part of the case.

Question 1: Create a prioritised problem list and list your top differentials for each problem.

1. Unilateral epistaxis
   • Nasal tumour (adenocarcinoma, sarcoma, lymphoma…)
   • Foreign body (grass seed…)
   • Infection (e.g. fungal – aspergillosis)
   • Trauma
   • Dental disease/oronasal fistula
   • Coagulopathy/thrombocytopenia
   • Hypertension
   • Hyperviscosity syndrome
2. Left pelvic limb lameness
   • Trauma (soft tissue, fracture)
   • Neoplasia (primary bone tumour [e.g. osteosarcoma], metastatic lesion)
   • Cruciate ligament rupture
   • Osteoarthritis
3. Retinal haemorrhage
   • Hypertension
   • Coagulopathy
   • Hyperviscosity syndrome
   • Inflammatory/infectious/neoplastic chorioretinitis
4. Splenomegaly
   • Benign cause (e.g. haematoma, hyperplasia)
   • Neoplastic (mass [e.g. haemangiosarcoma], infiltration [e.g. haematopoietic neoplasia])
   • Congestion (e.g. GDV, right-sided congestive heart failure, splenic torsion)
   • Immune-mediated haemolytic anaemia
5. Lethargy
   • Non-specific, likely related to underlying disease process

Question 2: What are your next diagnostic steps?

To start to investigate and rule in/out some of the above problems, a sensible starting point would be:

• Haematology, biochemistry, PT/APTT, urinalysis
• NIBP
• Imaging (e.g. radiographs) of left pelvic limb

DAY 2:

You proceed with haematology, biochemistry, coagulation profile, urinalysis, and blood pressure. Barney has eaten just 1 hour before the appointment, so you decide not to sedate straight away for any diagnostic imaging.

Average blood pressure measurement is 135mmHg.

Attached are the blood and urine results.

Question 1: Based on these results can you refine and update your problem list and top differentials? Are any differential diagnoses becoming more likely?

Question 2: Are there any specific precautions needed for Barney based on these results, from a nursing perspective?

Question 3: What are your next diagnostic steps? Justify your answers.

I will post the answers below to day two's questions, so we can move on to the next part of the case:

Question 1: Based on these results can you refine and update your problem list and top differentials? Are any differential diagnoses becoming more likely?

• Regarding initial problem list, coagulopathy/thrombocytopenia/hyperviscosity syndrome become more likely differential diagnoses for the retinal lesions and epistaxis, and hypertension becomes less likely.
• New problems and differentials are:
  • Neutropenia
    • Immune-mediated destruction
    • Overwhelming infection/inflammation
    • Bone marrow neoplasia (lymphoma, leukaemia, multiple myeloma)
  • Thrombocytopenia
    • Immune-mediated thrombocytopenia (primary vs secondary)
    • Bone marrow neoplasia (lymphoma, leukaemia, multiple myeloma)
    • Disseminated intravascular coagulopathy
    • Chronic/severe haemorrhage
    • Infectious disease (e.g. ehrlichiosis)
    • Splenic sequestration
    • Myelofibrosis
  • Total hypercalcaemia
    • Acute kidney injury/chronic kidney disease
    • Neoplasia (lymphoma, multiple myeloma)
    • Hyperparathyroidism
  • Increased creatinine
    • Acute kidney injury (toxicity, secondary to hypercalcaemia, reduced perfusion [e.g. hyperviscosity syndrome])
    • Chronic kidney disease
    • Renal neoplasia
    • Infectious (pyelonephritis)
    • Dehydration (pre-renal)
    • Post-renal (obstruction)
  • Hypoalbuminaemia
    • Inflammation
    • Haemorrhage
    • Protein-losing nephropathy
    • Reduced production (hepatic disease, multiple myeloma)
  • Hyperglobulinaemia
    • Polyclonal (infectious disease [bacterial, fungal, parasitic, protozoal, rickettsial], inflammatory response)
    • Monoclonal (neoplasia [multiple myeloma, lymphoma], certain infectious diseases [ehrlichiosis, leishmaniasis])
  • Prolonged PT/APTT
    • Disseminated intravascular coagulopathy
    • Clotting factor deficiencies/inhibition – various
    • Haemorrhage
    • Toxicity (rodenticide)

Question 2: Are there any specific precautions needed for Barney based on these results, from a nursing perspective?

• Barney should be barrier nursed due to neutropenia, and there should be no blood samples from the jugular vein due to thrombocytopenia and hypocoagulability.

Question 3: What are your next diagnostic steps?

• Ionised calcium (as total calcium is increased).
• Serum protein electrophoresis (to differentiate polyclonal vs monoclonal gammopathy).
• Serology (e.g. 4DX SNAP)
• Imaging to include abdomen (because of splenomegaly, azotaemia), left pelvic limb (due to lameness and pain) +/- head (due to epistaxis). Could also justify thoracic imaging to screen for underlying disease process.
  • Radiographs and ultrasound, vs CT.
• Would ideally obtain fine needle aspirate sampling of spleen +/- any other abnormalities based on imaging results, but coagulopathy and thrombocytopenia may preclude this in this case.

DAY 3

You elected to perform ionised calcium measurement, infectious disease screening (SNAP 4DX), serum protein electrophoresis (SPE) and CT scan of the head, thorax, abdomen and hindlimbs. Fine needle aspirates were not performed due to the risk of bleeding.

The ionised calcium measurement was 1.74 mmol/L (RI 1.18 – 1.37).

SNAP 4DX was negative for Dirofilaria immitis, Ehrlichia (canis and ewingii), Anaplasma (phagocytophilum and platys), and Borrelia burgdorferi.

The CT scan revealed splenomegaly and bony lesions throughout the long bones, vertebral bodies and pelvis (see images attached).

The SPE results are also attached below.

Question 1: Describe the main findings on the CT images.

Question 2: Interpret the SPE trace.

Question 3: What is your diagnosis in Barney’s case, and why?