PATIENT: Kiera Towers 8yo FN Golden Retriever 25kg
HISTORY: longterm history of very occasional diarrhoea. Feb 2015 cutaneous MCT removed from thorax. Further cutaneous MCT removed nearby original site in Nov 15. Then 2 months ago started vomiting, melaena then diarrhoea, dull, hyporexia, weight loss. Radiographs / gastroscopy NAD. ACTH stim normal, food allergy blood panel all negative. Faces positive for campylobacter, has had erythromycin but no clinical response. Also no clinical response to MNZ, salazopyrin, preds, omeprazole, zitac. In-house biochem WNL, pancreatic snap negative.
Complex findings. Distally in the ileum there is a marked luminal distension, with complete shadowing for part of its length (which in total is >30cm). This is compatible with abnormal luminal content of the ileum. Differentials here include foreign body, or alternatively solidified / impacted intestinal content, which could have accumulated subsequent to impaired flow through the s-shaped / abnormal 2-3cm segment of ileum, at the distal aspect of the luminal distension. However equally this segment of ileum could be a consequence of a foreign body. Differentials for pathology of the s-shaped ileum segment are – inflammatory change subsequent to attempted passage of a foreign body, or neoplasia / focal inflammatory lesion which itself is causing a partial obstruction. The adjacent mildly abnormal lymph node may reflect either reactive lymph node or neoplastic infiltration, depending on the pathology in the ileum wall. FNA’s of lymph node were collected and cytology is pending. Ultimately in the absence of evidence of neoplasia in the lymph node aspirates, surgical intervention will be required to relieve the partially obstructive lesion, and this may involve excision and histopathology of the s-shaped ileum segment.
BILIARY TRACT: Normal
LEFT KIDNEY: Normal
RIGHT KIDNEY: Normal
LEFT ADRENAL: Normal
RIGHT ADRENAL: Normal
URINARY BLADDER: Normal
ILIOSACRAL LYMPH NODES: Normal
VISCERAL LYMPH NODES: Abnormal – adjacent to reported abnormal segment of ileum, there is a rounded / ‘fat’ 1.3cm dia visceral LN which is mildly hyperechoic and non-vascular, with regular margins and a smooth echogenic capsule. The parenchyma is uniform / homogeneous.
SMALL INTESTINES: Abnormal – in the right caudal abdomen there is an abnormal segment of ileum. Approximately 20cm proximal to the ileocolic junction there is an abnormal tortuous segment of ileum which is only a few cm long and the wall of this segment is mildly thickened at 7mm, with indistinct layering and a markedly hypoechoic wall. This is likely adhesed to itself in an s-shape. Adjacent there is a mildly hyperechoic surrounding mesenteric reaction. Proximal to this there is marked luminal distension of the ileum (2.5cm lumen) with markedly echogenic solid content which distally (ie towards the ileocolic junction end) is non shadowing but more proximally is completely shadowing with total loss of deeper visualisation. This lasts for >30cm before the ileum returns to normal. The wall in the distended segment is 3mm thick and layering is preserved (ie normal). The remainder of the intestines are unremarkable.
LARGE INTESTINES: Normal
GENITAL TRACT: Not applicable
NVi comment on cytology: similarly to the ultrasound appearance, the cytology is most suggestive of a reactive / inflammatory process, however neoplasia remains a less likely possibility and is unfortunately still not fully excluded. Exploratory surgery with excision of the s-shaped segment of ileum and removal of the abnormal ileum content proximal to this, is neccessary.
FNAB mass (intestinal/lymph node?)
The smears contain low to large numbers of erythrocytes together with moderate numbers of variably preserved nucleated cells. Where intact, the latter consist predominantly of pleomorphic lymphocytes, predominantly small to intermediate cells with up to 10-15% large cells. The latter have minimal hyperchromatic cytoplasm and round to angular nuclei that are 1.5-2.5 x RBCs in diameter with fine basophilic chromatin and occasional moderately conspicuous nucleoli. Occasional mitoses are also evident. There are low numbers of neutrophils, eosinophils, macrophages and very rare plasmacytoid cells. Occasional lymphoglandular bodies are present in the background.
Interpretation and comment:
Overall, this is most suggestive of a reactive lymphadenopathy. However, there is a mild increase in large lymphocytes (described in detail, above) and, as such, I would not exclude early or metastatic lymphoma. More invasive investigation may be worthwhile.
BVSc, MVSc, MACVSC, DipACVP, MRCVS