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My dog is a 5.5 year old miniature schnauzer (neutered male).

Med history: Grade I mast...
My dog is a 5.5 year old miniature schnauzer (neutered male). Med history: Grade I mast cell tumor surgically removed (margins clean) in October 2007; diagnosed with SLO in May 2009 which went into remission after treatment with tetracycline, niacinamide, EPA/DHA; he also has a history of colitis and is a very sensitive and nervous dog. Three weeks ago, he started having loose stool (but with normal frequency and volume. He also had minor back spasms when petted on his back. These symptoms were originally attributed to 3 days of bad weather (he is terrified of thunder and lightning). After 4 days of diarrhea, I took him to his regular veterinarian and he had a temperature of 104.7. X-ray revealed an enlarged spleen. Blood tests on June 16 revealed WBC of 3.33 with a degenerative left shift (band neutrophils 14% and monocytes 31%), HCT 39%, globulin 4.2, bilirubin 0.71, other parameters were within normal limits. He received treatment with metronidazole and clavamox. There was no improvement after 2 days and he became more lethargic and was still having loose bowel movements. Over the next 6 days he received treatment with IV fluids and broad-spectrum IV antibiotics (ampicillin, doxycycline, baytril), famotidine, and omeprazole. Tests for PLI, parvo, fecal float, fecal giardia/crypto were all negative. Abdominal ultrasound revealed enlarged spleen with normal echogenicity, mild increase in size of right lobe of pancreas with mild increase in echogenicity of the mesentery, some intra-abdominal lymph nodes were noted. Blood tests were repeated while hospitalized which revealed leukopenia and anemia. Test results on June 18: WBC 2.27, HCT 36%, platelets 113K. Test results on June 20: WBC 6.88, globulin 3.6. Test results on June 21: plasma protein 7.9, HCT 33%, band neutrophils 0.2, monocytes 1.9, with rare eccentrocytes and pyknocytes, some spherocytes, and no agglutination. Test results on June 22: plasma protein 7.5, HCT 32%, WBC 9.8, band neutrophils 0.9, very rare eccentrocytes, pyknocytes, and possible spherocytes were present but in fewer numbers than previously observed. Test results on June 23: plasma protein 7.5, HCT 39%, WBC 7.4, band neutrophils 0.3, monocytes 2.2, occasional reactive lymphocytes. Test results on June 24: WBC 3.77, segs 45%, bands 4%, lymphocytes 32%, monocytes 17%, RBC 4.4, HCT 33%. For the past 3 days he has been home and is receiving oral antibiotics (clavamox, baytril, doxycycline). He has been afebrile for the past 6 days but has been lethargic and still has soft stool with yellow mucous in it. He is eating and drinking but not as much as usual. He also is barking less then usual and his voice is different. He has 3 places on his skin which are red. His chin is red and warm to the touch with a pimple-like bump, he has a red spot on his forearm, and his groin area is red and swollen. Multiple veterinarians have been unable to diagnose his condition. Please can you help? I love my dog very much, he is like my son and I’m afraid I’m going to lose him.
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Answered in 11 minutes by:
6/26/2010
VetInternist
VetInternist, Board Certified Veterinarian
Category: Dog Veterinary
Satisfied Customers: 1,181
Experience: Staff Internist and Medical Director
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That is a very thorough history, I can tell how much you care about this little guy!

My answer isn't going to be very long. My main focus for you would be on the spleen and lymph nodes in the abdomen. It is possible that he had an infection, but there maybe something else going on. I would recommend aspiration of the lymph nodes and spleen under ultrasound guidance and submission of the cells to a clinical pathologist for review. Everything may be reactive, but it is possible there is some other process affecting the abdomen. The ultrasound results isn't really scary, but the changes to the mesentary and other abnormalities are a little concerning. I would be looking for evidence of infectious organisms (may be difficult since he is on antibiotics) and unfortunately cancer. The earlier we can get an idea of what is going on, the better the chance we will have to make him feel better. If the aspirates of the lymph nodes and spleen aren't conclusive, surgical biopsies of the lymph nodes, intestines and any other abnormal organs (probably not the spleen since it bleeds a lot when biopsied) would be indicated.

ResidentVet
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Customer reply replied 8 years ago
Forgot to include this in my original narrative - the internal medicine vet did a spleen aspirate during the ultrasound and pathological review of this didn't find any cancer cells or other abnormalities. I'm hesitant to put him through general anesthesia or surgery unless the outcome would be worth it. I don't want to lose him but I also don't want to put him through undue stress or pain if the progrnosis is grave. Do you think it could be SLE or another autoimmune disease (IMHA or auto-immune neutropenia)? I can't understand why the blood counts normalized and then dropped again. Are the possible cancers treatable?
IMHA seems unlikely since his HCT isn't very low. Immune mediated neutropenia is a possibility, but the other signs are unusual unless he also has an infection on top of the immune mediated disease (possible, though). I would like to know what the cells look like in the lymph nodes if possible. An aspirate wouldn't likely require much more than mild sedation, but it may give us an answer. The SLE is possible, but this doesn't sound much like SLE, since the skin problems seem less aggressive than SLE and there aren't other abnormalities common with SLE on the blood work. Some cancers are treatable, but few are curable. Getting an answer is the first step; you have done a lot for your dog already, but more invasive tests may be necessary. I would also consider a bone marrow to see if a reason for the low white blood cells can be found.

ResidentVet
VetInternist
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Customer reply replied 8 years ago

Dear ResidentVet, thank you for your assessment of this unusual case.

 

Some more info: Chemistry profile over the past 10 days hasn't indicated any abnormalities with liver or kidneys. A fecal smear revealed some WBC and inflammatory cells present, moderate amount of mucous, no appreciable bacterial overgrowth. A rectal exam was unremarkable with no melena found, no significant findings, prostate and anal sacs normal. Multiple abdominal and chest radiographs and ultrasound have been performed and did not reveal any masses or endocarditis. Although abdominal ultrasound revealed splenomegaly, the echogenicity was normal. Could the GI symptoms just be IBD since he has a history of colitis and occasional vomiting (ever since he was a puppy)? He's very sensitive and nervous. Could all of the antibiotics be causing mucous and soft stool? There is no blood in his stool and he's not vomiting. If he has a severe infection, how long could that take to resolve? He's been on broad-spectrum antibiotics now for 10 days.

The GI symptoms could be IBD, but IBD severe enough to cause the other problems we are seeing would usually be associated with abnormalities on the chemistry profile, such as low protein. I also wouldn't expect a low white blood cell count or significant bands in circulation noted on the CBC. Antibiotics can definitely cause diarrhea, but it sounds like this problem was present prior to the administration of antibiotics. Severe bacterial infections usually begin to resolve or get much worse quickly. This isn't always true, but I would expect a change for better or worse in a few days. Fungal infections like histoplasmosis can cause these problems (GI problems, increased lymph nodes in the abdomen, bone marrow issues like low platelets or low white cells) and won't respond unless appropriate antifungal medications are used (fluconazole, itraconazole, or amphotericin). A urine test can be submitted to MiraVista laboratories for a histoplasma urine antigen test and will more than likely diagnose this type of fungal infection if present.

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