VUS Case of the Month - September 2018

Submitted by: Elodie Huguet, DVM and Kip Berry, DVM, DACVR, Veterinary Speciality Hospital of the Carolinas

Signalment & History:

  • A 13-year-old 5.0-kg male neutered mix-breed dog presented with a 2-week history of decreased appetite, diarrhea and intermittent episodes of vomiting.
  • Labwork performed on the day of presentation included a complete blood count, which documented a leukocytosis characterized by a neutrophilia, lymphopenia and monocytosis, as well as mild thrombocytopenia. A chemistry panel revealed a panhypoproteinemia (total proteins- 3.7mg/dL, albumin- 1.3mg/dL and globulin- 2.4mg/dL), hypocholesterolemia, hypoglycemia and increased alkaline phosphatase.
  • The patient was referred for an abdominal ultrasound and transferred following stabilization with IV fluids and dextrose supplementation.

ANSWER:

  • Multiple small intestinal segments have severe, diffuse, irregular and eccentric wall thickening. A focal, hypoechoic and eccentric jejunal wall mass characterized by loss of wall layering is identified within the left cranial abdominal region. The mass measures 8.1mm in thickness and is surrounded by hyperechoic mesentery. The remaining small intestine is diffusely corrugated and thickened. A mild amount of anechoic peritoneal effusion is observed adjacent to the small intestine and interdigitates the mesentery.
  • Additional diagnostics included an abdominocentesis and fine needle aspirates of the jejunal mass. The obtained peritoneal fluid was grossly serosanguinous and cloudy. The total protein levels were <2mg/dL with evidence of blood contamination. No additional abnormalities were observed on cytologic evaluation of direct, sediment and cytocentrifuged preparations. The peritoneal fluid was classified as a modified transudate and neoplasia was considered a possible etiology.
  • The fine needle aspirates of the jejunal mass documented lymphoma with concurrent evidence of inflammation.

COMMENTS:

In this case, lymphoma was the main contributor to the severity and diffuseness of the corrugation observed along with secondary inflammatory changes. The diffuse small intestinal thickening as observed in the current dog was likely associated with malabsorption and panhypoproteinemia. This was consistent with the lab work findings and peritoneal fluid analysis performed in this case. No evidence of mechanical ileus was identified as most commonly seen with alimentary lymphoma in comparison to other gastrointestinal tumor types. While endoscopic or surgical biopsies of the gastrointestinal tract for histopathologic evaluation with immunohistochemistry would have been a preferred diagnostic method, fine needle aspirates of affected gastrointestinal sites for cytologic evaluation can be beneficial as in this case to obtain a faster diagnosis to guide therapy and initial staging.

CYTOLOGIC INTERPRETATION (See Images Above):

Two digital photomicrographs (Infinity Analyze camera Model 2-3C) of a Wright’s stained cytologic preparation from the jejunal mass using an optical microscope (Olympus BX46) at 100x magnification. The specimen is highly cellular consisting predominantly of lymphoblasts (*) admixed with a few small lymphocytes (†), occasional non-degenerate neutrophils (‡), few macrophages (§), and rare well-differentiated epithelial cells (not pictured). The lymphoblasts contain a small amount of deeply basophilic cytoplasm. The nuclei are round with stippled chromatin and indistinct nucleolar rings. Mitotic figures are occasional (||). Several lymphoglandular bodies and numerous red blood cells are observed in the lightly proteinaceous background. Cytologic interpretation and image acquisition courteously provided by Dr. Nancy B. Collicutt (Antech Diagnostic Laboratories).