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GERIATRIC CARE— SIGNALMENT: “Giselle” Is a 14 Year Old Female Spayed Domestic Shorthair

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GERIATRIC CARE— SIGNALMENT: “Giselle” Is a 14 Year Old Female Spayed Domestic Shorthair Volume 10 | Issue 4 | April 2018 Clinical Consults What’s Your Diagnosis? PATIENT HISTORY GERIATRIC CARE— SIGNALMENT: “Giselle” is a 14 year old female spayed domestic shorthair. Weight Diligent Pursuit of Concurrent Disease 6.6 lb/3 kg. PERTINENT PAST HISTORY: “Giselle” has Donna J. Spector , DVM, DACVIM, Internal Medicine generally been a very healthy cat. “Giselle” experiences intermittent vomiting and has Case submission from Dr. Catherine Loughner, VCA Greenback Animal Hospital been presumptively diagnosed with food in Fair Oaks, California hypersensitivity. She eats a venison and green pea diet for this and her clinical signs are fairly well controlled. She is current on vaccinations antibody assay was negative. The chemistry abnormalities included a mildly elevated ALT at 110 and preventative care as recommended by her U/L (ref. range 10-100 U/L) and a mildly decreased creatinine of 0.5 mg/dL (ref. range 0.6-2.4 mg/ primary care veterinarian. dL). Clinical Note: A decreased serum creatinine is not unexpected in untreated hyperthyroid cats as it often reflects muscle mass loss/sarcopenia or the increased glomerular filtration rate CURRENT HISTORY: “Giselle” presented to her which is present in the untreated hyperthyroid state. The urinalysis (collected via cystocentesis) primary care veterinarian for evaluation of a revealed a specific gravity of 1.048 with 2+ proteinuria. There was 3+ occult blood and 11-20 RBC/ skin mass on her inner right thigh. On hpf on sediment examination which was felt to be related to a traumatic collection. examination, the mass was 4 cm x 3 cm on the medial aspect of the right pelvic limb. The CBC revealed moderate to markedly elevated WBC at 33,700/uL (ref. range 3,500-16,000/ The mass was alopecic but no erythema or uL). The leukocytosis was characterized by marked lymphocytosis of 25,949/uL (ref. range ulceration was noted. No local 1,200-8,000/uL). All other cell lines were within normal limits. Dr. Loughner requested a lymphadenopathy was noted. “Giselle’s” pathologist review which is detailed in Table 1. primary care veterinarian recommended removal of the mass for histopathology as well TABLE 1. as a senior wellness panel to assess her “GISELLE’S” CBC PATHOLOGY REVIEW overall health as four pounds of weight loss Leukocyte density is increased and is characterized by lymphocytosis. Lymphocyte morphology is had been noted gradually over the last several small and mature. Blast cells are not identified. Features may be compatible with“stress” years. Clinical Note: Fine needle aspiration (transient small lymphocytosis secondary to epinephrine-type stress/splenic contraction), antigenic should be advised prior to surgery. While stimulation (such as may occur following vaccination or with inflammatory disease),hyperthyroidism not all subcutaneous masses exfoliate cells or lymphoproliferative disease (chronic lymphocytic leukemia, etc.). well, mast cell tumors and some others will be readily identified and allow the best Correlate with clinical impression as reactive lymphocytosis can occasionally reach upwards of surgical planning. 30-40,000 in feline patients. Consider additional testing and/or monitoring as clinically indicated. If small lymphocytosis persists, or is ever associated with clinical illness or FeLV/FIV infection; a bone “Giselle’s” lab work included a CBC, marrow aspiration, flow cytometry of blood and evaluation for lymph node/splenic enlargement should chemistry panel, total T4, heartworm antibody be considered to rule out lymphoproliferative neoplasia. assay and a urinalysis. “Giselle” was noted to be hyperthyroid with a total T4 of 6.3 ug/dL I would advise flow cytometry as a first option on peripheral blood as it will not only assess (ref. range 0.8-4 ug/dL). Her heartworm clonality but if neoplastic, will also address phenotype. All of “Giselle’s” laboratory abnormalities were TABLE 2. considered potentially consistent with her POSSIBLE LABORATORY CHANGES IN HYPERTHYROIDISM diagnosis of hyperthyroidism. See Table 2 for laboratory changes in hyperthyroidism. • Polycythemia • Neutrophilia Control of her hyperthyroidism was recommended CBC prior to surgery for the skin mass on her right pelvic • Lymphocytosis limb to ensure “Giselle” was as safe of an • Eosinophilia anesthetic candidate as possible. “Giselle” was started on 2.5 mg methimazole every 12 hours. • Elevations of liver enzymes. Approximately 90% of cats have mild to Although a four week recheck was moderate elevations of ALT, ALP, and/or AST. Less commonly, serum recommended, her owner returned in six weeks. total bilirubin may be mildly increased (usually <2 mg/dL) • Azotemia. May develop from increased protein catabolism, concurrent The lab work revealed good control of her Chemistry panel renal disease, hypertension and pre-renal effects hyperthyroidism. The total T4 was normal at • Decreased serum creatinine and increased creatine kinase. Due to loss 1.7 ug/dL, ALT had normalized at 50 U/L and the of muscle mass and muscle protein catabolism, respectively serum creatinine was essentially unchanged. • Hypokalemia, hyperglycemia, hypercalcemia, hypernatremia, Her WBC was still moderately elevated at 28,000/uL hyperphosphatemia and was still characterized by a moderate to marked lymphocytosis of 16,240/uL. She had TABLE 3. also developed a mild anemia and her RBC count had declined from 8.8 million (38% HCT) “GISELLE’S” PELVIC LIMB SQ MASS HISTOPATHOLOGY to 5.6 million (24% HCT). Another pathology History: Mass on medial right hind limb, proximal to hock. Mass has been growing review revealed a similar small and mature population of lymphocytes and the anemia Description: Lesion is comprised of interwoven bundles and streams of immature fibroblasts and variable appeared non-regenerative which was amounts of collagenous fibers. The tumor cells are fusiform but in some areas are ovoid or stellate in confirmed with a reticulocyte count. Clinical shape. The nuclei are elongated or oval and hyperchromatic. The mitotic count (mitoses in 10 high power Note: While the anemia was possibly fields) is 41. There is no intratumoral necrosis. The overlying epidermis, however, is ulcerated. concerning for methimazole toxicity or due to Microscopic Findings: Fibrosarcoma, intermediate grade underlying disease, “Giselle” had been sedated at the time of the blood draw which Comments: Local excision appears to be narrow but complete with margins of 0.2 centimeters to all often results in splenic sequestration of RBCs. sides. The excision site should be monitored for evidence of recurrence as recurrence is not The decision was made to monitor the level of uncommon even following apparent complete excision. Clinical Note: In general, soft tissue anemia closely. sarcomas have a high rate of local recurrence even after apparent complete excision. The recommended gross margins are 3 cm laterally and one fascial plane deeper than the tumor. The “Giselle’s” skin mass was removed, submitted metastatic rate is low for low grade (<10%) and rises with tumor grade (high grade metastatic for histopathology (see Table 3) and found to be potential is up to 50%). a fibrosarcoma. Due to the narrow excision of the fibrosarcoma, “Giselle’s” owner was given the option of an oncology referral to discuss count in one month and then proceed with through Antech Diagnostics. See Table 4 for additional treatment options such as additional further testing if indicated at that time. indications and procedure for flow cytometry. surgery, radiation therapy, etc. which the owner declined. The primary care veterinarian One month later “Giselle” presented for a “Giselle’s” flow cytometry revealed a recommended a fibrosarcoma monitoring plan recheck. Although she had gained 6 ounces, homogenous expansion of CD4+ T-cells. The of physical examination/palpation once monthly she was vocalizing excessively throughout the findings were most consistent with T-cell for 3 months, followed by every 3 months for the day and night and seemed restless with pacing leukemia or lymphoma. Clinical Note: It is remainder of the year following surgery. noted at night. It was suspected her not possible to distinguish between these two hyperthyroidism may be out of control or she entities by immunophenotyping, but the most The primary care veterinarian further discussed had become hypertensive. Her blood pressure common phenotype of CLL in the cat is the lymphocytosis with “Giselle’s” owner. The was checked numerous times and was normal. CD4+. Thoracic radiographs and abdominal lymphocytosis had improved somewhat with Her total T4 was still controlled at 1.1. Her ultrasound imaging was recommended to control of her hyperthyroidism. The RBC count had returned to previous levels. Her identify other organs which may be involved in lymphocytosis could also be reactive to the lymphocyte count was persistently elevated at an infiltrative lymphoma process. The owners fibrosarcoma that had just been removed. It was 17,020/uL so her owner agreed to additional declined additional diagnostic workup and recommended to recheck “Giselle’s” lymphocyte testing. A flow cytometry was performed referral to an oncologist. Leukemia refers to a group of diseases DIAGNOSIS DISCUSSION characterized by clonal proliferation of Detailed discussions of feline hyperthyroidism Hyperthyroidism neoplastic hematopoietic cells within the bone and fibrosarcoma are beyond the scope of marrow. Leukemias are classified as either Subcutaneous fibrosarcoma this article and the reader is referred to the myeloid or lymphoid
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