From: Frank Bailey Gelder ClD Pathology, ASCP, Diosed p ABHI, PhD Pathology Referred to me from my Daughter Rachel Gable as pet owner. I would like your unbiosed opinion. Thank you. Frank: fgelder@probeinternationalinc.com INTERNAL MEDICINE Candice Bailey, DVM, MS, DACVIM Kristen Parker, DVM, MVSc Ashleigh Seigneur, DVM, MVSc, DACVIM RICHMOND I 5918 West Broad Street, Richmond VA 23230 P 804.716.4700 F 804.716.4705 Elizabeth Turner, DVM Patient: Bella Client: Eric Gable ID: 374803 Contact Info: 112 North Plum Street DOB: 10/4/2014 Richmond, VA 23220 Species: Canine (804) 528-7988 Breed: Poodle Mix Sex: Spayed Female Color: brown/white Date: Tuesday, December 12, 2017 Dear Dr. Mason: Pending tests: Please see lab work below. Assessment/Plan: We discussed these results with Mr. Gable. There are some concerning changes to the epithelial cells present that could represent a neoplastic process. However, with the entire case considered, there is also major concern for dysplastic change secondary to inflammation. We still cannot rule out an immune-mediated process. At this time, the owners would like to pursue the addition of another immunosuppressant with Dr. Williams and hold on advanced imaging of the region. The plan is to add mycophenolate @ 125mg q12h. Veterinary Dermatology of Richmond has prepared this medication for Mr. Gable to pick up. SOURCE/HISTORY: 6 months ago, patient developed cough and oral ulcerations. Responded to prednisone and cyclosporine. Cough has returned with debris prednisone. Following activation, red-tinged fluid collected from endotracheal tube. MICROSCOPIC DESCRIPTION: Two slides, one previously stained, of high cellularity are examined. Large numbers of erythrocytes are present within a variably dense, often thick eosinophilic proteinaceous background. The leukocyte population consists of primarily nondegenerate neutrophils with smaller numbers of vacuolated hemosiderin laden macrophages. Occasional macrophages exhibit erythrophagia. The moderate numbers of superficial squamous epithelial cells are present individually and in variably sized sheets. The remaining nucleated cell population consists of small to moderate numbers of polygonal cells that are present individually and in variably sized tightly cohesive clusters. The cells contain small to moderate amounts of deeply basophilic cytoplasm and round to ovoid nuclei. The chromatin is finely to coarsely granular and nucleoli, when visible, are basophilic and round to ovoid. There is mild to moderate anisocytosis and anisokaryosis in this population. An extensive search reveals no intracellular microorganisms. MICROSCOPIC INTERPRETATION: Neutrophilic inflammation with epithelial atypia. See comment. COMMENTS: A cause for the inflammation is not identified on the slides. The absence of visible microorganisms does not preclude infection. Given the presence of significant inflammation, it is not clear whether to polygonal cells represent a reactive or neoplastic population. Given the chronicity of the disease process and relatively young age of the patient, reactive change is considered more likely. Findings need to be interpreted in conjunction with any other relevant information and the clinical impression. Thank you for including the relevant clinical history; it is greatly appreciated. PATHOLOGIST: Jennifer Steinberg, DVM Diplomate, American College of Veterinary Pathologists Direct: 410-424-3545 1-888-433-9987, option 0 x43545 Email: jennifer-steinberg@idexx.com Thank you for entrusting Dogwood Internal Medicine with Bella's care. Please let us know if you have any questions or concerns about this case. Sincerely, Candice Bailey, DVM, MS, DACVIM 2. INTERNAL MEDICINE Candice Bailey, DVM, MS, DACVIM Kristen Parker, DVM, MVSc Ashleigh Seigneur, DVM, MVSc, DACVIM RICHMOND I 5918 West Broad Street, Richmond VA 23230 P 804.716.4700 F 804.716.4705 Elizabeth Turner, DVM Patient: Bella Client: Eric Gable ID: 374803 Contact Info: 112 North Plum Street DOB: 10/4/2014 Richmond, VA 23220 Species: Canine (804) 528-7988 Breed: Poodle Mix Sex: Spayed Female Color: brown/white Date: Monday, December 04, 2017 Dear Dr. Bowers: History: Bella, a 3 Yrs. 3 Mos. old Poodle Mix, was referred to Dogwood Veterinary Internal Medicine service for further evaluation of throat clearing/hacking. Bella had an acute onset of hacking up in June. This started after Bella had some form of dietary indiscretion that involved a bone. The owner pulled a bone out of Bella's mouth. She was taken to her pDVM and no foreign body was found but was found to have severe gingivitis and a broken tooth. This tooth was extracted and she was started on Clindamycin and later Doxycycline. Bella's hacking improved some on antibiotics but returned around the time she also presented with oral ulcers and a severe ear infection. She was seen by Dr. Williamson at VDR and started on Prednisone and Cyclosporine. Her ear infection has resolved and the oral ulcers are mostly resolved. She began hacking and neck extending. When attempting to taper the prednisone Bella's symptoms returned. Bella continues to hack on a daily basis. Owner reports that it occurs primarily after Bella wakes up or drinks water. Owner also reports that Bella's bark is decreased first thing in the morning but normalized afterwards. Owner says that Bella has hacked after drinking water since she was a puppy. No V/D/S. E/D well. Diet: Wellness Adult Dry; 1.5 cups BID + 1 cup sweet potatoes and/or green beans Current medications: Prednisone 20mg tab: 1/4 tab (5 mg) BID Cyclosporine 100mg tab alternating days: 100mg q24h, then 100mg q12h Examination findings: Vitals: 12/4/2017 2:54 PM Vital Sign RW Weight 24.1 kilograms Temp 101.8 Pulse 160 Resp panting MM pk CRT <2 sec Alert BAR Systems exam: BCS: 6/9 Hydration status: clinically adequate EENT: clear occular discharge OU Oral: SEE BELOW Cardiovascular: no murmur ausculted, normal rate & rhythm, pulses strong & synchronous Respiratory: lungs clear, normal bronchovesicular sounds bilaterally Lymph nodes: no obvious lymphadenopathy identified Abdominal palpation: within normal limits Neurologic: NSF Musculoskeletal: muscle wasting on head and along spine, ambulatory all 4s, no obvious lameness Integument: NSF Rectal: WNL Diagnostic Results: 3 -View Thoracic Radiographs: 3 thoracic radiographs are available. The cardiovascular structures • are normal for size and shape. No definitive mediastinal or pleural abnormality is seen. There is a mild diffuse interstitial and bronchial pattern. The trachea is normal for diameter. The extrathoracic osseous and soft tissue structures are within normal limits. CONCLUSIONS: Chronic diffuse tracheobronchitis. Allergic, inflammatory and infectious etiologies are possible. Airway sampling with culture and cytology may be helpful. Otherwise normal thorax. • CBC: WNL • Chem17/Lytes: glob 4.8 • PCV/TS: 52%/8.0 g/dL • Sedated orolaryngeal exam: marked hyperemia of caudal pharynx, 2-3 small 2mm ulcerative lesions cd hard palate, 1mm red blister lesion cd hard palate, bilateral laryngeal pararesis with marked hyperemic and inflamed arytenoid cartilages, bilateral tonsilar swelling, tonsils outside of crypts, 2-3mm ulcerative lesion inner upper left lip region, moderate dental tartar, no mass lesions identified. Problem List: Chronic hacking cough with neck extension movements Bilateral laryngeal paresis Marked laryngitis Bilateral tonsilitis Ulcerative oral lesions Hx of concern for immune mediated disease Hx of clear nasal discharge Hx of clear to cloudy occular discharge Hx of marked otitis externa Pending Diagnostics: None Treatment: INCREASE Prednisone from 5mg q24h to 10mg PO q12h Clindamycin 300mg cap: 1 cap PO q12h x2wks. written prescription provided Post procedure: Dex SP 3mg/mL: 0.12mg/kg (3mg, 1mL) IV once in the hospital Butorphanol: 0.1mg/kg IV once in the hospital Plan: Discussed with owner that Bella's case is not straight forward. Considering she responds to higher doses of prednisone, we would consider fungal or bacterial infection as the main etiology less likely, and an immune-mediated component higher on the list of differentials. Thus far, there has been no evidence of a neoplastic process (can't be completely ruled out right now). Once Bella's prednisone was tapered her symptoms returned. At this point, based on Bella's history and clinical signs, for an anatomic diagnosis, we are mostly concerned about her laryngeal/pharyngeal region. This could be a fucntional or mechanical issue. Considering these changes started after Bella had some sort of dietary indiscretion (owner pulled bone out of her mouth), it's not clear whether or not this could have been a trigger for her immune system. We can't rule out migration of foreign material that may require advanced imaging to identify. Recommend to start with 3V chest films, getting the cervical region on the right lateral in addition to CBC, chem/lytes. We will then move to a sedated oral exam. Pending these results, we can decide if we need to use the scope. Discussed with owner the findings of the chest films, labwork, and sedated oral exam. We have not been able to identify a definitive etiology; however, note that Bella's larynx is not moving appropriately (bilateral paresis). We suspect that this is secondary to the marked inflammation in the caudal pharynx and laryngeal regions, along with the other changes.. See sedated exam notes listed above. We susepct that these changes are the causes of her neck extension movements and hacking. We were able to obtain biopsy samples from one of the ulcers on the hard palate and a blister lesion and recommended to submit these for histo. Owner declined submitting these biopsies because we could not guarantee that these results would change approach to therapy considering Bella responds to higher doses of steroids and VDR was considering adding another immunosuppressant in attempt to get Bella off of steroid therapy. For now will increase Bella's prednisone therapy, add 2wks of clindamycin considering the amount of irritation secondary to the procedure, and recommend to follow up with VDR for further care. ADDENDUM: material/fluid from the ET tube was serosanginous to hemorrhagic. Preliminary in house cytology showed cells that had possible criteria of malignancy. Discussed this with owner at discharge and recommended submitting these slides to a pathologist for cytology. VDR will hold on adding mycophenolate until cytology results return. Owner to communicate with family about submitting the cytology and will call back tomorrow with decision. We were unable to identify a mass lesion on the oral exam today. Discussed with owner that if the cytology returns concerning for a neoplastic process, advanced imaging should be considered to find the lesion. Will increase Bella's prednisone back to 10mg PO q12h and add clindamycin pending the cytology results. Thank you for entrusting Dogwood Internal Medicine with Bella's care. Please let us know if you have any questions or concerns about this case. Sincerely, Candice Bailey, DVM, MS, DACVIM Rebekah Merritt, LVT (Internal Medicine) 3. BELLA GABLE PET OWNER: ERIC GABLE SPECIES: Canine BREED: Poodle GENDER: Female AGE: 3 Years PATIENT ID: 374803 Dogwood Veterinary Emergency and Specialty 5918 West Broad Street Richmond, VA 23230 804-716-4700 ACCOUNT #: ATTENDING VET: Candice Bailey, DVM, MS, DACVIM LAB ID: ORDER ID: 55423 DATE OF RECEIPT: 12/4/17 DATE OF RESULT: 12/4/17 IDEXX Services: ProCyte Dx Hematology Analyzer, Catalyst One Chemistry Analyzer Hematology 12/4/17 10:15 AM TEST RESULT REFERENCE VALUE RBC 7.36 5.65 - 8.87 M/μL Hematocrit 49.8 37.3 - 61.7 % Hemoglobin 17.5 13.1 - 20.5 g/dL MCV 67.7 61.6 - 73.5 fL MCH 23.8 21.2 - 25.9 pg MCHC 35.1 32.0 - 37.9 g/dL RDW 17.7 13.6 - 21.7 % % Reticulocyte 0.5 % Reticulocyte 33.1 10 - 110 K/μL WBC 8.77 5.05 - 16.76 K/μL % Neutrophil 58.1 % % Lymphocyte 24.4 % % Monocyte 12.4 % % Eosinophil 4.9 % % Basophil 0.2 % Neutrophil 5.09 2.95 - 11.64 K/μL Lymphocyte 2.14 1.05 - 5.1 K/μL Monocyte 1.09 0.16 - 1.12 K/μL Eosinophil 0.43 0.06 - 1.23 K/μL Basophil 0.02 0 - 0.1 K/μL Platelet 338 148 - 484 K/μL PDW 12.6 9.1 - 19.4 fL MPV 10.3 8.7 - 13.2 fL Plateletcrit 0.35 0.14 - 0.46 % Generated by VetConnect® PLUS December 29, 2017 03:46 PM Page 1 of 3 BELLA GABLE PET OWNER: ERIC GABLE DATE OF RESULT: 12/4/17 LAB ID: RBC Run Download RBC RBC_FRAG PLT RETICS WBC WBC Run Download NEU MONO URBC EOS BASO LYM Chemistry 12/4/17 10:23 AM TEST RESULT REFERENCE VALUE Glucose 113 74 - 143 mg/dL Creatinine 0.8 0.5 - 1.8 mg/dL BUN 14 7 - 27 mg/dL BUN:Creatinine Ratio 17 Phosphorus 4.2 2.5 - 6.8 mg/dL Calcium 10.3 7.9 - 12.0 mg/dL Sodium 150 144 - 160 mmol/L Potassium 4.9 3.5 - 5.8 mmol/L Na:K Ratio 30 Chloride 112 109 - 122 mmol/L Total Protein 7.9 5.2 - 8.2 g/dL Albumin 3.1 2.3 - 4.0 g/dL Globulin 4.8 2.5 - 4.5 g/dL H Alb:Glob Ratio 0.6 ALT 18 10 - 125 U/L Generated by VetConnect® PLUS December 29, 2017 03:46 PM Page 2 of 3 BELLA GABLE PET OWNER: ERIC GABLE DATE OF RESULT: 12/4/17 LAB ID: Chemistry (continued) TEST RESULT REFERENCE VALUE ALP 69 23 - 212 U/L GGT 2 0 - 11 U/L Bilirubin - Total 0.2 0.0 - 0.9 mg/dL Cholesterol 227 110 - 320 mg/dL Amylase 271 500 - 1,500 U/L L Lipase 666 200 - 1,800 U/L Osmolality 299 mmol/kg Generated by VetConnect® PLUS December 29, 2017 03:46 PM Page 3 of 3 4. Pathologist's Report SOURCE/HISTORY: 6 months ago, patient developed cough and oral ulcerations. Responded to prednisone and cyclosporine. Cough has returned with debris prednisone. Following activation, red-tinged fluid collected from endotracheal tube. MICROSCOPIC DESCRIPTION: Two slides, one previously stained, of high cellularity are examined. Large numbers of erythrocytes are present within a variably dense, often thick eosinophilic proteinaceous background. The leukocyte population consists of primarily nondegenerate neutrophils with smaller numbers of vacuolated hemosiderin laden macrophages. Occasional macrophages exhibit erythrophagia. The moderate numbers of superficial squamous epithelial cells are present individually and in variably sized sheets. The remaining nucleated cell population consists of small to moderate numbers of polygonal cells that are present individually and in variably sized tightly cohesive clusters. The cells contain small to moderate amounts of deeply basophilic cytoplasm and round to ovoid nuclei. The chromatin is finely to coarsely granular and nucleoli, when visible, are basophilic and round to ovoid. There is mild to moderate anisocytosis and anisokaryosis in this population. An extensive search reveals no intracellular microorganisms. MICROSCOPIC INTERPRETATION: Neutrophilic inflammation with epithelial atypia. See comment. COMMENTS: A cause for the inflammation is not identified on the slides. The absence of visible microorganisms does not preclude infection. Given the presence of significant inflammation, it is not clear whether to polygonal cells represent a reactive or neoplastic population. Given the chronicity of the disease process and relatively young age of the patient, reactive change is considered more likely. Findings need to be interpreted in conjunction with any other relevant information and the clinical impression. Thank you for including the relevant clinical history; it is greatly appreciated. For veterinarians not currently viewing this pathology report in VetConnect PLUS, please log onto www.vetconnectplus.com today to see the image associated with this case, at no additional cost. If you need help logging on, please contact your local IDEXX Customer Support Team. PATHOLOGIST: Jennifer Steinberg, DVM Diplomate, American College of Veterinary Pathologists Direct: 410-424-3545 1-888-433-9987, option 0 x43545 Email: jennifer-steinberg@idexx.com