How DVM STAT Helped Dr. Brian Avoid Invasive Surgery & Save His Patient

Dr. Brian J. Pileggi, DVM

Columbia Hospital for Animals, Columbia, TN

It’s one of THOSE cases. You know, the case you see on the schedule: New Client, New Pet: 3rd opinion.

It catches your eye, you swallow hard and then drop what you are doing to look into the appointment that is coming in later that afternoon. Curiosity has gotten the better of you. “Third opinion. Third opinion on what?”, you ask yourself. You see in the appointment detail that it is an 11 year-old M/N DMH with hematuria. The curiosity has left you… you go back to what you were doing before.

Then he gets here. You review the previous medical histories from the 2 prior DVM’s from across town (both of whom you have high respect for – very good DVM’s). Patient has been on a prescription urinary tract formula for nearly 8 years, has already had 2 urinalyses done within the past month, multiple abdominal radiographs and full blood work panel. All are wnl other than gross and microscopic hematuria. Has been treated with anti-inflammatories twice, various stress-reducing medications and supplements.

You can feel your own anxieties raising as most of your previous ideas of what to do on the “3rd opinion feline hematuria” have already been tried.

The patient

After performing the most thorough physical exam you are capable of, asking the client as many questions as your anxiety-ridden brain can come up with and ausculting the patient’s heart for at least 5 minutes (to buy you more thinking time), it hits you: time for an ultrasound! Surely this will tell you what you need to know and then the patient will be back to normal in no time!

Having confidence in your scanning abilities but letting the owner know you can send them to a specialist instead if they would like, owner ok’s getting the scan scheduled with you. The ultrasound goes smooth but of course, there are those subtle little changes on the scan that make you think, “is this subtle change an incidental finding or is it contributing to his hematuria?” Subtle variations in the renal cortices, a small, 3mm, mineralized nodule attached to the ventral bladder wall but otherwise, fairly normal abdominal scan. So, let’s run another urinalysis (which shows…wait for it…hematuria!! (you’re surprised, I know)) and maybe some background cocci bacteria (or fatty droplets or crystalline debris) seen in between the tntc rbc’s. You also check his blood pressure – normal. Owner declined urine C&S, so let’s try antibiotics and recheck ultrasound in 2-3 weeks, continue with anti-anxiety meds as previously rx’d and prescription urinary tract food. This has got to work. We’ll see in 2-3 weeks.

The 2-3 week recheck turns into a 10 day recheck b/c the hematuria has worsened. Of course it has (“why couldn’t I convince them to run that urine culture?”).  Owner reports that the patient improved for the first 2 days on antibiotics, then hematuria returned and now it is just straight blood coming out when he urinates – doesn’t look like urine at all.

I really wish I had a specialist on speed-dial. Don’t we all?

“Let’s recheck the ultrasound to see how things have changed”. Owner agrees. The 3mm bladder wall nodule is still present and while it is still 3mm tall, it may be more like 4-5mm wide (definitely larger than before) & still see mineralization to the surface. Subtle changes in renal cortices are still present – seem about the same, but maybe they are part of the problem (?). Wait, what is this? An enlarged hypoechoic object just medial to the left kidney. That was not there before!! And these! Enlarged inguinal lymph nodes? I definitely didn’t see these on the scan 10 days ago!!!

Help!!! I need a fourth opinion!!

After consulting with my colleague, we decide that surgical biopsies of the urinary bladder would give us a definitive diagnosis and during ex lap surgery, aspirates can be performed of enlarged lymph nodes. However, prior to surgery, I recommend we send the ultrasound scans to a specialist for a fourth opinion.

Owner consents for us to send these scans to DVM STAT Consulting to help us out prior to surgery. My list of differentials is expanding into the diseases that I only learned about in school 20 years ago. What am I missing?

Dr. Kristin Welch with DVM STAT Consulting sent a report back on the scans the next day.

Rule outs include lymphoma, other round cell neoplasia or granulomatous disease affecting bladder, kidneys, spleen and lymph nodes.  Dr. Welch cautioned about surgical intervention on the urinary bladder as many of the patients with infiltrative disease into the bladder wall can dehisce after surgical biopsies. FNA of the spleen and enlarged lymph nodes were recommended instead of surgical intervention.

Surgery was cancelled and sedation for ultrasound-guided aspirates were scheduled. Aspirates of the spleen were inconclusive, possible slight increase in lymphocytes but mainly showed hemodiluation of the sample. Lymph node aspirates showed many irregular histiocytes that may be present secondary to fungal disease or may represent histiocytic sarcoma. The differential list is shrinking!!

At this point, owner consented to MiraVista Blastomycosis Antigen testing. Itraconazole therapy was initiated while awaiting results. MiraVista Blasto test came back as positive for detecting antigen. After 2 weeks of itraconazole therapy, patient was markedly improved but was very difficult to medicate. Medications were changed to fluconazole and now at 35 days into therapy, is clinically normal!!

Thank you to DVMSTAT and to Dr. Welch. If it wasn’t for her quick response with a very thorough report, we would have proceeded with surgical biopsies and would have run the risk of dehiscence of surgical site not to mention saving the patient from a major surgical procedure. Incredibly grateful for a fourth opinion!!

With sincere thanks to Dr. Brian J. Pileggi, Owner of Precision Veterinary Ultrasound and Associate at Columbia Hospital for Animals, for sharing his experience. This story and accompanying images are shared with the pet owner’s permission.