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Ginger is a 9.5 yr old female spayed GSD who presented to AU Oncology Service on
May 9, 2014. Approximately 2 weeks prior, she had 2 days of nosebleeds that the
owner noted would stop within a minute. She was due for her annual wellness
anyways, so she presented to the rDVMon May 2. She was boarded with the rDVM
for a week while owners were away, during which time, the rDVMran baseline
bloodwork and noted the anemia and significant lymphocytosis. She also had a very
high monocyte count (20k/ul) which is believed to be additional lymphocytes that the
machine had mistaken for monocytes. Based on preliminary bloodwork findings,
Ginger was referred to our Oncology Service.
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On physical exam, Ginger was febrile, stiff/arthritic, and hypertensive. Her lymph
nodes palpated normally and no other abnormalities were noted.
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Based on the rDVMs bloodwork and the physical exam, our initial list of differentials
included stage V lymphoma, leukemia, and multiple myeloma.
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In order to assess Gingers current status, our initial diagnostic plan included
repeating the CBC and Chemistry to see a current status and trends for her
lymphocytosis and anemia. The imaging would be used to search for evidence of
metastasis, and the bone marrow aspirate would be used to help determine the
source and extent of the lymphocytosis.
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Gingers CBC results showed a mild regenerative anemia, a thrombocytopenia, and
the most significant finding was the severe lymphocytosis showing 130,000
lymphocytes. These images were taken of her blood smear. Using the neutrophil as a
size marker, the vast majority of the lymphocytes are large. The lymphocytes also
have irregularly shaped nuclei and indented nuclei.
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The primary significant finding on her chemistry was her hyperglobulinemia, which
would be contributing to a hyperviscosity syndrome in conjunction with her high cell
counts causing her high blood pressure.
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Gingers imaging came back with no evidence of metastasis to the lungs. But she did
have multiple hypoechoic nodules in the spleen on abdominal ultrasound which is
consistent with neoplasia, but could also represent extramedullary hematopoiesis
which could be consistent with her regenerative anemia or lymphoid hyperplasia.
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Gingers bone marrow aspirate came back with a highly cellular sample showing lots
of lymphocytes with irregularly round nuclei. Erythroid and myeloid precursor cells
were significantly decreased, which is likely the cause of her anemia. The abundance
of lymphocytes in the bone marrow is consistent with lymphoid leukemia and stage V
lymphoma.
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Since we did not find any evidence of neoplastic plasma cells, multiple myeloma was
ruled out from the differential list, leaving stage V lymphoma and leukemia.
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To differentiate between stage V lymphoma and leukemia, we performed flow
cytometry. Flow cytometry identifies markers on the lymphocytes in order to
differentiate cell populations into B-cell, T-cell, and hematopoietic stem cells. CD34
marker is indicative of hematopoietic stem cells, and in conjunction with a very low
presence of lymphoid markers, the flow cytometry is most consistent with acute
lymphoblastic leukemia.
Since german shepherds are a breed known to carry the MDR gene mutation which
would affect her ability to tolerate certain chemotherapeutic agents, she was also
tested to see if she carries that mutation. The MDR testing came back normal.
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Gingers final diagnosis was acute lymphoblastic leukemia.
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So what is acute lymphoblastic leukemia? Simply put, it is an acute onset of
neoplastic lymphoblasts in the bone marrow that can also appear in circulation in
high numbers. Lymphoblasts are CD34+, differentiating it from lymphoma cells. ALL is
characterized by a very rapid progression of disease that is poorly responsive to
treatment. This results in a poor prognosis with a median survival time of 2-3 wks,
even with chemotherapy.
On physical exam, ALL can present with several nonspecific signs. Gingers primary
complaint was having a couple mild nosebleeds, and a fever was noted during her
physical exam. However, her CBC showed all of the common hematologic findings
associated with ALL.
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Treatment for Ginger was focused on chemo drugs that would not be
myelosuppressive because she already had markedly decreased erythroid and
myeloid cell lines in her bone marrow that we do not want to further suppress.
She was given diphenhydramine and elspar for her initial chemo induction. Because
of her high burden of neoplastic cells, she was kept in IMC for supportive care and
monitoring for tumor lysis syndrome. She was given acepromazine for anxiety,
cerenia for nausea, clavamox as preventative antibiotic, metronidazole for her
diarrhea, and omeprazole and famotidine as GI protectants.
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Ginger was kept in IMC overnight for observation and developed anorexia and
diarrhea. A CBC was repeated on 5/10 revealing her hematocrit and platelet count
had dropped. However, it did show some response to Elspar as seen by the drop in
the lymphocyte count. Her fluid rate was gradually reduced from 190 mL/hr to 100
mL/hr over the course of the day and she was kept one more night for observation.
On 5/11, her PCV returned to 30%. Therefore, she was sent home on oral
medications for supportive care. She was also sent home with cyclophosphamide,
another chemotherapy agent, to be given over 3 days (5/12-14) with plans of
returning the following week for a recheck and next chemo dose.
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Ginger returned to Auburn on 5/19. Her HCT and Plt were holding fairly steady, but
her lymphocyte count had nearly doubled from her 75,000 on 5/10 to 140,000 on
5/19. She was treated with vincristine and discharged. When she returned for her
most recent recheck on 5/27, her lymphocyte count had climbed even higher to
158,000. At this time, the owners elected to stop chemotherapy because of her lack
of response to chemo and elected to try administering prednisone at home for as
long as she continues to maintain good quality of life.
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The take home messages from this case its important to emphasize annual
wellness exams with bloodwork particularly for geriatric patients. The owners
werent highly alarmed by the few nosebleeds that would quickly resolve, but since
she was due for her annual wellness exam anyways, they brought it up to the rDVM
during the routine exam which ultimately led to an earlier diagnosis and probably
extended the amount of quality time they will have with Ginger.
Also, be willing to keep an open mind when forming differentials. I initially was
expecting a problem in the nasal passages when I signed up for an oncology patient
presenting for occasional nosebleeds, but the bloodwork that the owners brought
with them from the rDVMredirected the differentials more towards a lymphatic
tumor rather than a nasal problem.
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