Epitheliotropic Tcell Lymphosarcoma in a Horse Author Ashley French 1714 Mizzou Pl Apt 6A Columbia MO 65201 AshleyFrenchmizzouedu 8163094848 Mentors Alison LaCarrubba DVM ABVP Martha ID: 912995
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Obstructive Small Intestinal Epitheliotropic T-cell Lymphosarcoma in a Horse
Author: Ashley French1714 Mizzou Pl Apt 6AColumbia MO 65201AshleyFrench@mizzou.edu816-309-4848Mentors: Alison LaCarrubba DVM ABVP, Martha Rasch DVM, Philip Johnson BVSc MS ACVIM ECEIM MRCVS University of Missouri College of Veterinary Medicine
Slide2Signalment“Hopi”393 kg (866 lbs)
25-year-old QH gelding
Slide3History
Retired dressage horse living on pasture at a retirement horse farm in MissouriIn 2006, treated for an obstructive small intestinal colic consistent with proximal enteritis. Vaccinated 3/11 for EEE, WEE, West Nile, influenza, tetanus, rabies, and EHV-1,4.Dental prophylaxis 3/11Dewormed regularly, last deworming: 3/11 (pyrantel)
Slide4History Continued…
5 lbs of Purina Equine Senior™ feed BID with free choice hayWeight loss of two months durationAnorectic on the morning of presentationKicking at abdomenPassed a small amount of loose manure Presented to MU-VMTH ambulatory service on 4-7-11 with acute colic
Slide5Initial ObservationsActively colickyKicking at abdomen
Flank watchingInappropriate recumbencyBCS: 3/9 (1 = very thin; 9 = obese)MM: pink and moistCRT 2 seconds (rr: <2s)
Slide6Vital SignsHeart Rate: 60 bpm (rr: 28-40 bpm)
Respiratory Rate: 20 bpm (rr: 12-20 bpm)Temperature: 98.9⁰F (rr: 99-102⁰F)
Slide7Clinical Findings Continued…
Normal borborygmi (right); decreased (left)Hirsutism HalitosisRectal examination revealed prominent small intestine, not significantly distendedNasogastric tube yielded net 4 L yellow-green reflux + moderate amounts of ingesta
Slide8Diagnostic considerations
Implicative for small intestinal obstruction colicRefluxPalpation findingsPrior historySuspect PPIDPhysical appearance and ageSignificance of halitosis?Dental diseaseGastric squamous cell carcinoma?
Slide9On Farm Treatment
Analgesic medication (IV)Flunixin meglumine -400 mg (1 mg/kg)Xylazine HCL- 100 mg (0.25 mg/kg)Butorphanol tartrate- 1.5 mg (0.004 mg/kg)Administered 12 L lactated Ringer’s solution (IV)
Slide10Problem List
Abdominal painGastric refluxTachycardiaAnorexiaChronic weight lossHalitosisHirsutism
Slide11Differential Diagnosis
Tachycardia: pain, circulatory compromise, fear, cardiac diseasePain was most likely attributable to colic (pain); normal CRT and pink MM mitigated against hypovolemia, etc.Abdominal pain: Usually GIT obstruction; non-obstructive (“false”) colic could be considered. Palpation findings were implicative for small intestinal obstruction. Considerations included intraluminal obstruction (food impaction), infiltrative disease of the intestinal wall (neoplasia, granulomatous enteritis, etc), proximal enteritis (ileus), strangulation (mesenteric lipoma, mesenteric rent, volvulus, etc)Gastric reflux was implicative for small intestinal obstructionAnorexia
: Many considerations: pain, systemic illness, dental disease, dysphagia, neurological disease, esophageal obstruction, etc
Hopi had an acute loss of appetite, consistent with abdominal painChronic weight loss: Many considerations (common component of disease of most organ systems): malnutrition, endoparasitism, dental disease (geriatric attrition), EIA, chronic intestinal disease (
malassimilative
and/or protein-losing
enteropathies
), neoplasia,
etc
C
hronic intestinal disease was considered likely in light of the chronic and recurrent colic problem (also noting the regular deworming, dental care, and appropriate plane of nutrition).
Slide12Differentials Continued…
Halitosis: Dental disease, gastric disease, oral, esophageal, or gastric cancer, oral wounds or ulcerationsDental disease ruled down based on results of oral cavity examination: age increased the risk of neoplasia and GI diseaseHirsutism: Time of year, pituitary pars intermedia dysfunction (PPID), severe parasitism, malnutrition Age was supportive for PPID; severe parasitism and malnutrition were less likely (management practice)Gastric reflux: obstruction due to either ileus or mechanical obstruction (usually small intestinal; sometimes gastric); ileus, proximal enteritis, strangulation, luminal occlusion (food impaction, etc), mass lesion (neoplasia, granuloma, etc), pyloric outflow obstruction (eg persimmon, neoplasia, etc)
All of these differentials were valid possibilities. Small intestinal condition was more likely based on palpation findings at this point
Slide13Diagnostic Plan
CBC/Chemistry: evaluate systemic inflammatory response and organ functionAbdominal Ultrasonography: evaluate appearance & function of viscera, esp. abnormalities of GITAbdominocentesis: evaluate peritoneal fluid for evidence of intestinal devitalization, peritonitis or neoplasiaGastroscopy: evaluate esophagus and stomach for obstructive lesions, neoplasia, and/or ulcerations
Slide14Referral
Pain and reflux persisted in spite of field treatmentReferral to VMTH for hospitalized treatmentRestricted budget (fluids/observation/reflux retrieval only)On admission at VMTHquiet & alertHR 88 bpm RR 16 bpm Temp 100.6°F MM pink and moist, CRT <2s
Slide15Treatment at the VMTH
Held NPO & monitored for painIV fluid therapy LRS: 2 L per hour overnightEvaluate for NG reflux every 2 hInitially, reflux quantities were 3-5 L, gradually reducedReflux was not evident the next morning (tube removed)Further signs of colic not observed
Slide16Diagnostic ResultsPCV
: 39 (rr 30-45)TS: 7.2 g/dL (rr 5.8-8.7)CBC: mature neutrophilia - likely from stressChemistry:Hypoalbuminemia (1.9 g/dl; rr, 3.2-4.5 g/dl): GIT protein losing disease, negative acute phase protein, iatrogenic (fluid therapy) Hyperfibrinogenemia (0.7; rr, 0.2-0.4 mg/dl): inflammation of >48 h durationHyperglycemia (124; rr, 83-115
mg/dl): likely due to stress ± PPIDHyperglobulinemia (5.5 g/dl; rr,
3.3-4.2 g/dl): likely from chronic inflammation (neoplasia, infection, GIT ulceration)F
ecal culture (biosecurity)
:
negative for Salmonella (reported later)
Slide17Ultrasonography
Abdominal ultrasonography revealed increased peritoneal fluid and an abdominal mass closely associated with the small intestine.The mass appeared to be in the wall of the small intestine and was located in the ventral abdomen, cranial to the prepuce. Images were highly suggestive of neoplasia or less likely abscessation.
Slide18US image obtained at IC space 16 (left), depicting spleen and increased quantity of peritoneal fluid
spleen
peritoneal fluid
Slide19US image obtained at IC space 17 (left, ventral), depicting spleen and mass (showing infiltrated wall of intestine)
spleen peritoneal fluid
Intestinal wall infiltration
Slide20Gastroscopy
Gastroscopy revealed mild ulcerations on the squamous epithelium
Slide21Endoscopic image of stomach depicting mild squamous epithelial ulceration
Margo plicatusulcers
Slide22Abdominocentesis
Cloudy straw-colored fluidTotal protein: 4.0 mg/dL (rr<2.0 ) TNCC: 12,436 cells/uL (rr
<5,000) Negative bacterial culture
Exudative suppurative peritonitis
Primary differentials: neoplasia, abdominal abscess, perforating ulcer
Slide23Macrophage exhibiting
leukophagocytosisCytospin revealed primarily non-degenerate neutrophils; no neoplastic cells observed
Abdominocentesis Cytology
Slide24Treatment Continued…
Treatment for infectious peritonitis was startedantibiotic therapy: potassium penicillin G, gentamicin, metronidazoleFlunixin meglumine 1.1 mg/kg SID, IV ProbioticSaccharomyces cervisiae (Yea-Sacc™)Lactated Ringer’s solution 1L/hr, IVSlowly reintroduced to Purina Equine Senior® food (as mash)
Slide25Outcome
1Throughout the first 72 h of hospitalization…Horse improved remarkably – no pain, no refluxLow dose flunixin meglumine treatmentsBright, alert, and responsivePassed manureBorborygmi returnedExcellent appetiteDuring gradual progressive re-feedingFluids discontinued and treatment continued
Slide26Outcome
2Signs of abdominal pain recurred at +72 hReflux was recoveredDue to age and unfavorable prognosis the owner elected humane euthanasiaExploratory coeliotomy was not allowedCosmetic necropsy performed burial at the owner’s request
Slide27Necropsy Results
Two multi-nodular mural masses ranging 14-17 cm were present in the wall of the jejunum. Partially digested plant material was present in the lumen. The wall of the jejunum had multifocal thickenings of up to 1.5 cm. The affected areas were white on cross section, severely ulcerated with sloughing mucosa and had areas of necrosis and abscessation that oozed purulent material when cut.
Slide28Cosmetic necropsy: appearance of intra-abdominal mass at ventral mid-line location just cranial to the prepuce
Slide29Cosmetic
necropsy: appearance of resected intestines + mass submitted to the VMDL
Slide30Cosmetic necropsy:
suppurative material identified in area of abscess development within the tumor
Slide31Necropsy Results
Neoplastic infiltration
Jejunum
Abscessation
Mass
Slide32Histopathology
Neoplastic infiltrationSmall intestinal lumen
Villlous mucosa
Magnification 2x
Slide33Positive for CD3 = T cell Lymphoma
Nuclear molding
Anisocytosis
Anisokaryosis
Abnormal mitotic figures
Criteria of Malignancy
Negative for CD79a (B cell)
Monoclonal round cell population
In an abnormal location
Slide34Final Diagnoses
Jejunal epitheliotropic T-cell lymphosarcomaPeritonitis resulting from cancer-mediated jejunal epithelial ulceration and infection
Slide35Equine Alimentary
LymphosarcomaCommon tumor of the GI tractPoor prognosis: most horses do not live greater than 6 months after diagnosis regardless of treatment methodMost common clinical signs: weight loss and colicCommonly associated with malabsorption syndrome Segmental thickening of the small intestineAssociated with hypoproteinemia, and hypoalbuminemiaPossible TreatmentsSurgery to remove affected intestine
Chemotherapy: cytosine arabinoside, cyclophosphamide, vincristine, and prednisolone
Slide36Further Reading
Joseph Bertone in Tumors and Tumor Like Lesions of the Abdomen. in: Equine Geriatric Medicine and Surgery. Saunders Elsevier, St. Louis. 2006. Pp. 158-160.Yvonne Elce in Neoplastic Disease of the Gastrointestinal Tract. In : Current Therapy in Equine Medicine. Ed 6. Robinson, Sprayberry. Saunders Elsevier, St. Louis. 2009. Pp 448-449.Head, Else, Dubielzig in Tumors of the Alimentary Tract. In: Tumors in Domestic Animals. D. Meuten. Iowa State Press, Blackwell Publishing Company. 2002. Pp 158, 401-483.Jour, Mair, Hillyer, Taylor, Pearson. Primary
Epitheliotropic Intestinal T-cell Lymphoma in a Horse Journal of Veterinary Diagnostic Investigation March 1, 2002 14: 150-152
Taylor, S., Pusterla, N., Vaughan, B., Whitcomb, M. and Wilson, W. (2006), Intestinal Neoplasia in Horses. Journal of Veterinary Internal Medicine, 20: 1429–1436.
doi
: 10.1111/j.1939-1676.2006.tb00762.x
Slide37Thank you to…
Pictures provided by: Melanie Spoor DVM Sean Spagnoli DVM Alison LaCarrubba DVM ABVP Philip Johnson BVSc MS ACVIM ECEIM MRCVS Mentors: Alison LaCarrubba DVM ABVP Martha Rasch DVM
Philip Johnson BVSc MS ACVIM ECEIM MRCVS University of Missouri College of Veterinary Medicine