I have been trying to track down the cause of hypercalcemia in a 10 YO MN terrier mix. Patient vomits regularly. Pretty much ruled out primary hyperthyroidism, spurious, Addisons, Renal, Idiopathic. Still considering granulomatous, Osteolytic, and neoplasia. Have not measured Vitamin D levels, but may do that if no where else to go.
I have been trying to track down the cause of hypercalcemia in a 10 YO MN terrier mix. Patient vomits regularly. Pretty much ruled out primary hyperthyroidism, spurious, Addisons, Renal, Idiopathic. Still considering granulomatous, Osteolytic, and neoplasia. Have not measured Vitamin D levels, but may do that if no where else to go.
- The PTH is low (0.4 and 0.0)
- The PTHrp is 0.)
- The ionized Ca++ is high
- US of the parathyroids reveals small glands bilaterally at the proximal thyroid lobes.
- Fine needle aspirations of liver, spleen, skin masses, and pylorus all negative for neoplasia.
I am still suspicious that the lesion is in the stomach/pylorus/duodenal area. I know that gastric adenocarcinomas don’t exfoliate very easily and am considering sending this patient for endoscopy/biopsy, but would like to see if anyone else thinks this area of the stomach is abnormal.
Comments
Not sure that I see the mass
Not sure that I see the mass in the pylorus. Is that an enlarged LN at 5:00 on cine loop 2.
Make sure you check the anal sacs for adeno-carcinoma.
The one case of gastric- lymphoma that I have seen and verified in a cat did not exfoliate either on FNA. Histopathology confirmed the Ddx
(https://sonopath.com/forum/pylorus-mass)
I would also check out EL algorithm on a recent post-
https://sonopath.com/forum/parathyroid-enlargement
Not sure that I see the mass
Not sure that I see the mass in the pylorus. Is that an enlarged LN at 5:00 on cine loop 2.
Make sure you check the anal sacs for adeno-carcinoma.
The one case of gastric- lymphoma that I have seen and verified in a cat did not exfoliate either on FNA. Histopathology confirmed the Ddx
(https://sonopath.com/forum/pylorus-mass)
I would also check out EL algorithm on a recent post-
https://sonopath.com/forum/parathyroid-enlargement
Note the loss of mural detail
Note the loss of mural detail at the arrows and the expanded submucosal layer on the long arrow. Meets neoplastic criteria (Carcinoma first lsa second) but hypertophic pyloric gastriopathy does this as well and would actually be my third diff as the LN that randy mentions at 4 cm depth in video 2 is concerning and too big for typical gastritis. I dont know if I have seen hypercalcemia from gastric masses (lsa or carcinoma) not to say it isnt possible. If no evidence of mets needs a Billroth sx. i do core bx of both these lesions but tough sticks and need experience on them FNA corkscrew technique may give cells enough for th edx but they may not exfoliate readily. If a long term chornic vomiter then gastritis and lymphadenopathy wiht HPG my first choice but if circling the drain vomiting progressivley over th elast month then carcinoma better fit. Needs tissue at this point.
search gastric masses in the basic search for more of this presentation
Note the loss of mural detail
Note the loss of mural detail at the arrows and the expanded submucosal layer on the long arrow. Meets neoplastic criteria (Carcinoma first lsa second) but hypertophic pyloric gastriopathy does this as well and would actually be my third diff as the LN that randy mentions at 4 cm depth in video 2 is concerning and too big for typical gastritis. I dont know if I have seen hypercalcemia from gastric masses (lsa or carcinoma) not to say it isnt possible. If no evidence of mets needs a Billroth sx. i do core bx of both these lesions but tough sticks and need experience on them FNA corkscrew technique may give cells enough for th edx but they may not exfoliate readily. If a long term chornic vomiter then gastritis and lymphadenopathy wiht HPG my first choice but if circling the drain vomiting progressivley over th elast month then carcinoma better fit. Needs tissue at this point.
search gastric masses in the basic search for more of this presentation
Hypertophic pyloric
Hypertophic pyloric gastropathy should not give hypercalcemia and with the normal PTH lymphoma is unlikley. Consider pythiosis (Pythium insidiosum) as hypercalcemia has been reported in one case:
LeBlanc C, Echandi RL, Moore RR, Souza C, Grooters AM. Hypercalcemia associated with gastric pythiosis in a dog. Vet Clin Pathol. 2008;37:115-120.
A 20-month-old castrated male Labrador retriever with a 3-month history of anorexia, weight loss, and vomiting was evaluated. Plasma biochemical abnormalities included marked hyperglobulinemia and hypercalcemia. Serum levels of parathyroid hormone, parathyroid hormone-related protein, 25-hydroxyvitamin D, and 1,25-dihydroxyvitamin D were either low or within reference intervals. Gastric wall thickening and abdominal lymphadenomegaly were observed with abdominal ultrasonography. Cytologic evaluation of a sample obtained via fine-needle aspiration of the gastric wall revealed pyogranulomatous inflammation and numerous poorly stained hyphae. Partial gastrectomy was performed, and a diagnosis of gastric pythiosis was made by immunohistochemical staining of infected gastric tissue, as well as by immunoblot serology. This case demonstrates that diagnostic samples for cytologic evaluation can be obtained by fine-needle aspiration of Pythium insidiosum-infected tissues and that a presumptive diagnosis can be made by examination of a Romanowsky-stained smear. Furthermore, pythiosis should be considered as a differential diagnosis for hypercalcemia, especially in young dogs with inflammatory lesions that have a granulomatous component. The mechanism for the hypercalcemia in this dog was not determined; however, calcium concentrations normalized after surgical resection of the gastric lesion.
Hypertophic pyloric
Hypertophic pyloric gastropathy should not give hypercalcemia and with the normal PTH lymphoma is unlikley. Consider pythiosis (Pythium insidiosum) as hypercalcemia has been reported in one case:
LeBlanc C, Echandi RL, Moore RR, Souza C, Grooters AM. Hypercalcemia associated with gastric pythiosis in a dog. Vet Clin Pathol. 2008;37:115-120.
A 20-month-old castrated male Labrador retriever with a 3-month history of anorexia, weight loss, and vomiting was evaluated. Plasma biochemical abnormalities included marked hyperglobulinemia and hypercalcemia. Serum levels of parathyroid hormone, parathyroid hormone-related protein, 25-hydroxyvitamin D, and 1,25-dihydroxyvitamin D were either low or within reference intervals. Gastric wall thickening and abdominal lymphadenomegaly were observed with abdominal ultrasonography. Cytologic evaluation of a sample obtained via fine-needle aspiration of the gastric wall revealed pyogranulomatous inflammation and numerous poorly stained hyphae. Partial gastrectomy was performed, and a diagnosis of gastric pythiosis was made by immunohistochemical staining of infected gastric tissue, as well as by immunoblot serology. This case demonstrates that diagnostic samples for cytologic evaluation can be obtained by fine-needle aspiration of Pythium insidiosum-infected tissues and that a presumptive diagnosis can be made by examination of a Romanowsky-stained smear. Furthermore, pythiosis should be considered as a differential diagnosis for hypercalcemia, especially in young dogs with inflammatory lesions that have a granulomatous component. The mechanism for the hypercalcemia in this dog was not determined; however, calcium concentrations normalized after surgical resection of the gastric lesion.
Yes, the anal sacs are
Yes, the anal sacs are palpably normal.
Pythiosis has been on the rule out list as we do see it occasionally in the Memphis area. At one time when the patient seem to be having gastric outflow obstruction with a full, churning stomach full of fluid/ingsta, I did see some fungal/yeast like structures from an FNA taken from the area. These didn’t quite look like pythiosis, as they stained well with diff-quik and just seemed more like opportunistic type elements at the time. Follow up aspirates have failed to repeat them.
Money is an issue, and the workup has been extensive so far, but with no luck. I quess I’m wondering if I should be aggressive and refer for endoscopy, or explore the area myself or even wait it out a bit longer as something else may reveal where the problem is? The patient is doing well on a blended diet and cerenia and metoclopramide, not vomiting with the regularity that he was.
Yes, the anal sacs are
Yes, the anal sacs are palpably normal.
Pythiosis has been on the rule out list as we do see it occasionally in the Memphis area. At one time when the patient seem to be having gastric outflow obstruction with a full, churning stomach full of fluid/ingsta, I did see some fungal/yeast like structures from an FNA taken from the area. These didn’t quite look like pythiosis, as they stained well with diff-quik and just seemed more like opportunistic type elements at the time. Follow up aspirates have failed to repeat them.
Money is an issue, and the workup has been extensive so far, but with no luck. I quess I’m wondering if I should be aggressive and refer for endoscopy, or explore the area myself or even wait it out a bit longer as something else may reveal where the problem is? The patient is doing well on a blended diet and cerenia and metoclopramide, not vomiting with the regularity that he was.
And a slurry feed of
And a slurry feed of hydrolyze diet and then rescan in a couple weeks if it’s chronic inflammatory it should be improving if it is neoplastic it will look worse. This all of course if sampling is not an option. Regarding endoscopy most of the pathology is mural and not luminal so I’m concerned an endoscopy may not tell the whole story. The fast surgeon can get full thickness biopsies & the lymph nodes within a very short time that it would take for scope.
And a slurry feed of
And a slurry feed of hydrolyze diet and then rescan in a couple weeks if it’s chronic inflammatory it should be improving if it is neoplastic it will look worse. This all of course if sampling is not an option. Regarding endoscopy most of the pathology is mural and not luminal so I’m concerned an endoscopy may not tell the whole story. The fast surgeon can get full thickness biopsies & the lymph nodes within a very short time that it would take for scope.
As Eric states – endoscopy
As Eric states – endoscopy may not be of help. A laparotomy could be both diagnostic and therapeutic. Also bear in mind the effect of hypercalcemia on the kidneys causing progressive tubular degeneration. Emperical therapy of hypercalcemia would be cortisone but not great if pythiosis is present. Another procedure that you can use to differentiate hypercalcemia of malignancy is to treat with asparginase and if the hypercalcemia resolves/improves then you are dealing with neoplasia and not a granulomatous lesion.
As Eric states – endoscopy
As Eric states – endoscopy may not be of help. A laparotomy could be both diagnostic and therapeutic. Also bear in mind the effect of hypercalcemia on the kidneys causing progressive tubular degeneration. Emperical therapy of hypercalcemia would be cortisone but not great if pythiosis is present. Another procedure that you can use to differentiate hypercalcemia of malignancy is to treat with asparginase and if the hypercalcemia resolves/improves then you are dealing with neoplasia and not a granulomatous lesion.
Awesome points…Thanks!!!
Awesome points…Thanks!!! I’ll keep ya posted.
Awesome points…Thanks!!!
Awesome points…Thanks!!! I’ll keep ya posted.