Case Study

11-00012 Annie J Amyloidosis: Renal, GI and Lymph Nodes

History of abdominal mass first noted 9-29-10. At first presentation, appetite diminished, was lethargic, febrile, dehydrated, icteric, and had lost weight. A heart murmur was also noted (grade 3-4/6). Treated with supportive care (fluids, pepcid, pain medication, potassium) and antibiotics (baytril and amoxicillin). Responded well to treatment and has been doing well until yesterday. Represented for vomiting and lethargy and weight loss. The original abdominal mass has enlarged and is irregular, encompasses the majority of her abdomen. Also noted a new mass in caudal abdomen. Previous ultrasound guided aspirate of mass in September revealed severe inflammation. Blood work as of 1-27-11: has a leukocytosis (16,600/uL) with a neutrophilia (13,778/uL) with 1+ toxic changes and resolved monocytosis. Hct 15% (normocytic, normochromic non-regenerative anemia), TP 7.2 g/dl. Azotemia – BUN 126 mg/dl, Creat 6.7 g/dl, Phos 14.3 mg/dl, Ca 7.3 mg/dl, K normal 4.7 mEq/L.

History of abdominal mass first noted 9-29-10. At first presentation, appetite diminished, was lethargic, febrile, dehydrated, icteric, and had lost weight. A heart murmur was also noted (grade 3-4/6). Treated with supportive care (fluids, pepcid, pain medication, potassium) and antibiotics (baytril and amoxicillin). Responded well to treatment and has been doing well until yesterday. Represented for vomiting and lethargy and weight loss. The original abdominal mass has enlarged and is irregular, encompasses the majority of her abdomen. Also noted a new mass in caudal abdomen. Previous ultrasound guided aspirate of mass in September revealed severe inflammation. Blood work as of 1-27-11: has a leukocytosis (16,600/uL) with a neutrophilia (13,778/uL) with 1+ toxic changes and resolved monocytosis. Hct 15% (normocytic, normochromic non-regenerative anemia), TP 7.2 g/dl. Azotemia – BUN 126 mg/dl, Creat 6.7 g/dl, Phos 14.3 mg/dl, Ca 7.3 mg/dl, K normal 4.7 mEq/L.

DX

Amyloidosis

Sonographic Differential Diagnosis

Progressive mesenteric root lymph node mass. Sublumbar mass and suspicion for metastatic thoracic disease given the pleural effusion or potential right congestive heart failure with passive congestion of the liver. Concurrent renal calculi passage, ureterolithiasis, chronic inflammatory bowel disease, probable emerging lymphoma type gastrointestinal presentation, chronic pancreatic disease with cystic and inflammatory type lesions.If thoracic neoplasia is not present then potential treatment may be possible if the abdominal pathology represents chronic inflammation owing to resistant bacteria or other forms of granulomatous disease such as FIP. The prognosis is significantly guarded to poor. Ureterolithiasis is a new development in which may be treated by aggressive fluid therapy given that the calculi are likely small enough to pass

Image Interpretation

9-3-10 Ultrasound exam: The gastrointestinal tract presented a prominent stomach wall and muscularis with epigastric lymph node that was enlarged at 0.66 cm, yet uniform. Surrounding reactive fat was noted throughout the intestinal tract. The mid to distal small intestine also presented a thickened muscularis with areas of loss of detail. A 3.8 x 2.9 cm, mixed hyperechoic and hypoechoic mass was noted in the left cranial abdomen. This is likely of lymph node origin given that a large artery was present in the middle of the mass, which is suggestive of mesenteric artery. Reactive fat was noted throughout that region. 1-28-11 The current sonogram revealed persistence of the ileocecocolic mass, which is likely of lymph node origin. It measured 4.8 x 1.97 cm. The mass in the mesenteric root is persistent with reactive omentum and is most consistent with granulomatous type lymph node with the potential of chronic bacterial infection.The left kidney presented hydronephrosis that is consistent with chronic pyelonephritis. It now measured 3.7 cm. Pylectasia was evident and measured 1 x 1 cm. Ultrasound-guided pyelocentesis would be ideal. However, the left ureter was now dilated with a focal calculus within a proximal ureter. The right kidney presented persistent dystrophic changes with areas of corticomedullary mineralization and proximal ureteral dilation. A small 0.27 cm calculus was noted.