Case Study

Lymphoplasmacytic enteritis, granulomatous lymphangitis in a 13 year old MN Beagle. May 2010 COM

A 13-year old MN Beagle dog was presented with vomiting, diarrhea, inappetance, and lethargy. The clinical exam revealed 5% dehydration and mildly tender mid-cranial abdomen. CBC, biochemistry, and urinalysis were normal. Folate was mildly elevated. CPL was Negative. Empirical treatment with metronidazole, Cerenia, and SQ fluids produced only minor positive clinical response.

A 13-year old MN Beagle dog was presented with vomiting, diarrhea, inappetance, and lethargy. The clinical exam revealed 5% dehydration and mildly tender mid-cranial abdomen. CBC, biochemistry, and urinalysis were normal. Folate was mildly elevated. CPL was Negative. Empirical treatment with metronidazole, Cerenia, and SQ fluids produced only minor positive clinical response.

DX

Lymphoplasmacytic enteritis with severe granulomatous lymphangitis

Sonographic Differential Diagnosis

Focal transmural small intestinal disease with emerging peritonitis, underlying inflammatory bowel disease, granulomatous enteritis, infectious enteritis, emerging lymphoma, mast cell disease or other neoplasia is suspected.

Image Interpretation

The intestine noted in the mid upper 1/3 of the screen reveals a mild mucosal prominence and is approximately twice the width of adjacent small intestine noted in the near field (Video 1). Curvilinear contour is maintained even though mucosal hypertrophy is present. Further distally along the thickened small intestine the presentation demonstrates loss of mural detail and reactive omentum associated with the affected portion of intestine (Video 2). This reactive omentum is associated with and adhered to the serosal layer of the intestine. This indicates intestinal perforation may be imminent with transmural pathology. The patient also displayed discomfort upon imaging of this region (positive Murphy Sign). Close-up view of the affected small intestine reveals further loss of detail in the layers of the intestinal wall (Video 3). The normal well-defined curvilinear interface between these layers noted in Video 1 is now losing detail in an “echo cloud” of inflammation. Deviation from the normal curvilinear straight lines between the layers is evident.

Outcome

The pet was started on prednisone and Imuran and bland diet. The pet had episodes of vomiting and bloody stool while on the prednisone. The patient was managed periodically with metronidazole, hypoallergenic diet and gastrointestinal protectants. One year later the owner reported that the pet is doing well. The pet is currently taking metronidazole 125mg SID, Dexamethazone 0.375mg EOD, tapering dose of Imuran, colostrum 2 BID, and various neutraceuticals.

Clinical Differential Diagnosis

GI tract disease – obstruction (foreign body/neoplasia), IBD, infectious (bacterial/viral), intestinal lymphoma.

Sampling

Full-thickness surgical biopsy and resection of the affected bowel. Images 1 and 2 reveal reactive fat and hemorrhage (arrows) that corresponds to the reactive omentum in videos 2 and 3 noted in the sonogram. The smaller arrows in image 3 represent the transition from normal bowel thickness to that affected by the transmural pathology. Biopsy results revealed moderate, chronic, lymphoplasmacytic enteritis with severe granulomatous lymphangitis.