Case Study

RAD – US – Esophageal nodule with mineralization, tracheal collapse, lung scarring, hepatomegaly, splenic nodules, nephritis and arthritis in a 12 year old MN Papillion dog

This 12 year old MN Papillion dog was previously diagnosed with collapsing trachea elsewhere, pet presented in October 2015 for limping rt front. Rads showed arthritic changes.

Chem: ALKP 1191, calcium 11.6, trig 599, USG 1.022, 3+ protein

Pet continued limping, pain medication changed to tramadol andcarprofen. Developed cough/increased breathing issues with tramadol on board, would start with pant then turn into coughing episode

This 12 year old MN Papillion dog was previously diagnosed with collapsing trachea elsewhere, pet presented in October 2015 for limping rt front. Rads showed arthritic changes.

Chem: ALKP 1191, calcium 11.6, trig 599, USG 1.022, 3+ protein

Pet continued limping, pain medication changed to tramadol andcarprofen. Developed cough/increased breathing issues with tramadol on board, would start with pant then turn into coughing episode

Physicalexam – abd felt full with organomegaly, increased breath sounds, with a continual pant, no other coughing. Rads show remodeling at right elbow and an area of consolidations of left middle lung field

DX

Internal esophageal nodule at the cardia with mineralization. Mild dynamic tracheal collapse and redundant tracheal membrane. Diffuse parenchymal hepatopathy with hepatomegaly suggestive for vacuolar hepatopathy. Bilateral nephropathy suggestive for chronic nephritis with renal cortex cyst and non-obstructive calculus of the left kidney. Bilateral osteoarthritis of the elbows and antebrachiocarpal joints.

Image Interpretation

Rads of the thorax, abdomen and front limbs; Ultrasound of the abdomen –
Radiographic findings:
The patient is mildly obese.
Thorax/abdomen:
There degree of inspiration is fair.
Mild degenerative changes and mild age related osteopenia is seen along the axial skeleton.

There is a redundant tracheal membrane level with the caudal neck and thoracic inlet.
True dorsoventral flattening of the tracheal lumen by 10 % is noted for the cervical
trachea during expiration.
The caudal thoracic esophagus is seen as a tubular soft tissue opacity with mild widening cranial to the diaphragm.
Mild cranial mediastinal widening is noted which is compatible with fat deposition.
Subtle interstitial lung consolidation without a mass effect or volume loss is seen
within the caudal compartment of the left cranial lung lobe.
The remainder of the lungs presents a mild generalized bronchointerstitial pattern.
The heart and pulmonary vasculature are within normal limits.
The liver reveals moderate generalized enlargement with rounded lobar margins and
rotation of the gastric axis.
The left kidney reveals mild symmetrical enlargement. A mineral opaque focus is
superimposed onto the region of the left kidney.

Front limbs:
Both elbow joints show an enlarged articular soft tissue opacity.
The left elbow reveals marked cranial contour blurring of the medial coronoid process
(Pcm) with adjacent trochlea notch sclerosis. Moderate osteophyte formations are seen
at the periarticular margins including prominent bony spurs at the medial and lateral
humeral epicondyles. Compared with the right elbow moderate irregularity of the
subchondral bone plates with multifocal cystic lucencies is noted.
The right elbow reveals marked cranial contour blurring of the medial coronoid
process (Pcm) with adjacent trochlea notch sclerosis. Moderate osteophyte formations
are seen at the periarticular margins including prominent bony spurs at the medial and
lateral humeral epicondyles.
Moderate osteoarthritis of both antebrachiocarpal joints with distal bony spurs at the
accessory carpal bones is noted.
There are semicircular enthesiophytes at the right medial styloid process of the radius
level with the sulcus of the abductor pollicis longus tendon and tendon sheath.

Ultrasonographic findings:
Both kidneys reveal multifocal echogenic foci throughout the cortices and medulla
with reduced corticomedullary definition and mild loss of renal echoarchitecture.
A simple 3.5 cm large cortical cyst is noted within the cranial pole of the left kidney.
Moreover a 1 cm non obstructive renal calculus is noted. The left renal cortex presents
multiple small cysts. Mild generalized enlargement of the spleen and parenchymal heterogeneity is noted throughout. A
mixed hypoechoic, non expansive nodule of 1.5 cm diameter is seen within the splenic
tail. The liver reveals moderate generalized enlargement with rounded lobar margins and
mild overall increase in echogenicity and heterogeneity throughout. The GI presented An eccentric hypoechic luminal nodule of 1 cm diameter with amorphous
mineralization is noted at the dorsal wall of the cardia level with the gastroesophageal
inlet. Partial loss of wall layering and mild oral distension with gas is noted.

Outcome

Internal esophageal nodule at the cardia with mineralization. Differentials include
Spirocerca lupi (nematode with worldwide endemic distribution in warm climate
zones) granuloma – these may transform to fibro-, osteo-, or chondrosarcoma,
squamous cell carcinoma, leimyosarcoma, lymphosarcoma, other. Consider endoscopy
with sampling for further definition.
The lung changes are compatible with expected geriatric findings and scarring after
pneumonia. Mild interstitial pneumonia/pneumonitis or an emerging lobar neoplastic
infiltrate cannot be ruled out entirely but is low for potential. If further workup is
warranted ultrasound guided fine needle aspiration of the lung may be considered
and/or broncoalveolar lavage during endoscopy (see above).
Organomegaly likely exacerbated by mild chronic hypoxic state as this is
common in patients with a tracheal collapse. Consider fine needle aspiration of the
liver for further definition and to rule out diffuse inflammatory or neoplastic infiltrate.
Splenic nodule suggestive for benign nodular hyperplasia. Emerging neoplasia cannot
be ruled out. Ultrasound guided fine needle aspiration or alternatively recheck within 4
weeks recommended.
Most cortical cysts in dogs are incidental
findings and subclinical. Further measures – such as ultrasound guided chemoablation
– may be considered in case of clinical signs.
Polypoid mucosal hyperplasia gallbladder – likely incidental. Subclinical cholecystitis
possible. No evidence of mucocele at this point.