Lymphoma sucks

One of my Urgent Care patients last night was a 4 year old standard poodle named Wes who almost certainly has lymphoma.

Wes had about a 10 day history of some nonspecific clinical signs: lethargy, decreased appetite, and occasional vomiting and diarrhea. Wes's owners felt the need to bring him to their regular vet yesterday afternoon when Wes started sneezing blood (epistaxis).

The rDVM ran some bloodwork that showed a very low platelet count of 23,000. Normal platelet numbers are 200-500,000. This thrombocytopenia could have one of several causes and could certainly be the cause of Wes's epistaxis.

However, the CBC that showed the thrombocytopenia had another concerning finding -- a white blood cell count of almost 70,000 (normal being less than 12,000).

Wes's rDVM was suspicious of lymphoma, so submitted another CBC to an outside laboratory to have a pathologist examine a blood smear and give a definitive "yes or no" on lymphoma by this morning.

But Wes's epistaxis hadn't stopped, and out of concern that he might hemorrhage to death overnight, Wes's owners brought him to the VTH.

On presentation Wes was extremely dull and dumpy. He would wag his tail on occasion, but otherwise had no energy for anything other than lying in a heap on the floor. His gums were pale and dry. His heart rate was very elevated (190 beats per minute, normal in a dog his size being probably 80-100) and he was panting heavily with some obvious difficulty breathing. He was febrile at 103.8 (normal 100-102.5).

Unfortunately, the most pertinent finding was that all of Wes's peripheral lymph nodes were significantly enlarged. Additionally, Wes also had a large mass in his cranial abdomen, which I suspect was an enlarged spleen.

Based on Wes's clinical presentation, we absolutely agreed with his rDVM's top rule-out of lymphoma. We looked at a blood smear, which had a huge population of abnormal cells that I'm 99.9% sure were lymphoblasts (cancerous precursors of a type of white blood cell affected in lymphoma). We offered to do fine needle aspirates of some of Wes's lymph nodes and have them examined by a pathologist at the VTH, so that Wes's owners could have an answer immediately instead of waiting until morning.

However, Wes's owners were hellbent on doing as little as possible until morning when they got their test results -- just enough to keep Wes "comfortable" overnight. Our eventual compromise was to hospitalize Wes on IV fluids and place him in an oxygen cage. His heart rate declined somewhat overnight, though it was still elevated at 150 this morning. Wes still struggled to breathe, even in oxygen. He was still mildly dehydrated this morning. His fever, at least, had come down to 102.9.

After I came in to check on Wes this morning, his owners were still trying to make up their minds what to do with him, having not received their tests results from his rDVM yet. They had pretty much ruled out the recommended aggressive chemotherapy protocol which would probably buy them about a year of quality time with Wes but could cost $4-5000. (And I'm not passing any judgment on that. It's a lot of money for a gamble at getting a few months to a year.) It's just tough to see lymphoma in a dog so young -- Wes will only just turn 4 next month. While it's "nice" that lymphoma is one of the few cancers that responds more readily and reliably to chemotherapy than other cancers, it just plain sucks that it hits dogs so young. Last time I was on Urgent Care last fall, I had another 4 year old poodle freshly diagnosed with lymphoma. I hope that Wes's owners will at least put him on some oral steroids for awhile, to buy him a few weeks or months of feeling good at minimal expense.