Case advice please: lethargic Cockerpoo with voice change

RE: Case advice please: lethargic Cockerpoo with voice change

Julian Earl — Mon, 09 May 2022 16:38:31 GMT

Read this and thought... Neurological probably?? HTH?? Goodluc. maybe a suitable referral is needed?

RE: Case advice please: lethargic Cockerpoo with voice change

Virginia Campbell — Mon, 09 May 2022 15:54:13 GMT

Thanks for the update. Every day is a learning day - I'd never heard of this condition.

RE: Case advice please: lethargic Cockerpoo with voice change

Clare Smith — Thu, 07 Apr 2022 11:41:02 GMT

And so many of them have problems ..

RE: Case advice please: lethargic Cockerpoo with voice change

Lucy Fleming — Thu, 07 Apr 2022 11:37:35 GMT

[quote userid="5746" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30221/case-advice-please-lethargic-cockerpoo-with-voice-change/236764#236764"]sadly it's another Cockerpoo[/quote]

I am increasingly convinced that cockerpoos are the only dogs that even exist nowadays.

RE: Case advice please: lethargic Cockerpoo with voice change

Martin McDowell — Wed, 06 Apr 2022 12:33:37 GMT

OMG in regards to getting another cockerpoo.

Would agree with Bob, sometimes the pathology becomes more evident with time.

Interesting case Claire. Shame how it ended but do think it was the best resolution for owners and dog.

RE: Case advice please: lethargic Cockerpoo with voice change

Clare Smith — Fri, 01 Apr 2022 16:21:36 GMT

Yes, Reading and Cambridge would be a bit of a trek fur us. I'd enquired about referral for larynx exam and CT at a more local referral practice fairly early on but the owner had declined. Sadly CT would have been useful at that stage and a diagnosis would have been reached more rapidly. I saw the owner today and he has already bought a new dog: sadly it's another Cockerpoo.

RE: Case advice please: lethargic Cockerpoo with voice change

niamhjl — Fri, 01 Apr 2022 14:37:18 GMT

Cambridge Radiology Referrals (run by Paddy Mannion, based just behind Cambridge vet school) also do outpatient imaging and are excellent.

RE: Case advice please: lethargic Cockerpoo with voice change

Thomas Johnson — Fri, 01 Apr 2022 14:27:42 GMT

[quote userid="6550" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30221/case-advice-please-lethargic-cockerpoo-with-voice-change/236760#236760"]We just have to accept limitations in general practice where CT/MRI options are limited. We used to be able to send patients off for imaging and interpretation alone which was more affordable than full referral.[/quote]

There are still a few outpatient CT services about, Castle Vets in Reading do them, but that might be a bit far for you https://www.castle-vets.co.uk/services/ct-referrals

RE: Case advice please: lethargic Cockerpoo with voice change

Bob Russell — Fri, 01 Apr 2022 10:54:45 GMT

Very interesting case.

There are plenty of cases where we are left waiting for something to appear or happen that provides us with sufficient information to make a reasonable diagnosis. Sometimes we have to wait for a tumour to become evident!

It may be that a human patient would have been able to point out what is hurting to guide a clinician to a diagnosis.

We just have to accept limitations in general practice where CT/MRI options are limited. We used to be able to send patients off for imaging and interpretation alone which was more affordable than full referral.

RE: Case advice please: lethargic Cockerpoo with voice change

Roger Wilkinson — Fri, 01 Apr 2022 08:23:16 GMT

Thanks Clare

RE: Case advice please: lethargic Cockerpoo with voice change

Clare Smith — Thu, 31 Mar 2022 21:31:36 GMT

As promised, I have an update on this unusual case and I'm sorry to say that it hasn't been good news.

Benji had been booked in for an ACTH stim test once he'd been off the prednisolone for 4 weeks. However, he became progressively more hyporexic and lethargic so the bloods were done sooner and the owner restarted the medication. The blood cortisol levels were not suggestive of Addison's disease. The CK was checked and was high but the lab felt that the result might have been affected by haemolysis of the sample. At the time of sampling a subtle swelling was detected on Benji's head. A FNA sample was taken and sent for cytology which revealed 'a proliferation of suspected spindle cells showing some criteria of cytologic atypia which could raise the possibility of malignancy'. The origin of the cells was not completely clear and biopsy was recommended.
Despite restarting the steroids, Benji's appetite did not improve. I admit that I was away from work by this time, watching from afar, and my colleague stepped in, convincing the owner that further investigation was required to get to the bottom of Benji's problems. An ultrasound scan of his abdomen and head were scheduled. On the day of admission, he was found to be very painful around his head and neck especially around a solid swelling on the caudal part of temporal area on the left side above the pinna.

Ultrasound of the L temporal area revealed a large, hyperechoic 3.1cm diameter soft tissue mass deep to temporalis and adjacent to skull, extending down the side of his ear canal caudally.

In addition, abdominal ultrasound revealed that the abdominal fat was markedly bright around the R lobe and body of pancreas, and the pancreas itself was markedly and convincingly hypoechoic in contrast to the adjacent mesentery.

It was felt that the temporal mass which looked highly ominous and a biopsy was taken for histology. It was difficult to imagine this being anything other than a neoplasm and probably malignant and that it could well be attached to/infiltrating/originating from his skull. It was thought also that this could be a plausible cause of the altered voice too as it might have been impinging on origin of facial nerve.
To make things worse he also had a convincing-looking acute pancreatitis.
The histology report indicated that the temporal mass was a malignant chondro-osseous neoplasia.

'The multilobulated appearance, histological characteristics and the location are most consistent with a multilobular sarcoma of bone (MLSB). However, because these tumors can progress and become more aggressive a more malignant transformation cannot be ruled out.'

'Multilobular sarcoma of bone (MLSB) also known as multilobular tumour of bone is an anatomically constrained tumour that becomes
progressively more malignant over time (transitioning into a highly aggressive, locally infiltrative and metastatic sarcoma). This tumour generally arises from the flat bones of the skull but has rarely been reported at other sites (non-cranial locations). It exhibits a slow and progressive growth and can infiltrate locally compressing structures such as the brain. With time, it can metastasize, spreading to the lungs (most common site) and other distant sites. Metastatic lesions may also be slowly progressive. Surgical removal is difficult due to the location of this tumour and local recurrence happens in around 50% of cases. Malignant transformation usually occurs in those tumours that are long-standing or recurrent. Osteosarcomas and
chondrosarcomas may arise from MLSB leading to a rapid growth and metastasis.'

Surgery was not considered to be a viable option and the owner elected for euthanasia.

After an initially gradual onset, this case took a dramatic rapid progression which had a very sad outcome.

Thanks to all who offered suggestions and especially to Roger Wilkinson for his expertise and advice.

RE: Case advice please: lethargic Cockerpoo with voice change

Clare Smith — Thu, 17 Mar 2022 04:38:43 GMT

Thanks for your advice Roger. The ACTH stim was normal. Hopefully we can get a CK run at the lab.

RE: Case advice please: lethargic Cockerpoo with voice change

Roger Wilkinson — Wed, 16 Mar 2022 16:28:57 GMT

Hi Clare,

Depends a bit exactly how skint they are. I agree this has a distinct feel of neuromuscular disease affecting larynx and potentially other systems too.

https://pubmed.ncbi.nlm.nih.gov/16400098/

Broadly speaking polymyositis type issues and myasthenia worth considering.

Either of those could potentially be steroid-responsive. The fact that it did appear to respond makes some of the other potential causes of LP less likely.

There are reports of dogs with laryngeal paralysis associated with hypoadrenocorticism.

It's cheap to run a CK looking for myositis and probably sensible to check adrenal function.

Must admit I'm not sure I subscribe to the idea that you can do this whilst on preds.. but a month off steroids should be enough considering not been on huge doses long term.

Could do less cheap anti-ach receptor abs too.

In an ideal world I'd like a really close look at the larynx by scope to check for any evidence of pathology e.g. granulomatous laryngitis.

All the best

Roger

RE: Case advice please: lethargic Cockerpoo with voice change

Clare Smith — Mon, 14 Mar 2022 06:08:50 GMT

Will do!

RE: Case advice please: lethargic Cockerpoo with voice change

Silvia Maldonado — Sun, 13 Mar 2022 22:54:02 GMT

Please, keep us updated. I'm curious, and it is an unusual case.

RE: Case advice please: lethargic Cockerpoo with voice change

Clare Smith — Thu, 10 Mar 2022 19:21:12 GMT

Thanks David. I have the same feeling about the preds... It would be nice to have a diagnosis but this might be one of those cases where we don't find one.

RE: Case advice please: lethargic Cockerpoo with voice change

David Mills — Thu, 10 Mar 2022 18:47:38 GMT

Laryngeal paralysis may be part of a systemic autoimmune/idiopathic neuromuscular issue - often comes with proprioceptive deficits in hind limbs.

Localised MG seems to pop up on differentials for anything odd in the oesophagus/throat/chest but never knowingly seen it, not sure if anyone else he or it’s just one of those referral/textbook things.

Not convinced Addison’s fits (although everything referred these days seems to get tested for it), but a basal cortisol will rule it out normally (you can do this whilst on preds - speak to your lab).

It’s probably going to end up on preds.

RE: Case advice please: lethargic Cockerpoo with voice change

Sarah Keir — Wed, 09 Mar 2022 10:18:50 GMT

4 weeks off steroids should be long enough but it does depend on dose of steroids

RE: Case advice please: lethargic Cockerpoo with voice change

Hamish Denham — Mon, 07 Mar 2022 21:20:25 GMT

Apologies it was a fat thumb problem. Wouldn’t be surprised if it has happened before. The react button seems to be directly in the thumb line.

RE: Case advice please: lethargic Cockerpoo with voice change

Clive Ansell — Mon, 07 Mar 2022 20:47:43 GMT

Just one of many ddx's I guess?

RE: Case advice please: lethargic Cockerpoo with voice change

Clare Smith — Mon, 07 Mar 2022 17:07:09 GMT

Thanks Sarah. I haven't come across localised MG. Do you think 4 weeks off steroids is long enough before checking CRP?

RE: Case advice please: lethargic Cockerpoo with voice change

Sarah Keir — Mon, 07 Mar 2022 09:53:06 GMT

Localised myesthenia gravis?

Some form of autoimmune disease e.g. IMPA? Perhaps test CRP when been off the steroids for a while - not specific but will let you know if there is something to be concerned about in the background.

RE: Case advice please: lethargic Cockerpoo with voice change

Clare Smith — Sun, 06 Mar 2022 20:31:07 GMT

Thanks Julian. He didn't respond to NSAIDs when used first line but will bear it in mind.

RE: Case advice please: lethargic Cockerpoo with voice change

Julian Earl — Sun, 06 Mar 2022 17:17:18 GMT

[quote userid="5746" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30221/case-advice-please-lethargic-cockerpoo-with-voice-change"]was a suggestion of reduced abduction of the left vocal cord on inspiration. T[/quote]

Causes of laryngeal paralysis in dogs? Recognised in Spaniels IIRC?

Non-steroidals a sensible first option as inflammatory disease is likely somewherein the neurological pathway!

HTH?

RE: Case advice please: lethargic Cockerpoo with voice change

Clare Smith — Sun, 06 Mar 2022 17:05:10 GMT

That's an interesting one Clive. Makes me think it's worth keeping an eye on all peripheral lymph nodes.