Itsy’s Lymphoma

 D. E. Larsen, DVM

I looked again at Itsy’s tonsils. They were huge. Large tonsils and diarrhea equaled salmon disease in my mind until I proved otherwise.

But Itsy’s tonsils were not simply enlarged; they were huge. Opal stood wringing her hands on the other side of the exam table. She knew me well enough to know that I was concerned about something when I was quiet during an exam.

I started checking Itsy’s lymph nodes. They were all huge, even nodes that were not obvious in many dogs.

I looked at Opal. “She hasn’t had any salmon?” I asked.

“No, there hasn’t been any fish in our house for months,” Opal said. “What do you think is wrong, Doctor Larsen?”

Opal was an older lady, and she liked to keep her relationship with me on a somewhat formal basis. She had no problem calling me at night when Itsy spit up on the carpet, but she always addressed me as Doctor Larsen.

Before I answered Opal, I palpated Itsy’s abdomen. I could feel large lymph nodes all along her intestinal tract.

“Opal, I am going to look at an aspirate from one of these lymph nodes,” I said. “All of Itsy’s lymph nodes are very large. We just have to figure out why.”

“This is something bad,” Opal said. “I can tell. When it is bad, you get very quiet and serious looking.”

“Opal, I am going to do an aspirate first,” I said. “Then, if necessary, I will collect a biopsy from this lymph node.” I pointed to the left prescapular lymph node.

“Biopsy,” Opal said. “You think this is cancer. Oh, my God, what will Bitsy do without Itsy?”

“We don’t have a diagnosis yet,” I said. “Let’s make sure we have something to worry about before we get upset.”

Itsy and Bitsy were litter mates, adopted by Opal the day after Mucho died. I looked at them the same day. A couple of puppies that would fit into a coffee mug. They were not much to look at, but they have become Opal life.

I clipped some hair over the large prescapular lymph node. Prepped it with Betadine and stuck a twenty-gauge needle into the node. I twisted the needle a couple of times and withdrew. Then, with a syringe attached, I squirted the sample onto a microscope slide. After a quick stain, I put the slide under the microscope.

It was bad. In my mind, a definite lymphoma. I knew from experience that the pathologist would not make a diagnosis from a smear of an aspirate. He would want a biopsy.

When I returned to the exam room, Opal had Itsy on her lap and hugged her to her chest. Opal’s eyes were moist, but no tears were evident.

“Opal, this looks like Itsy has lymphoma,” I said. “The pathologist will want a biopsy to confirm that diagnosis.”

“I don’t know what you mean when you say lymphoma,” Opal said.

“Lymphoma is a cancer of the lymphatic system,” I said. “It is lymphatic leukemia. Lymphoma is a serious disease Opal. A dog with lymphoma will die from that disease. We can do things to make her feel better and to buy some time, but that is all.”

“I want to do what is best for Itsy,” Opal said. “I want to buy as much time as possible.”

“Okay, then we need to get a biopsy,” I said.

“If we know what it is, why do we need a biopsy?” Opal asked.

“If we are going to do what is best, I will send you to Eugene for treatment,” I said. “They will require a diagnosis from a pathologist, and the pathologist will require a biopsy. The biopsy won’t take long. I can do it right now with local anesthesia. That way, we can get an answer from the pathologist by the end of the week and start treatment at the same time.”

“Can you give Itsy something to make her feel better until then?” Opal asked.

“Now we get into some serious questions,” I said. “Chemotherapy is not the most pleasant treatment in people and dogs. We could give Itsy some prednisone now, and it would make her feel better right away. But the downside is that it often makes the chemotherapy less effective. So that is sort of a quality of life issue. We can make Itsy feel better, but that may reduce the time we can buy for her.”

“How much time are we talking about, Doctor Larsen?” Opal asked.

“I’m afraid not much time,” I said. “You never know, but if we use prednisone, we seldom buy more than a month or two. With chemotherapy, they use a nineteen-week treatment program. That usually gives Itsy a remission. How long that remission lasts is always variable. It might last six months or more if we are lucky. I have not seen it last a year. When the lymphoma returns, the second course of treatment is seldom as effective as the first treatment. My patients who have gone for treatment have all survived the nineteen weeks of treatment. Some remissions have lasted only a week or two. And in those cases, the patient did not survive the second course of treatment. I have only seen one patient survive nearly six months following diagnosis.”

“That’s not much time, Doctor Larsen,” Opal said. “I don’t know what to do. If you send me to Eugene, I would guess it will be expensive.”

“Yes, I don’t know how expensive, but the last couple I sent down there gave up their second car and their cell phones,” I said. “Their dog went into remission, but it only lasted a few weeks. And the dog died a couple of weeks into the second treatment.”

“What would you do, Doctor Larsen,” Opal asked, tears streaming down her face.

“I can’t answer that question for you, Opal,” I said. “You know your finances, but more importantly, you have to understand what Itsy means to you and Bitsy. It can’t be an easy decision, but you must make it.”

“Okay, let’s do it,” Opal said. “You do the biopsy, and I will take Itsy home and wait for your call.”

We took Itsy to the treatment table and clipped a wide area around her left shoulder blade. After prepping the site, I injected some lidocaine for local anesthesia. Itsy looked at me out of her left eye as Terri held her down on the table. I made a short incision over the swollen prescapular lymph node. Then with a six-millimeter biopsy punch, I collected a good sample and placed it in the formalin bottle.

There was no significant bleeding from the biopsy site. That was probably an indication of the unregulated growth in the lymph node. I closed the incision with three simple sutures.

“I wouldn’t expect Itsy to have any problems with this incision, but call if she does,” I said as we returned Itsy to Opal’s lap. “If you haven’t heard from me by Thursday afternoon, you should call. I am going to build a fire under everyone, so I expect you to have an appointment in Eugene on Friday, and the pathologist should have his work done by then.”

***

The diagnosis came back as an aggressive lymphoma. Opal took Itsy to Eugene, and they went through the nineteen-week treatment protocol. 

Itsy did go into remission, but after almost five weeks, Opal called the clinic in tears.

“Doctor Larsen, Itsy is all swollen up again, and she is not feeling well,” Opal said. “She looks at me, and her eyes say, please, don’t do that again.”

“What do you want to do?” I asked. 

“Maybe you can give her some of that stuff buys a week or two of good days,” Opal said. “If we can have a few good days together, I think we will be ready to say goodbye.”

“That sounds like a good plan, Opal,” I said. “You bring her over, and I will start her off with an injection and then send you home with some pills.”

Opal and Itsy were in the clinic within the hour. I gave Itsy a large dose of dexamethasone for an initial dose and sent them home with some prednisone tablets.

“Opal, this is a good plan, but for it to work well, you will have to decide to say goodbye while Itsy is still feeling well,” I said. “If you try to wait too long, she will be sick again or even die suddenly.”

“We just need a few good days, Doctor Larsen,” Opal said. “I just want to see her eyes dance with joy one more time. And Bitsy so enjoys it when Itsy is feeling well.”

Only a few days later, Opal brought Itsy in for her final visit. Everyone was at peace. Opal and her husband Bill sat in the exam room holding Bitsy as we placed a catheter and said goodbye to Itsy.

Photo by Wallace Chuck on Pexels.

The Taint That Ain’t, from the Archives

D. E. Larsen, DVM

It was 12:30 on Thursday, and we were mostly closed. Thursday afternoon was reserved for golf. But the phone kept ringing, Sandy had stepped into the back, and I was tempted to not answer. But duty calls.

“Good afternoon, this is Doctor Larsen,” I say as I picked up the receiver.

“Oh, Doctor Larsen, I am so happy I caught you,” the lady said. “I know you close early on Thursday.”

I recognized the voice. It was one of the sisters who lived on a small farm not far out of Sweet Home. They were older, maybe spinsters, but I did not know much about them. They were Edith and Elsie, it was almost impossible to tell apart in person. On the phone, I had no chance of knowing which sister I was talking to. Most of the time, their emergencies were minor problems or no problem at all.

“Yes, we are closed, I was just about to switch the phone over to the answering service,” I said. “Is there something I could help you with briefly.”

“This is Edith, I know that you probably have a golf game scheduled this afternoon,” Edith said. “But we were feeding our pig just now and noticed that he has some large swellings on his rear end. He doesn’t act sick, but if he has a large abscess, I would hate to have to leave it for another day.”

“Tell me about this pig,” I said. “How old and how big is he?”

“He is young, I think we got him in February as a weaner pig,” Edith said. “He is growing fast. He is getting big enough that we are going to have him slaughtered sometime in October.”

“Has he been castrated?” I asked.

“Castrated, will I guess. Don’t they usually do that to weaner pigs?” Edith said.

“Just where on the rear end are these swellings?” I asked. I was convinced now that they had just noticed the testicles on this pig.

“They on just below his butt, they are just bulging out,” Edith said. “They can’t be normal, Doctor. We would really like you to check them.”

“It sounds to me like you are looking at his testicles,” I said.

There was a long pause on the phone. Then I could hear the sisters talking to each other.

“He thinks they are testicles,” Edith says. 

“Testicles?” Elsie says. “I don’t think they could possibly be testicles. They are way too large.”

Now I remembered, Edith always did the phone calls and most of the talking. Elsie just seemed to disagree with everything that was said.

“Doctor, we don’t think they could be testicles,” Edith says into the phone. “These swellings are larger than a grapefruit. Each one of them.”

This discussion was going nowhere fast. And it was not going to be resolved over the phone.

“I’ll tell what,” I said. “I will be going right by your place on my way to the golf course. I will stop and just get a look at this pig. If it looks like something that won’t wait until tomorrow, I will stop by on my home and take care of it tonight.”

“Thank you, Doctor,” Edith says. “We were hoping you could get a look at him.”

“You be ready, I am leaving here shortly, and I won’t have much time,” I said. “I am just going to glance at him for now.”

“We will be waiting for you,” Edith said. “He is in a small pen, so it won’t be any problem looking at him.”

I pulled into the driveway, and both sisters were waiting for me. It was just a short walk to pigpen out beside the small barn. The thought occurred to me that I might not be acceptable on the golf course if I got splattered with pig manure, but I didn’t have time to put on coveralls and boots just to glance over the fence.

I could see the pig through the slats in the fence of the pigpen as we approached. This was a good looking young pig, probably over 200 pounds. He had a long body and black and white in color.

I approach the pen so I could get a good look at the rear end of this pig. One glance and I stepped away. 

“Those swellings are testicles,” I said.

“But Doctor, they are so large,” Elsie said. “Are you certain, I mean, I have seen lots of testicles but nothing like these?”

“I didn’t make the design, that is just way pigs are put together,” I said. “I am certain, and I have seen a few testicles also. Now you probably have a couple of choices to make with this guy.”

“What do you mean by choices?” Edith said.

“When pigs are not castrated, their testicles will produce products that can flavor the meat when they reach sexual maturity. This guy is close to market weight but has obviously gone through puberty. You may be okay if you slaughter him now rather than waiting until fall. Otherwise, castrating him now would be a good idea.”

“What do you mean when you say flavor the meat?” Elsie asked.

“It is called boar taint,” I said. “It is in the fat, and in bad cases, it will run you out of the house when you put sausage in the frying pan. Some people say it tastes like piss. It probably occurs in 20 to 30 percent of boars slaughtered. The larger he gets, the more the chances that his meat will be tainted.”

“We were hoping to get him bigger,” Edith said. “I mean, he is growing so well.”

“It might be a good idea to talk with the place you are going to have him slaughtered,” I said. “Some of those places won’t even consider hanging a boar in their cooler.”

“A boar, I have been told you can’t eat a boar,” Elsie asked. “When do you start calling him a boar?”

“I would say about when those testicles start hanging there, so they are noticed. That is why I would suggest you either slaughter him now or have him castrated.”

“And I suppose that castrating him is going to cost some money,” Edith said. “That will sort of change the economics of this whole project.”

“At this age, if I castrate him, it will require anesthesia,” I said. “And yes, it will cost a little money. Actually, there will be more expenses than just the surgery and anesthesia. The procedure always comes with some risks, and he will lose some of his growth. That is why it is so much easier to do it when they are a few days old.”

“We will give it some thought,” Elsie said. “But I think we will go ahead and slaughter him on our original schedule. The odds are in our favor.”

It was sometime in November when Edith stopped by the clinic to let me know that I was probably correct.

“Elsie still is determined to eat that pork, but I make her cook it outside on the barbecue,” Edith said. “It is just like you said it would be when it hits the frying pan, it runs me out of the house. I won’t touch the stuff, but Elsie isn’t going to admit that she was wrong in her decision. She says it ain’t too bad.”

Photo by Leah Kelley from Pexels

Malignant Catarrhal Fever

 D. E. Larsen, DVM

I stepped back from the chute to get a wider view of the cow. This was a sick cow. She was probably going to die. But what is going on with her?

“Bill, has this cow been anywhere other than here?” I asked. 

“No, she was born right here,” Bill said. “She hasn’t stepped off the place in her whole life.”

“I have only seen two cows that looked like this, and both were in school,” I said. “One had bluetongue, and the other had malignant catarrhal fever. Bluetongue is usually seen in sheep, but it can occur in cattle. I am not sure that it is seen in Oregon.”

“I haven’t heard of either of those, but they don’t sound good,” Bill said.

“I think it is more likely that she has a bad case of bovine virus diarrhea,” I said. “That is much more common, and I see a lot of it around here. But I haven’t seen a case of BVD that looked this bad.”

“What does all of that mean for the cow?” Bill asked.

“I think it means this cow is going to die,” I said. “Some cows will recover from BVD, and a few will recover from bluetongue, but the cows with MCF all die. My guess is this cow is going to die. Her eyes are both infected, making her blind. The mucus membranes in her mouth have many blisters and ulcers. It looks like the skin on her tongue is going to slough off. She has swollen lymph nodes and is draining mucus from her nose. She has a lot of trouble breathing, but I think most of that is upper airway issues.”

“Maybe we should just shoot the poor girl,” Bill said.

“That might be an option. There is really no effective treatment for any of this, especially MCF,” I said. “But the state will want a say in this case.”

“That doesn’t sound very good,” Bill said. “They will want me to spend a lot of money finding out what is wrong with my dead cow.”

“I think they are going to want to know what is wrong with her,” I said. “But, the testing they do will be at their expense. They won’t be asking you to pay for any of it.”

“What about my other cows?” Bill asked.

“We have talked about BVD before, and we did some vaccines last fall,” I said. “That distracts from that diagnosis, but some individuals will still contract the disease, even if they are vaccinated. Bluetongue is spread by biting flies and is considered to have no direct transmission. MCF is

spread from carrier animals, usually sheep, and infected cattle are not considered a source of infection to herd mates.”

“So is the state going show up with a bunch of vets, or what?” Bill asked.

“I don’t think that is going to happen,” I said. “I will collect some blood and some tissue from her mouth, which might be all they need. I will give you a call after I talk with them.”

After I collected the samples, I returned to the office and called Doctor White at the state veterinarian’s office. He was an assistant state veterinarian but much easier to work with than the other veterinarian in the office.

“Doc, I am pretty sure I looked at a cow with MCF today,” I said. “I collected some tissue off her tongue, some serum, and a purple top tube of blood that I can send to your lab. Are you going to want to look at this cow?”

“The only thing we worry about with MCF is making sure we are not dealing with a wildebeest strain,” Doctor White said. “What is the status of the cow?”

“She is pretty sick,” I said. “I think she will die in a day or two, maybe sooner. I didn’t treat her with anything. In school, I was always told it was a waste of time and money.”

“If she dies, just have the rendering company drop her off at OSU’s diagnostic lab for a necropsy,” Doctor White said. “I will call them so the rancher isn’t charged for anything.”

“So, this guy thinks that shooting her might be a good option,” I said. “I guess there is no problem with diagnosis if we do that.”

“Well, one disease they like to rule out is rabies,” Doctor White said. “Shooting her in the head might disrupt the tissues for that diagnosis.”

“That’s just great,” I said. “I never even considered rabies as a differential diagnosis. I was involved with a necropsy of a rabid cow when I was in school. We had a group of students and professors who had their hands and arms in the mouth of that cow. And I ended up getting some vaccines after that event. I think we will just wait for her to die. I doubt he will want to pay for a bottle of euthanasia solution.”

“Well, send me your samples, and send the cow to the diagnostic lab when she dies,” Doctor White said. “I will let you know about the diagnosis as soon as I have it.”

“The book says that there is no risk to the rest of the herd from this cow. Is that correct in your experience?” I asked.

“That’s correct,” Doctor White said. “This virus is probably carried by a sheep, and the sheep aren’t bothered. Transmission is somewhat of a mystery. It happens with direct contact but also from airborne transmission up to a few miles away. Don’t ask me how.”

“I don’t think there is a place in the valley where you can be over two miles from a sheep,” I said.

“Probably not, but the good thing is this a rare disease. If you see more than a couple of cases in your lifetime, that would be unusual.”

As soon as I finished my conversation with Doctor White, I called Bill to let him know the plan.

“She is going to make things easy for those state boys,” Bill said. “That cow fell over dead, not more than a half hour after you left.”

“Yes, that makes things easier,” I said. “We will call the rendering truck for you. They drop her off at the diagnostic lab in Corvallis. It might take a few days, but we should have a confirmed diagnosis.”

“What I don’t understand, Doc, is how the hell did she get this MCF stuff?” Bill asked. “I mean, she hasn’t left this place, and no new animals have come into the place in years.

“This virus is carried by sheep,” I said. “It doesn’t make the sheep sick. The book says it is transmitted by direct contact or through the air. They don’t know how it gets through the air, but it can travel a couple of miles.”

“Well, hell, there isn’t a place in this valley two miles away from some damn sheep,” Bill said. “What am I supposed to do about that.”

“It is rare, Bill,” I said. “Don’t lose any sleep over it. I will probably never see another case in my lifetime.”

***

The cow’s diagnosis was malignant catarrhal fever, and it was the usual sheep strain. I was relieved that the rabies virus was not involved.

Oddly enough, I did see another cow with MCF a couple of months later, about two miles down the road from Bill’s place. And there was a flock of sheep between the two places.

So I saw the cow in school and the two cases in Sweet Home. There was never another case. Three cases in a lifetime, all coming within a few years of each other.

Photo by Kris Rae Orlowski on Unsplash.

https://www.merckvetmanual.com/generalized-conditions/malignant-catarrhal-fever/malignant-catarrhal-fever-in-animals#v3275876