HISTORY / CLINICAL SIGNS: Several month Hx of chronic sneezing (+/- epistaxis, or nasal bleeding) that has worsened over time. Ulcerative lesion on the nose that has enlarged over the past few months.
PHYSICAL EXAM FINDINGS: Sneezing with some bloody discharge. Concave ulcerative, depigmented lesion on nasal planum. Mild ambulatory paraparesis. Moderate periodontal disease. Moderately enlarged submandibular lymph nodes. Otherwise, PE unremarkable.
What is on your differential diagnosis list? What diagnostic tests would you order? Any other questions?
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DIFFERENTIALS of Nasal Disease: Discoid lupus erythematosus (DLE). Neoplasia. Fungal infection (ex. aspergillosis). Lymphocytic-plasmacytic infiltration. Nasal foreign body.
If this patient had presented with bleeding from the nasal cavity only (without the nasal lesion), what would differentials be for the epistaxis?
DIAGNOSTIC TESTS & RESULTS:
- Bloodwork: Mild lymphopenia. Slight elevation in ALP. Otherwise, unremarkable.
- Urinalysis: pH 8.0. Small triple phosphate crystaluria. Otherwise, unremarkable.
- Skull radiographs: No obvious skeletal defects or bony infiltration, sinus infiltration, or masses.
- Submandibular LN FNA: Reactive lymphoid hyperplasia: mild neutrophilic & macrophagic inflammation. No cytologic evidene of infectious agents or neoplasia.
- Nasal biopsy: Intranasal sample: mild, diffuse, lymphoplasmacytic rhinitis. Extranasal sample: dermis replaced by glandular epithelial cells arranged in numerous, irregular tubules supported by a fibrous stroma; these cells have 1-2 variably sized nucleoli; moderate anisocytosis & anisokaryosis; 5 mitotic figures in 10 400X fields; stroma heavily infiltrated by lymphocytes, plasma cells, rare neutrophils.
Based on this patientโs signalment, clinical signs, physical exam findings, and test results, what is your diagnosis, recommended treatment, and prognostic outlook?
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DIAGNOSIS: Nasal adenocarcinoma. Nasal adenocarcinoma is a malignant cancer. While they tend to be slow-growing, they are invasive to the surrounding structures and carry the possibility for metastasis to nearby lymph nodes/lungs as the neoplasia progresses.
TREATMENT/OUTCOME: Due to the anatomical location of this nasal tumor, surgery is tricky. Chemotherapy is generally unsuccessful. Radiation was discussed with the owner, who declined in favor of palliative care, involving pain relief (tramadol) and immunosuppressive prednisone.
Any other questions, comments, or suggestions?
Unless otherwise stated, these clinical cases are real-life cases that I have managed as a veterinarian in general small animal veterinary practice or else assisted with as a student in vet school. These cases are a great real-world learning tool for vet students and other veterinary professionals. They shall be used for learning purposes and collaboration of knowledge only. These cases are not intended to diagnose or treat any disease by pet owners. – Maranda Elswick, DVM
