10 year old labrador patient, "Theo," arrives with a history of vomiting. He's been previously in good health, but the last 2-3 days he had been lethargic, less willing to walk around, not interested in eating, and every time he tries to drink, he vomites shortly afterwards.
On physical exam, Theo was very depressed, dehydrated, and appeared nauseated. His bladder felt small on palpation of his abdomen, and otherwise, his physical was unremarkable. Being an ill geriatric large breed dog, I recommended some in-house blood testing to rule in or out serious illness. Unfortunately, we were just about to find out how serious of an illness he indeed had been hiding.
Theo's kidney values were sky-high. His potassium was elevated. His ionized calcium off the charts. All signs pointing to severe kidney failure, severe enough to be decreasing the amount of urine being produced by Theo's kidneys.
Theo's loving family and I discussed the lab findings; discussed the potential causes of his symptoms. I considered the following diagnoses; cancer (lymphoma most likely, but many other types also possible), acute kidney failure from a toxin (many plants, human drugs, and poisons can be directly toxic to the kidneys), a severe kidney infection, or less likely hypertension, or kidney stones.
Theo's family wished to start treatment, and continue the search for the original cause of his symptoms, even with the knowledge that his disease may have a poor prognosis. A urinary catheter was placed to monitor his urine output. He was started on IV fluids, to improve his hydration and provide improved circulation to the kidneys. Anti-emetics and anti-acid medications were started to relieve his nausea. After several hours and several liters of fluid, Theo failed to produce more than a few drops of urine.
A diuretic medication was initiated in hopes of restoring urine production; a common saying in the treatment of kidney failure is "where there's pee, there's hope." Theo did start producing urine, and the diuretic treatment also brought his calcium down to a more normal level. He stopped vomiting, but still didn't choose to eat.
After Theo's metabolic condition was stabilized, the owners and I discussed again his progress. It was important to get to the bottom of his illness, to find the original culprit of the elevated calcium.
The hunt for cancer was on.
Chest radiographs were performed initially as a screening tool for metastatic neoplasia. To all of our suprise, a very large mass occupied >60% of Theo's chest. Theo had no symptoms associated with difficulty breathing, coughing, and no abnormal breath sounds were present. In dogs and cats, who can't tell us the details of how they're feeling, imaging often is a very important tool to look inside of their body cavities and find out what may be hiding underneath. This often includes chest radiographs (x-rays), abdominal ultrasound, and sometimes more advanced testing such as bone marrow aspirates, aspirates of abdominal organs, or imaging of the brain (CT scan or MRI).
Unfortunately for Theo, the whole picture was complete. His tumor had caused an elevation in the blood levels of calcium, which in turn had caused his kidney failure and then his resulting symptoms; lethargy, vomiting, inappetence, and malaise. His loving owners were grateful to know that they gave him every chance, that his diagnosis was certain, and they spent quality time with him before later that weekend, they helped Theo pass over the "rainbow bridge."
We had almost exactly the same case recently - a 16 year old Sheltie with severe hypercalcemia, azotemia. The rDVM referred him to us for the weekend to "manage" his hypercalcemia. No imaging had been done. The first thing I told these owners was that hyperCa2+ in a dog this old is going to be CANCER. They wanted to wait for further diagnostics at their rDVM. I wasted $1200 of their money for a weekend of IV fluids only to have the rDVM confirm the giant chest mass on Monday. Sad case. Turned out to be LSA
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