Case 2: 8-year-old, female, spayed Terrier mix
2019 Image Interpretation-Case 2: Lymphoma - 1 week post-CCNU
8 year FS Terrier mix One week prior to presentation, the patient had begun CCNU therapy for lymphoma that was diagnosed via surgical excision of a newly developed cervical subcutaneous mass. She was referred to the surgical oncology service even through the mass had been removed and an internist had started chemotherapy. At presentation, she was weak and lethargic and the owner indicated had been in appetent. No prior imaging was provided at presentation.
What's Your Diagnosis? Answers posted after the Image Interpretation Session!
- Right renal pelvis is dilated with heterogeneously mildly hyperechoic structured appearing material and peripheral areas of uniform anechoic fluid
- Moderate parenchymal thinning and poor corticomedullary distinction in the right kidney
- No left renal pelvic dilation and the left kidney has good corticomedullary distinction
- Mottled splenic echotexture and mild enlargement based on thickness and rounding of margins
- Mild bilateral enlargement of the medial iliac lymph nodes; both maintain normal shape and parenchymal architecture features
1) Right hydronephrosis with mixed echogenic and anechoic fluid/material
2) Mild splenic enlargement and mottled parenchyma
3) Bilateral mild medial iliac lymphadenopathy – more likely reactive based on US features
The presumptive diagnosis was pyelonephritis, with infectious pyelonephritis being most likely when episodic pyrexia was documented once admitted to the hospital for supportive care. Ultrasound guided pyelocentesis was performed since urinalysis documented no no pyuria or bacteriuria. With advancement of the needle into the right renal pelvis, fluid was not aspirated. Instead, core-like tissue was aspirated. Cytologic evaluation reveal fungal hyphae. Unfortunately, the patient rapidly deteriorated in the days following diagnosis of fungal pyelonephritis. There was an acute vestibular episode where the patient fell to the right and developed a right head tilt. A new heart murmur was diagnosis five days after presentation and echocardiographic findings were concerning for infectious endocarditis. Seven days following the initial US exam, the patient arrested presumably from an opportunistic systemic fungal infection.