pISSN 1598-298X / eISSN 2384-0749 J Vet Clin 34(1) : 39-42 (2017)
http://dx.doi.org/10.17555/jvc.2017.02.34.1.39
39
Grain Foreign Body Embedded in the Spleen and Immune-Mediated Hemolytic Anemia in a Maltese Dog
Joong-Hyun Song, Hyo-Mi Jang, Hee-Chun Lee, Jung-Hyang Sur*, Byeong-Teck Kang** and Dong-In Jung1 Research Institute of Natural Science, College of Veterinary Medicine, Gyeongsang National University, Jinju 52828, South Korea
*Department of Pathobiology, Small Animal Tumor Diagnostic Center, College of Veterinary Medicine, Konkuk University, Seoul 05029, South Korea
**Laboratory of Veterinary Dermatology and Neurology, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk 28644, South Korea
(Received: September 19, 2016 / Accepted: December 23, 2016)
Abstract : An 8-month-old, intact male Maltese dog was referred to us because of anorexia, diarrhea, and jaundice.
Hematologic examination revealed immune-mediated hemolytic anemia, and abdominal ultrasonography revealed heterogeneous changes in mesenteric fat and coarse echotexture in the splenic parenchyma. Septic peritonitis was diagnosed on the basis of a bacterial culture test of the peritoneal fluid. Exploratory laparotomy and subsequent omental biopsy and splenectomy were performed. On histopathological examination, the omental mass and splenic lesions were diagnosed as grain foreign body granulomas. This report describes a rare case in which a grain foreign body was embedded in the spleen of a dog.
Key words : Dog, Foreign body, IMHA, Septic peritonitis, Spleen.
Introduction
Intraabdominal foreign bodies are common in dogs (23).
Foreign body migration also represents a sufficiently docu- mented entity in veterinary literature. The majority of migrating foreign bodies are grass awns (6,15,17,22), grass seeds (33), and other plant materials (11,18,25); nevertheless, other types of foreign bodies have also been reported (8,12,20,23,31).
These can migrate to multiple body regions through diverse routes and can result in a wide variety of clinical manifesta- tions, depending on the site of inflammation.
Case
An 8-month-old, 1.71-kg, male Maltese dog with no previ- ous history of related medical problems or surgery presented with a 2-week history of anorexia, diarrhea, and jaundice. The dog lived strictly indoors, and all vaccinations had been com- pleted. The dog had a history of eating a lot of grain (Oryza sativa L.), and the clinical signs had developed since he had started eating grain.
Abdominal distension and lethargy were noted on physical examination. The temperature, pulse, and respiratory rate were normal. A complete blood count (CBC) revealed severe leukocytosis (53.8× 109/l; reference range, 6.0 to 17.0 × 109/l) and severe anemia (hematocrit, 11.6%; reference range, 37 to 55%). Abnormalities in its serum biochemical profile included
hypoalbuminemia (1.8 g/dl; reference range, 2.5 to 4.4 g/dl), hypoproteinemia (4.5 g/dl; reference range, 5.4 to 8.2 g/dl), hyperbilirubinemia (1.6 mg/dl; reference range, 0.1 to 0.6 mg/
dl), and increased serum alkaline phosphatase activity (1082 U/l; reference range, 20 to 150 U/l). The saline agglutination test result was positive, and spherocytosis was commonly seen in the blood film. However, there was no evidence of infection.
Thoracic radiography did not reveal any abnormal find- ings. However, abdominal plain radiography revealed poor serosal detail and abdominal distension. Abdominal ultrasono- graphic examination revealed echogenic free fluid through- out the peritoneal cavity, generalized abdominal lymphade- nopathy, corrugated small intestine, and heterogeneous changes in mesenteric fat (Fig 1A). Peritoneal fluid analysis revealed many degenerative neutrophils on cytologic evalua- tion and a positive result on an aerobic bacterial culture test.
Treatments for immune-mediated hemolytic anemia (IMHA) and septic peritonitis were performed along with other symp- tomatic therapies. At first, explorative laparotomy was not performed at the owner’s request. A reexamination performed approximately 1 week after presentation revealed recurrence of severe anemia (hematocrit, 13%) and hyperbilirubinemia (0.9 mg/dl) on serum biochemical analysis. A repeat ultra- sonography showed heterogeneous changes in mesenteric fat expanding from the stomach to the spleen, and the splenic parenchyma showed coarse echotexture (Fig 1B). Computed tomography revealed no additional findings.
Based on the clinical history, an exploratory laparotomy was performed. Perioperative evaluation revealed a solid mass within the greater omentum and dark coloration of the
1Corresponding author.
E-mail: [email protected]
40 Joong-Hyun Song, Hyo-Mi Jang, Hee-Chun Lee, Jung-Hyang Sur, Byeong-Teck Kang and Dong-In Jung
spleen (Fig 2A and 2B). A thorough abdominal exploratory surgery revealed no perforations in the alimentary tract and no abnormalities in any other abdominal organs. Partial omentectomy and splenectomy were performed. Based on histopathological examination of the omental mass as well as the spleen, the dog was diagnosed with foreign body granu- loma caused by multiple grains (Fig 3). The dog made a full recovery, with no recurrence of clinical signs 2 months after discharge. In addition, follow-up CBC, serum biochemical analysis, and ultrasonographic examination showed normal results.
Discussion
Foreign bodies in organs other than those in the gas- trointestinal tract are uncommon in dogs (23), and these for- eign bodies migrate to various regions, including the thoracic and abdominal cavities, ears, eyes, brain, neck, vertebrae, liver, bladder, and subcutaneous tissue (2,4,9,13,25,33,34). For-
eign body migration into the spleen, as seen in the present case, is rare. Only six cases of foreign bodies penetrating the spleen have been reported to date in the veterinary and human literature (3,5,11,16,23,27). In these previous cases, the splenic foreign body was detected by diagnostic imaging (radiography or ultrasonography). Some reports also describe cases in which detecting the migrated foreign body by using radiography and ultrasonography was difficult (9,26,29,33).
In the present case, we found no signs of the foreign body on diagnostic imaging, and instead, it was identified on histo- pathological examination. We believe that the grain foreign body size was too small to allow detection, and the physical properties of the grain might have interrupted radiographic or ultrasonographic visualization.
In small animals, peritonitis is most commonly the result of gastrointestinal rupture, perforation, or dehiscence. These complications are mostly secondary to ulceration, foreign body obstruction, neoplasia, or trauma (30). Conversely, a perfora- tion of the gastrointestinal tract by an ingested foreign body Fig 1. Ultrasonography of the cranial abdomen showing heterogeneous changes in mesenteric fat (arrows) with echogenic free fluid in the peritoneal cavity (A). On reexamination, the heterogeneous changes in mesenteric fat are seen expanding from the stomach to the spleen, and the splenic parenchyma shows a coarse echotexture (short arrow) (B).
Fig 2. Intraoperative photographs showing a solid mass (arrows) within the greater omentum (A). The spleen appears dark in color (long arrow) (B).
Splenic Grain Foreign Body in a Dog 41
is difficult to diagnose when no peritonitis or abscess forma- tion is observed (5). In addition, extraluminal migration of the foreign body should be considered in animals with evi- dence of unexplained inflammatory disease (18). According to previous reports, the foreign bodies detected in the spleen have included a sewing needle in a dog and plant material a cat (11,23), and the principal origin of migration to the spleen was the gastrointestinal tract. Considering the position of the foreign bodies and the existence of peritonitis in the present case, we postulate that the sharp tip of a grain (Oryza sativa L.) might have penetrated the omentum and the spleen through the stomach wall. The grain could also have accidentally penetrated through the skin and into the peritoneal cavity.
However, the dog had no history of skin injury or iatrogenic events. Moreover, the dog had a history of eating a lot of grain before the onset of clinical signs, which make these possibilities less likely.
Direct methods of detecting migrating foreign bodies include plain radiography, contrast sinography, ultrasonogra- phy, computed tomography, magnetic resonance imaging, sur- gical exploration, and histopathological examination (1,9,11, 15,17,23,25). Indirect methods can also help clinicians diag- nose foreign body migration, and these include the identifica- tion of peritonitis on ultrasonographic examination (11), detection of evidence of alimentary tract perforation on surgi- cal exploration (18), and identification of granulomatous reaction on histopathological examination (10,24,32). In the present case, ultrasonographic examination with a peritoneal fluid bacterial culture test revealed septic peritonitis. More- over, the foreign body and granulomatous reaction were well detected on histopathological examination. However, no fibrous tract and scar were identified in the alimentary tract wall at the time of surgery.
In the present case, septic peritonitis and IMHA were iden- tified, and these clinical states may be associated with the
septic inflammation induced by foreign body migration. In previous reports, peritonitis secondary to foreign body migra- tion has been sufficiently documented in dogs and cats (7,11,12,17,18). IMHA is secondary to bacterial infection, as well as certain chronic inflammatory statuses (21). In case of secondary IMHA, antibodies are formed against the foreign bodies, such as bacteria, viruses, or drugs, that abnormally coat the red cells (19,28). Infections may also trigger “flares”
of immune-mediated disease (14). In the present case, these comorbidities were resolved by surgical retrieval of the for- eign bodies.
This report describes a case of splenic and omental for- eign body in a dog. This diagnosis appears to be extremely rare in animals. In the present case, septic peritonitis and IMHA were associated with foreign body migration, and sur- gical resection of the granuloma together with the retrieval of the foreign body successfully improved all clinical symp- toms.
References
1. Appleby R, Zur Linden A, Singh A, Finck C, Crawford E.
Computed tomography diagnosis of a thoracic and abdominal penetrating foreign body in a dog. Can Vet J 2015; 56:
1149-1152.
2. Armbrust LJ, Biller DS, Radlinsky MG, Hoskinson JJ.
Ultrasonographic diagnosis of foreign bodies associated with chronic draining tracts and abscesses in dogs. Vet Radiol Ultrasound 2003; 44: 66-70.
3. Baccarani U, Risaliti A, Sainz-Barriga M, Adani GL, Donini A, Toniutto P, Bresadola F. Ileosplenic fistula and splenic abscesses caused by migration of biliary stents in a liver transplant recipient. Gastrointest Endosc 2003; 58: 811-813.
4. Beischer D, Robins G. Vertebral osteomyelitis, ataxia and paraparesis caused by a satay stick. Aust Vet Pract 1993; 23:
7-10.
Fig 3. Images acquired during histopathological examination. Pathologic evaluation comprised gross inspection of the foreign bodies, as well as plain (A, C) and polarized light microscopic examination (B, D) of tissues embedded in paraffin and stained with hematoxylin- eosin. Note the foreign bodies (arrows) embedded in the omentum (A, B) and the spleen (C, D) showing granulomatous reaction.
42 Joong-Hyun Song, Hyo-Mi Jang, Hee-Chun Lee, Jung-Hyang Sur, Byeong-Teck Kang and Dong-In Jung
5. Brankov O. Migration of an ingested foreign body (sewing needle) to the pancreas tail and spleen. Khirurgiia 2007: 64- 66.
6. Brennan KE, Ihrke PJ. Grass awn migration in dogs and cats:
a retrospective study of 182 cases. J Am Vet Med Assoc 1983; 182: 1201-1204.
7. Brennan SF, Connery N, Tobin E, Mooney CT, Jones BR.
Gastrocutaneous fistula as a result of migration of a foreign body in a dog. J Small Anim Pract 2004; 45: 304-306.
8. Calvo I, Weilland L, Pratschke K. Traumatic myocardial laceration as a result of suspected cranial migration of a sewing needle from the stomach of a dog. Aust Vet J 2011; 89: 444-446.
9. Choi H, Lee Y, Wang J, Yeon S, Lee H, Lee H. Metallic foreign body in the liver of a dog. J Vet Med Sci 2010; 72:
1487-1490.
10. Coleman DL, King RN, Andrade JD. The foreign body re- action: a chronic inflammatory response. J Biomed Mater Res 1974; 8: 199-211.
11. Culp WT, Aronson LR. Splenic foreign body in a cat. J Feline Med Surg 2008; 10: 380-383.
12. Day JL, Pechman RD, Bahr RJ. Migration of a retained surgical swab into the jejunum in a dog. J Small Anim Pract 2012; 53: 705-708.
13. Dennis MM, Pearce LK, Norrdin RW, Ehrhart EJ. Bacterial meningoencephalitis and ventriculitis due to migrating plant foreign bodies in three dogs. Vet Pathol 2005; 42: 840-844.
14. Ettinger SJ, Feldman EC. Immune-mediated Hemolytic Anemia and Other Regenerative Anemias. In: Textbook of veterinary internal medicine, 7th ed. Philadelphia: Saunders. 2009: 761- 772.
15. Gnudi G, Volta A, Bonazzi M, Gazzola M, Bertoni G.
Ultrasonographic features of grass awn migration in the dog.
Vet Radiol Ultrasound 2005; 46: 423-426.
16. Gongaware RD, Rose JS, Berdon WE, Weil R 3rd. Intra- splenic foreign body. The use of induced pneumoperitoneum for diagnosis. Am J Surg 1972; 124: 694-696.
17. Hopper BJ, Lester NV, Irwin PJ, Eger CE, Richardson JL.
Imaging diagnosis: pneumothorax and focal peritonitis in a dog due to migration of an inhaled grass awn. Vet Radiol Ultrasound 2004; 45: 136-138.
18. Hunt GB, Worth A, Marchevsky A. Migration of wooden skewer foreign bodies from the gastrointestinal tract in eight dogs. J Small Anim Pract 2004; 45: 362-367.
19. Johns IC, Desrochers A, Wotman KL, Sweeney RW. Pre- sumed immune-mediated hemolytic anemia in two foals with Rhodococcus equi infection. J Vet Emerg Crit Care 2011;
21: 273-278.
20. Johnson GC, Mann FA, Fair N, Casteel SW. Transmural intestinal penetration of polyester fibers as an uncommon cause of peritoneal adhesions in a dog. J Vet Diagn Invest 1992; 4: 473-476.
21. Klag AR, Giger U, Shofer FS. Idiopathic immune-mediated hemolytic anemia in dogs: 42 cases (1986-1990). J Am Vet Med Assoc 1993; 202: 783-788.
22. Linon E, Geissbuhler U, Karli P, Forterre F. Atlantoaxial epidural abscess secondary to grass awn migration in a dog.
Vet Comp Orthop Traumatol 2014; 27: 155-158.
23. Mahajan SK, Anand A, Sangwan V, Mohindroo J, Singh K.
Surgical retrieval of a metallic foreign body from the spleen of a dog. Can Vet J 2012; 53: 399-401.
24. Malizia AA, Jr., Reiman HM, Myers RP, Sande JR, Barham SS, Benson RC, Jr., Dewanjee MK, Utz WJ. Migration and granulomatous reaction after periurethral injection of polytef (Teflon). J Am Med Assoc 1984; 251: 3277-3281.
25. Mateo I, Lorenzo V, Munoz A, Pumarola M. Brainstem abscess due to plant foreign body in a dog. J Vet Intern Med 2007; 21: 535-538.
26. Matteucci ML, Spaulding K, Dassler C, Lee D. Ultrasound diagnosis: intra-abdominal wood foreign body. Vet Radiol Ultrasound 1999; 40: 513-516.
27. Potter FA, Fiorini AJ, Knox J, Rajesh PB. The migration of a Kirschner wire from shoulder to spleen: brief report. J Bone Joint Surg Br 1988; 70: 326-327.
28. Sellon D, Wise L. Disorders of the hematopoietic system.
In: Equine Internal Medicine, 2nd ed. Philadelphia: Saunders.
2004: 721-768.
29. Shah ZR, Crass JR, Oravec DC, Bellon EM. Ultrasono- graphic detection of foreign bodies in soft tissues using turkey muscle as a model. Vet Radiol Ultrasound 1992; 33:
94-100.
30. Silverstein D, Hopper K. Peritonitis. In: Small animal critical care medicine, 2nd ed. Philadelphia: Saunders. 2014: 643-648.
31. Takahashi K, Morimura N, Sakamoto T, Nagashima H, Hirata M. Medullar injury caused by sewing needle puncture.
J Emerg Med 2011; 40: 65-67.
32. Tornero J, Palou J, Prados M, Salvador J, Vicente J. Bladder perforation caused by foreign body migration. Int Urol Nephrol 2000; 32: 241-243.
33. Vansteenkiste DP, Lee KC, Lamb CR. Computed tomographic findings in 44 dogs and 10 cats with grass seed foreign bodies. J Small Anim Pract 2014; 55: 579-584.
34. Wyatt K, Marchevsky A, Kelly A. An enterovesical foreign body in a dog. Aust Vet J 1999; 77: 27-29.
