Wednesday, February 8, 2012

870. A 12-year-old Jack Russell coughs fresh blood for last 2 days

This case illustrates the importance of using relevant evidence-based medicine to provide a standard of veterinary care affordable and expected by the sophisticated younger generation of Singaporeans. This google generation knows much more than the baby-boomer generation and wants answers quickly as to what is the cause of the problem with their sick pet. Not more than one visit will be the best as Singaporeans are time-pressed.

Yesterday morning, I was the vet on duty. A young man came with his 12-year-old Jack Russell which was in excellent body condition. "He coughs blood in the last two days."

The dog's gums were slightly pale. Rat bait poisoning? Unlikely as the dog was supervised when outdoors and there were no rat baits used in the apartment. This was a much loved dog as he would try and attack the newspaper delivery man every morning but not his family members and the family's friends. He was a puppy when the young man was in Primary 5 or Primary 6 and now 12 years or more had flown by.

"Is he a scavenger?" I asked as the Jack Russell started coughing when I palpated his throat from the larynx downwards. The dog coughed and retched. Fresh red blood with white mucous came out from his mouth onto the floor of the consultation room.

"Yes, he swallows any food he would find in the house." the young man asked me for tissue to clear the mess.

"Is he like my son's Bichon who waits for some chairs not pushed inside the dining table to jump onto the table to eat the chicken bones?"

"Yes, yes, he is like that!" the man said.
"As the throat is so painful, it is possible that there is a chicken bone poking the throat and causing coughing and bleeding. I will need to X-ray the throat, lungs and stomach area."

The owner must be given the advice and if he does not want the X-rays, this must be recorded in the case sheet. He wanted the X-rays and complete blood test.

"My dog had a fierce cancerous lump removed from his neck skin at another vet clinic," the owner said to me. He phoned the vet and they faxed over the report in the afternoon. It was a sebaceous gland carcinoma which had grown red and fast on the dog's lower neck 2 years ago. The skin in that neck area was hairless but no recurrence of tumour was seen.

So, was this a case of chicken bone trauma or not? I got the X-rays done. "Pleural effusion," commented two vets as the X-ray of the lung showed radio-opacity instead of black spaces as for normal lungs. Based on clinical signs and the history of a cancer as well as diffuse nodules seen on the X-ray, I advised the owner that it was most likely metastases of cancer cells to the lungs. Bronchoscopy and lung biopsy could be done but this would add to the cost.

The owner decided on euthanasia and was present when I administered the injection. It was sadness in the evening but he was satisfied with the evidence-based medicine done. If the vet had just given some injections and drips without advising X-ray, this coughing of blood would continue and the owner would become much unhappy with another visit. Therefore, the vet must know what to do in a case of coughing blood. In retrospect, this dog had been coughing for the past year but had not coughed blood till the last 2 days.

Blood test revealed an increase in total white cell count suggesting a bacterial infection, red blood cells and haemoglobin in the lowest range of normal values, suggesting blood loss probably from the lung bleeding. I explained the findings to the owner. He had to decide what to do further.

The diagnosis of tumours in the lung due to metastases from the sebaceous gland carcinoma is quite possible. Veterinary costs need to be minimal so I did not suggest bronchoscopy and lung biopsy to confirm the lung tumours as this would prolong suffering in this dog. Coughing of fresh blood is very likely from the lungs as the amount was much more and persistent.

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