Visiting Vet: Queenie’s symptoms

Diagnosing conditions can be tricky.

Queenie, a middle-aged Corgi, didn’t have a regular Island veterinarian, but her owner called my office when the dog began acting oddly. “She stopped eating a few days ago,” her mom reported. I asked questions, gathering clues as to what could be going on. Any history of trauma? She sometimes jumped down hard off the couch, but that’s all. Vomiting or diarrhea? A touch of the runs today, but nothing dramatic. Coughing? An occasional gaggy cough, but that had been going on for a year.

Queenie was “BAR.” That’s bright, alert, responsive. But she was panting vigorously, her sides moving in and out with marked effort. “Is she breathing like that at home?” I asked. Sometimes parameters like pulse and respiration will be altered by the stress of visiting the veterinarian. Since Queenie and I were meeting for the first time, I had no baseline with which to compare her current behavior. “I think she’s just nervous,” her mom replied hesitantly. “Well … maybe she’s been breathing a little hard at home.”

I grabbed my stethoscope. Queenie’s incessant panting made it hard to assess her heart and lungs. My assistant tried gently closing her mouth, but Queenie wasn’t having it, and the last thing I wanted was to add additional stress to a dog who already had labored breathing. “OK,” I said. “Let her pant.” The lung sounds were not normal, and, try as I might, I could barely hear her heart. “We’d better take x-rays,” I said.

Plain radiographs show three different “densities.” Bone. Air. Fluid or soft tissue, which look the same. Normally there is a distinct line between chest and abdomen, the big sheet of muscle called the diaphragm separating the two body cavities. Heart and lungs are on one side. Stomach, intestines, liver, kidneys, spleen, and so on, are on the other side. In Queenie’s films, this usually obvious separation was not so obvious. Fluid, called pleural effusion, surrounded her lungs, and there were other poorly defined but clearly abnormal soft tissue densities in her chest. Her lungs were compressed, the outline of her heart obscured. Could Queenie have a diaphragmatic hernia?

A hernia is a condition in which an organ or body part that is supposed to be in one place protrudes through the muscle or connective tissue that normally contains it. For example, in males, abdominal tissue or intestine often slips through the inguinal canal into the groin area, resulting in an inguinal hernia. Young animals often have umbilical hernias at the navel, with abdominal contents pushing through the belly wall. Diaphragmatic hernia (DH) occurs when abdominal contents move through a torn diaphragm into the chest. This may be a birth defect (congenital) or, more commonly, from injury (traumatic.) Any sudden, forceful blow, such as being hit by a car, can change the pressure between chest and abdomen, tearing the diaphragm, allowing abdominal contents to move into the chest, which then compromises breathing and cardiac function.

A dog with a small congenital DH may show no symptoms at all, or just a chronic cough. Signs can develop later in life. Dogs with traumatic DHs often present in shock and acute respiratory distress. However, up to a fourth of cases of traumatic DH are not diagnosed until weeks after injury. Signs may include progressively worsening respiratory issues, cough, poor appetite, and/or vomiting. Respiratory symptoms depend on the size and location of the diaphragmatic defect, degree of lung compression, and amount of fluid accumulation. Gastrointestinal signs depend on what abdominal contents end up in the chest, and exactly what organs are involved. Vomiting, diarrhea, loss of appetite, bloating, and pain may occur if an entrapped organ such as intestines, liver, or spleen gets twisted or strangulated.

“Are you sure there’s no chance she was hit by a car?” I asked again, looking at her films. “Or fell off a porch?” Her owner reiterated that she may have landed hard jumping off the couch, but there was no history of other recent trauma. I couldn’t tell exactly what was going on, but she had labored breathing, muffled heart and lung sounds, loss of appetite, diarrhea, and radiographic changes consistent with possible DH, including loss of diaphragmatic line, loss of heart silhouette, displaced lungs, and pleural effusion. Perhaps a small congenital DH was the cause of the chronic cough. Perhaps that defect had suddenly torn larger when she jumped hard off the couch.

In any case, treatment for diaphragmatic hernia involves stabilization of cardiovascular and respiratory status, followed by surgery — the sooner the better. Left untreated, it can become life-threatening. I advised Queenie’s mom to consult a board-certified veterinary surgeon at a referral center with 24-hour nursing care and all the bells and whistles, including continuous cardiac monitoring, oxygen cage, and ventilator. Specialists could confirm the diagnosis with ultrasound or other additional imaging, then begin appropriate treatment.

When Queenie got to the specialists, they immediately did an ultrasound. They then drained the fluid that was accumulating around her lungs, relieving some of the pressure. She was placed in an oxygen cage while the fluid was sent for immediate analysis by a pathologist. That’s when we got the bad news. The laboratory found tumor cells in that fluid consistent with carcinoma. Queenie did not have a diaphragmatic hernia. She had cancer.

The type of fluid buildup seen in Queenie’s chest typically occurs after a malignancy has spread, “seeding” the whole area with cancer cells. The disseminated cancer, and subsequent fluid buildup, distorted her normal anatomy in such a way that I thought the initial radiographs showed a possible diaphragmatic hernia. I made the best recommendations I could with the information I had at the time. I am grateful the specialists were able to quickly make the correct definitive diagnosis. Sadly, the prognosis is poor. Although they were able to make her more comfortable temporarily, Queenie was discharged for home hospice care. With analgesic medication and appetite stimulants to optimize her quality of life, may she breathe easy for as many pain-free days as possible.