RE: Causes of Enlarged Lymph Node
I found this post while searching for a reason why my vet, an internist, thought my dog had cancer and removed a kidney because he had an enlarged lymph node in his throat, a low grade fever, and a small lump in his kidney when she did ultrasound. It turned out that it was a middle ear infection all along. The lump in his kidney was just a cyst. Now that I know more about the lymph system, I wonder why she never even considered the possibility of a middle ear infection, even though he had a history of ear infections, and had one less than two weeks before I found the enlarged node, and how she concluded that this node somehow indicated a problem in his abdomen. She saw him for nearly a year, and was never able to diagnose him. She concluded that it was cancer or an immune-mediated disease that she couldn't identify. The only thing she did was prescribe very high doses of prednisone.
As I read the first post in this thread, I felt a horrible sense of dread for the poster, thinking she was probably going to experience the same awful thing that I did, but you picked up on the middle ear issue without any other evidence at all. I wonder how the internist I saw could have failed so miserably. I told her of his ear issues, and how his ears had turned bright red just a week earlier, and how he cried out when I touched the side of his head. I also told her how he'd stop halfway though a yawn, but as I was telling her this, she indicated that she didn't want to hear about it because it wasn't related. I later got the records and found she didn't even write down what I told her. I just don't understand it. She's now out of practice, and her partner, who also saw my dog, won't speak to me on the phone. Instead of calling me back, she sent me a note saying, "He had no clinical signs of a middle ear condition when we saw him." It's crazy. Are you that good, or was my vet that bad?
Great news! Happy New Year to You as well!
This thread has important lessons for all MedHelp readers/writers and in both veterinary and human medicine.
When a diagnosis is in doubt, get a second opinion and more importantly get it from a veterinarian with advanced training in the organ-system area of interest. Veterinary specialists exist in a variety of clinical disciplines including surgery (Diplomate of the American College of Veterinary Surgeons; DACVS is the qualification), ophthalmology (DACVO), dermatology (DACVD), nutrition! (DACVN) and internal medicine (DACVIM) with 3 subspecialties (general internal medicine, oncology and neurology).
While many general practice veterinarians have one or more strengths in a variety of areas or in many areas, not all are created equal. The most important characteristic ultimately is knowing what you dont know, admitting it to yourself and seeking the information or making a referral. Basically, being honest with yourself and in so doing keeping the patient and client first.
For pet owners there is little to go on in judging competence. Many people judge their veterinarian on personality rather than actual skill. This is understandable, we all want to like those professionals we choose to hire. But lets not fool ourselves in this. Liking someone and trusting their professional judgment may not always correlate.
On a personal note, when my mother needed a hip replacement several years ago, and knowing the inherent risk in such an invasive procedure I researched the surgeon she chose in this way:
1. Checked that no disciplinary actions were underway or concluded
2. Met him and asked him three questions:
a. How many total hip replacements have you performed in your career?
b. How many total hip replacements have you performed in the last 12 months?
c. How many serious complications occurred and how were they resolved?
His satisfactory answers to these questions gave me the confidence to advise my mother she had a great chance at a good outcome. (Remember, mal-result is not mal-practice...it's medicine not auto mechanics). The guy was nice enough, but even if he had been an arrogant s-o-b, I still would have gone ahead. In the end what mattered was likelihood of a good outcome!
Happy New Year to all!
Indeed you are correct, it is a stretch to talk about cancer based upon one enlarged lymph node in a 3 year old dog. Personally i would be looking for other sources of local inflammation, local being head and neck.
A common source of such inflammation might be a diseased tooth or an ear infection...perhaps the middle ear. Dental problems are diagnosed with dental (intra-oral) xray imaging. Ear problems are diagnosed with the otoscope and perhaps with skull imaging such as xray imaging or mri. If there is no head tilt, head shaking, discharge from ears or odor, ear infection is less likely. A normal neurologic exam supports this as middle ear disease may affect the inner ear and then certain nerve signs appear, such as head tilt or odd eye movements.
Lymph node aspiration has limits as you are removing a few cells from their normal architecture within the lymph node. If such an aspirate comes back definitively positive for cancer say, well then the dog has it. When it comes back negative however, one has to consider that the dog may be truly negative or the aspirate missed the abnormal cells and got normal cells only. That is why a biopsy is more accurate as an entire piece of or a whole lymph node is submitted for analysis. On the orther hand biosy is not as noninvasive and inexpensive as aspiration, which is why we do it first.
That said, a 3 year old with normal blood work and an inconclusive lymph node aspirate from a single enlarged node, is unlikely to have cancer of any type until proven otherwise. On the premise that common things happen commonly, I would be looking for a source of inflammation in the head and neck, other than cancer. Infection is one such source of inflammation or inflammation may exist without infection and of course remotely various forms of cancer. Dental disease is a grossly underdiagnosed source of thead and neck inflammation
In any case, what kind of shape are your dogs teeth and gums in? By three, most dogs have at least gingivitis (inflammation of gums) all the way to early periodontitis (inflammation of ligament and bone supporting teeth). Smaller dogs with crowded mouths have even more of it.
In many cases, enlargement of a single lymph node resolves without ever determining why it enlarged in the first place. Have the dog examined for head and neck diseases and do scale back your concern at this time. There just isnt enough evidence of serious disease to go on. Now if your dog was 11, an enlarged lymph node might be more ominous, but is much less so in a 3 year old.
Good luck and if in doubt, get a second opinion (as you are doing here) from another local veterinarian, particularly one that does a lot of dentistry and takes dental xray images.
Please let us know how it turns out.
Arnold L. Goldman DVM, MS
A related discussion, squamous cell carcinoma
You are welcome! Yes my mother had many more good years and with a pain free new hip!
You are so right about this thread's important information. Your personal experience regarding the choosing of a surgeon is a lesson to be learned. As far as a vet's competency, it is very difficult to decipher. The way in which people choose their vets is by asking friends/family (who are pet owners) who they use. Unless you have an animal who has health issues, you don't really think to delve into specifics regarding how the vet would handle a major health problem. I don't think that I even realized that there were vets that were specialists in internal medicine until this situation happened.
Anyway, thanks again for your input. (I hope that everything worked out well for your mother.)
Hi Dr. Goldman. I just want to follow up with you regarding my dog. I took her to another vetinarian's office today- a rather large group with 24 hour care and several specialists on staff. I saw an internal medicine vet and she gave my dog a full examination and read all the lab reports that I brought with me. She concluded that the size of the lymph node has reduced (previously it was the size of an almond and now much smaller) and the lab reports specify that the fluid drawn was non-cancerous and therefore felt that my dog definitely does not have cancer and just has some non-specific infection. She wants me to continue giving her the doxycylcine for another 2 weeks and wants to recheck her at that point. The doctor was very reassuring and I felt at ease.
Thanks again for your advice with all of this. It was so helpful.
Hope you have a happy & healthy new year.
Thank you so much for your detailed response. I must say that I feel a little better after reading your thoughts regarding this situation. I am going to discuss the possible scenarios that you presented, with my vet. I may even take my dog to another vet for a second opinion.
I will post an update to let you know what happens.