My Patients and Other Animals

by Suzy Fincham-Gray

  I turned to the technician next to me and handed over the slide. “Can you please stain this so I can decide if we need to get more samples before waking Ned up?”

  The technician left for the in-house lab, and I had about five minutes before I could look at the sample.

  Blood had begun to slide from Ned’s right nostril, pooling on the towel under his head. It was to be expected, but it was still disconcerting. I dabbed ineffectually at the narrow stream and glanced at my watch. While I was worrying over Ned’s bloody nose, another patient, Clyde, had popped into my mind, and refused to leave. It was too soon for Ned’s slide to have been stained, but suddenly I couldn’t wait any longer.

  I had examined Clyde a month or two earlier. He was also a young male dog rescued from Mexico, and he had been brought in with blood dripping from his prepuce—the sheath of skin covering the penis. Previous urine testing and abdominal X-rays had failed to reveal a cause. Before ordering an abdominal ultrasound to evaluate his urinary bladder, prostate, and urethra, I performed a full examination of Clyde’s prepuce and penis. Circling the base of his penis, at the bulbous glandis, almost out of sight, was a red, ulcerated, cauliflower-like mass. I grabbed a microscope slide and pressed it firmly onto the affected area, hoping to transfer cells that could be sent to the pathologist for cytologic interpretation. With Clyde’s history, however, I knew what I was expecting them to find. I made another slide to look at myself.

  After focusing the microscope at 1000x magnification, I peered excitedly at the collection of cells from Clyde’s penis. A veterinary cytology book opened to the page on transmissible venereal tumors (TVT) lay on the counter next to me.

  Spread across my view through the lens, strewn like a carpet of spring flowers, was a collection of purple-stained cells, each one an almost perfect replica of the one next to it, only variable in size. The individual cells were round to ovoid, looking like perfectly prepared fried eggs, with the deeply hued, indigo nucleus offset from the center. The outer cytoplasm was a paler shade of pinky blue, scattered with clear bubbles—vacuoles. The appearance of the cells was distinctive and definitive. I checked the page next to me to be sure.

  “Yes!” I looked up from the sea of cells for a receptive audience. “I knew it. I knew it was going to be a TVT.”

  I grabbed the closest intern, who also happened to be on the internal medicine service that month. “Come and look at this,” I said. “Bet you’ve never seen one of these before. Come on, this is so cool.” I tugged on her sleeve, dragging her with me to the corner lab.

  “Look!” I stood behind the intern, gesticulating at the microscope. “Do you know what this is? Have you seen one before? If I told you this came from a dog’s penis, could you guess what it might be?”

  The intern slid along the counter and turned to me, “Uh, lymphoma?”

  “No. What if I told you this dog came from Mexico?” I said. She remained silent. “It’s a TVT—a transmissible venereal tumor. It’s so cool. Look at those cells—aren’t they beautiful? They’re just like the picture. I’ve never seen one before. Have you heard of it?”

  The intern glanced behind her, maybe looking for an escape route.

  “Um, I think so,” she said. “But Dr. Tyler is expecting me in room 5 with lab work. I’ve got to hurry.” She shrugged sympathetically, grabbed a page from the stack of completed lab results on the counter, and scurried away.

  Aside from the cells’ beauty under the microscope, the canine transmissible venereal tumor is a fascinating disease. It is one of only two known transmittable tumors in the world—the other being found in the Tasmanian devil—and it is the oldest continuously surviving cancer in nature.

  As its name suggests, TVT most commonly affects the venereal, or genital, area, and cancer cells are transferred by direct contact between dogs. So, yes, TVT is a canine sexually transmitted disease, curable with a six-treatment course of chemotherapy. It has been almost completely eradicated in the United States due to control of free-roaming dog populations and extensive spay-neuter programs, although the disease remains in remote indigenous communities. In Mexico, the prevalence of TVT is estimated at around 20 percent, and the disease is endemic in at least ninety countries worldwide. The large, ulcerated, proliferative masses caused by the tumor are most commonly located on the genital and perineal area. However, given dogs’ social habits, it can also develop in the oral and nasal cavity.

  Clyde. Ned. Mexico. Bleeding. Could a TVT grow in the nose?

  I hurried across the treatment room to the lab, the memory of the cells from Clyde’s sample flashing on my retina every time I blinked. When I got there, Ned’s stained slide was still drying, and I waved it around vigorously. As soon as the last water molecule evaporated, I dashed the slide onto the microscope stage. I adjusted the eyepieces, increased the magnification, and looked into the cellular world I’d plucked from Ned’s nose.

  I took a moment to scan the slide a second time and, satisfied, ran back to the procedure room.

  “We’ve got it!” I said. “We’ve got a zebra! The sample’s awesome. I’m sure Ned has a TVT.”

  “I’ll turn off the gas, then?” my technician asked.

  “I’ll check his nose to make sure the bleeding’s stopped first,” I said, moving to the front of the table, bouncing on my toes. “This is so cool! It’s something we can fix with chemotherapy—remember Clyde?”

  “Ned has the same thing in his nose that Clyde had on his penis?” my technician asked.

  I laughed. “Yes. Ned has been putting his nose in places he shouldn’t have. I feel a bit embarrassed for him.”

  I bent to look at his right nostril. The bleeding had almost stopped. “We can wake him up. Just watch out when he recovers. He might start sneezing blood everywhere. Keep out of the line of fire.”

  “Why?” my technician asked. “Can we catch it?”

  “No! No need to worry about that; I didn’t want you to mess up your scrubs, that’s all.”

  I was eager to give Ned’s owners the good news, but I waited for him to recover before calling them. I also had to remind myself that the owners of my patients didn’t always view their pet’s diseases with the same enthusiasm I did.

  Thirty minutes later, Ned was sitting at the front of his cage barking at whoever passed in an attempt to discharge himself from the hospital.

  “What time is he going home?” a technician asked, using the accepted hospital code for Please get this animal out of here.

  “I’m calling his owners now,” I replied, “so within the next hour or two.” I didn’t wait for a response, knowing that another hour or two of Ned’s barking was unlikely to please anyone in the treatment room.

  I returned to my office to call Karen and Julie.

  “I’m pleased to report that Ned’s doing really well,” I said after Karen answered and put me on speakerphone so Julie could hear, too. “Anesthesia went well and he recovered without any problems.”

  “That’s a relief,” Karen said. “We’ve been so worried about him.”

  “Do you know what the problem is?” Julie asked.

  “We’ll have to wait for the pathologist’s report to be sure, but yes, I think we’ve found what’s going on.”

  “Tell us, Doc. We haven’t thought about anything else,” Karen said.

  “I think Ned has a transmissible venereal tumor in his nose,” I said.

  There was a moment of silence and then Karen said, “That doesn’t sound good. A tumor—that means cancer, right?”

  “Actually, this type of tumor is completely curable with treatment, and there should be no lasting effects. It’s good news.”

  “I’ve never heard of it,” Julie said, the formality fading from her voice. “How did he get it?”

  “He probably picked it up in Mexico, before you adopted him. It’s a tumor that spreads betwee
n dogs with direct contact, most commonly during mating. So my guess is that Ned was sniffing a bottom he shouldn’t have been.”

  “Ned has a sexually transmitted disease?” Karen giggled, and it made me smile.

  “We need to wait for the biopsy results before we’ll know for sure, but yes, most likely he does.”

  “How do we treat it?” Julie asked. “Can we start today?”

  “If Ned has a TVT, then treatment is four to six doses of a chemotherapy drug called vincristine. It’s usually well tolerated, but I’d prefer we wait until we have a confirmed diagnosis before we start. We’ll get the results from the lab in forty-eight hours, so we can get him in early next week to start treatment. But we’ll talk more about that once we have the results.”

  We arranged a time for Ned’s discharge, and a tentative appointment for his first treatment on Monday—if my diagnosis proved correct.

  After hanging up I sat and petted Emma. Excitement tingled through me. I would be able to give Ned and his owners a normal life back, free from nosebleeds and illness.

  On Monday morning, Ned’s biopsy results were waiting on my desk when I arrived. The bottom line confirmed my suspicion—transmissible venereal tumor. I danced happily on the spot. I couldn’t wait to get through my morning appointments and share the good news with Ned’s owners.

  I felt like Ned when I bounded into the exam room, his results under my arm.

  “It’s good news. Ned does have a transmissible venereal tumor in his nose. We can start treatment today.”

  Karen and Julie grinned and reached for each other’s hands across the exam room bench.

  “We knew you were right,” Karen said. “Jules and I looked up TVT on the Internet. We don’t know how you figured it out. You’re like Dr. House.”

  Ned ran joyous circles around the room in response to the excited tone of Karen’s voice.

  “I’m not sure I quite live up to his standards,” I said, feeling a flush of happy embarrassment. House was a favorite in our home; Rob and I never missed an episode. I couldn’t wait to tell him about the compliment I’d received.

  “You do!” Karen said. “If it wasn’t for you we don’t know what would’ve happened to Ned. Our vet had no idea what was going on, and you figured it out straightaway. We’re so grateful, Doc. Really, you have no idea how relieved we are.”

  I beamed. “I’m glad I could help Ned. We’ve just got to get him through the chemotherapy and he’ll be back to his normal self. No more nosebleeds.”

  “We’re going to tell the people who rescued Ned from Mexico what happened,” Julie said. “We had no idea there were diseases south of the border that aren’t here in San Diego.”

  “Maybe when we adopt a brother or sister for Ned we’ll stick to San Diego dogs. Right, Jules?”

  I thought of Emma, my own San Diego rescue, with her broken pelvis and right hind limp that had never resolved. It was impossible to predict the future. Whether we buy them from an expensive breeder with an AKC-registered pedigree, save them from the streets of Tijuana, or spring them from the county shelter, there is no formula—medical or otherwise—to determine the time we have with the animals we love.

  CHAPTER NINE

  Monty

  Monty had always been an old cat. I guessed he was eight or nine when I adopted him in Philadelphia. Fred and Harry, on the other hand, were the babies of the family. Once Fred grew out of kittenhood and Harry moved through his lanky teenage phase, the passage of time had no impact on their appearance or demeanor. So it wasn’t until I thought about how long I’d lived in America that I realized that my nine-year-old cat was edging closer to nineteen.

  I should’ve been cognizant of Monty’s age, but my perception of time had become blurred by my love for him, my first cat. Refusing to confront Monty’s advancing years also meant ignoring the consideration of his life expectancy, which was never going to be long enough.

  When I asked about an animal’s age at every initial examination, I encountered the same irrational condensation of time and memories I was now applying to my own pet. It was a question I asked every owner, despite my evaluation of their pet’s dentition, hair coat, and subtler indicators, including gait, muscle wasting, and skin texture, that suggested the age range they likely fell into. The answers were far more revealing than a number. Occasionally the response was succinct, but more commonly I heard a description of how an animal and its people came together.

  I’d heard stories of stray cats on doorsteps, in parking lots, and in car yards, and ex–next door neighbors who’d left their pets behind. There were tales of breeders visited, litters viewed, and puppies selected, chosen for the way they’d snuggled into their new owners’ laps. I listened to discussions of vacations, birthdays, and family milestones that provided a temporal framework for their pets, whose lives were not measured in the same units.

  These narratives were my introduction to the lives of my patients and their families, and I never tired of them, no matter how many times I heard about the kitten that once fit into the owner’s palm or the dog adopted at the eleventh hour, ten years earlier, after being returned to the shelter three times by other adopters. Sometimes the story would tumble out in the first ten minutes of the consultation, including information that was more pertinent to an owner’s health than their pet’s. Other times, the narrative would be more reticent, and it would take several visits before it was fully revealed.

  One of my patients was a black cat named Bagheera. He wasn’t remarkable because of a deft diagnosis, a lifesaving feat of heroic medicine, or any of the other reasons that had once defined the importance of a case. Rather, he was an old black cat with the type of chronic geriatric disease I commonly encountered. He was longer and taller than Monty, with the smallest patches of white—maybe twenty hairs—dotting his back, but he carried himself with Monty’s aging grace. And his owner, an earnest graduate student, didn’t seem far from the version of myself who’d taken Monty home.

  I saw Bagheera for management of kidney disease and an overactive thyroid gland—hyperthyroidism. I’d treated Monty for hyperthyroidism with radioactive iodine years before in Baltimore when he’d developed the condition.

  Over the past thirty years, since its first description in 1979, hyperthyroidism has rapidly become the most common geriatric feline endocrine disorder. It is a modern-day epidemic, estimated to affect more than 10 percent of cats over the age of ten. Despite the abundance of patients with this condition, the cause for the explosion in cases is unknown. Factors including iodine levels in the diet and environmental chemicals and pollutants have been implicated, but their role has yet to be proven. What is certain is that, due to the rising longevity of our pets, the diagnosis of age-related disease will continue to increase.

  Bagheera’s owner had adopted him from a shelter a year prior to our first meeting, and she’d been told he was nine years old at that time. His clinical signs and physical exam suggested that his age was closer to twelve, but I kept that to myself. While I discussed diagnostic and treatment options for Bagheera, he lounged patiently on his owner’s lap. He was a quiet cat, reserving his affections for the person who loved him most. I wondered, as I did for Monty, how he’d ended up without a home. His time in the shelter, likely extended because of his age and coat color, was so long that his previous history had been lost.

  “I want to do whatever I can to keep him comfortable,” his owner, Leslie, told me. She had metal-framed glasses and long brown hair that was tied back in a ponytail. Her skin was pale, I imagined due to hours spent in windowless laboratories, and her slim build accentuated her youth.

  “I don’t think he’s ready to give up yet, right, buddy?” she said, her confidence growing the more she talked about Bagheera. “And he’s given me so much; I want to do everything I can for him.”

  “It’s pretty common to be dealing with more than one medi
cal problem as our pets get older,” I said. “Our goal right now should be to get him feeling better, which I think we can do.”

  “My vet told me that treating his hyperthyroidism could make his kidneys worse. Is that right?”

  “Yes, kidney dysfunction is common in older cats, and we often see it in combination with other diseases such as hyperthyroidism. Sometimes treatment of one condition can exacerbate the other, and lowering his thyroid level can decrease blood flow to the kidneys, making kidney disease worse.”

  “What can we do? I don’t want to do anything that will hurt his kidneys. The last thing I want is to make him feel worse.”

  “Absolutely. There’s a middle ground that may not be ideal for either condition, but is the best option for maintaining a good quality of life. We will need to monitor him closely and adjust his treatments to give him the best life we can.”

  “So we’re not going to make him better?” Leslie’s hand paused in her stroking of Bagheera’s skinny body.

  “We can cure his hyperthyroidism with radioactive iodine treatment. But that will likely affect his kidneys and, unfortunately, short of a kidney transplant we can’t cure his kidney disease.”

  She nodded slowly, her eyes fixed on her cat.

  “But the progression can be variable, and some cats can live a normal life. In other cases, no matter what we do, the kidney damage continues to progress. We don’t know yet how Bagheera’s going to respond to treatment, but we’ll get a better sense over the coming months.”

  I looked at the page of lab results with the most recent assessment of Bagheera’s kidney function. My gut told me that Bagheera might have only a year left, but I decided that information was too much to burden my new young client with. Revealing my suspicions would change nothing for Bagheera.

  “He’s only nine, though,” Leslie said. “Doesn’t he seem young to have such serious kidney problems? I read somewhere that cats should live to be fifteen or sixteen.”