Epistaxis, better known as a nose bleed, can be very frightening and “Percy’s” owners woke during the night to find him bleeding profusely from the right nostril on the bed where he slept with the owners. “Percy” is a 10-year- old castrated male Whippet with no serious illnesses in the past and who had been acting healthy until the nose bleed. He had had a soft heart murmur for many years but it had never become a problem. Since the nose bleed happened in the middle of the night, he came in through the emergency service where the initial examination did not reveal any clues to the cause of the epistaxis. The only abnormal findings were the blood coming from the right nostril and the long-term heart murmur. There are several different possible causes of epistaxis including head trauma, inflammation or infection in the nose, hypertension (high blood pressure), a foreign object stuck in the nose, blood clotting problems, and cancer. In an older dog with bleeding only coming from one side the biggest concern is for a possible tumor in the nose. Since the bleeding started while he was just sleeping on the bed, head trauma as the cause could be eliminated from consideration. The owner was asked about bleeding anywhere else on the body, as might occur with a problem with blood clotting, and the owners reported that there had been no other recent bleeding and that “Percy” had never had any unusual bleeding in the past.
The epistaxis was immediately addressed by instilling dilute epinephrine into the nostril to constrict the blood vessels and slow blood flow to allow the blood to clot. He was also given Yunnan Baiyao, a Chinese herb for bleeding, both orally and into the nose. Testing was initiated in the emergency service to start narrowing the list of possibilities and also to evaluate the need for other treatments. The blood pressure was not high and the blood tests were mostly normal. He was not anemic from the nose bleed and the tests that evaluate the ability of the blood to clot were OK. There was some discrepancy between the initial rapid measurement of blood protein levels, which was normal, and the protein on the full profile, which was high. Chest radiographs were taken to be sure that if a tumor was present in the nose it had not started to spread and to look at the heart because of the heart murmur and everything looked good.
After being stabilized in the emergency, he was evaluated by the Internal Medicine service where, finding no other clues to the epistaxis on another physical exam, he was scheduled for evaluation of the nose under anesthesia the next day using computed tomography (CT or “Cat” scan) and rhinoscopy (inserting a camera into the nose to look around and get samples). Blood samples were submitted to the commercial lab because of the discrepancies on the bloodwork done in the hospital. The evaluation of the nose under anesthesia was aborted when the bloodwork showed important abnormalities in the blood protein levels.
The chemistry profile showed the total protein in the blood to be only slightly high (7.8 g/dl with the normal being 5.0-7.4) but albumin, usually the primary protein in the blood, was very low (0.9 g/dl; 2.7-4.4) while the globulins, all the other proteins lumped together, was very high (6.9 g/dl; 1.6-3.6). To follow up on the abnormal proteins, more detailed evaluation of the blood proteins (serum protein electrophoresis) and an abdominal ultrasound were done. The only abnormal finding on the ultrasound was an enlarged spleen with a mottled appearance so a sample of the spleen was taken to see if this might be related to the abnormal proteins and the nose bleeds. This was accomplished with “Percy” awake, as it usually is, with a very thin needle that he barely even felt. The pathologist found many abnormal plasma cells in the spleen and the detailed evaluation of the high blood proteins show all the extra protein to be just one specific protein, called a monoclonal gammopathy, rather than being from more of many proteins. The combination of lots of abnormal plasma cells anywhere in the body-the spleen in “Percy’s” case-and a monoclonal gammopathy is diagnostic for multiple myeloma.
Multiple myeloma is an uncommon cancer of plasma cells and is commonly associated with abnormal bleeding such as “Percy’s” nose bleed. Plasma cells are part of the immune systemic and are the cells that, under normal circumstances, produce antibodies to help fight off infection. However, when one of these plasma cells become malignant they start producing large quantities of their particular antibody even though there is no infection, just because they’re cancerous. This antibody is what is measured as the extra protein in the blood, the monoclonal gammopathy. This extra protein makes the blood thicker which damages blood vessels. The protein also coats the platelets, the small blood cells needed for the blood to clot, and keeps them from working well. These effects result in abnormal bleeding and were the cause of “Percy’s” nose bleed.
He was started on chemotherapy for multiple myeloma which is the combination of cortisone-type steroids and melphalan (trade name is Alkeran). However, since melphalan, like many drugs not made specifically for animals, did not come in the correct size, a special size had to be ordered for him. While waiting for the melphalan to arrive he was given both l-asparaginase and cyclophosphamide, two other chemotherapy drugs that can work for multiple myeloma. While we were figuring out exactly what was wrong with “Percy” his nose bleeds caused him to become very anemic and weak and he was given a blood transfusion to give him time to respond to the chemotherapy. He spent over a week in the hospital to work through the tricking diagnosis and to become stable enough, with the help of the transfusion, before he could go home.
Just ten days after starting chemotherapy the bloodwork was moving in the right direction with improvement in the anemia, the albumin up to 1.9 g/dl and the globulins down to 4.1 g/dl which is only slightly elevated. He was having a little diarrhea from the whole ordeal and some of the drugs but this was getting better each day and he was feeling well with no further nose bleeds. A month after that he was doing very well with no nose bleeds, no anemia, normal globulins and an albumin that was just barely low. At this time we could declare the multiple myeloma in complete remission. Remission is not the same as a cure but half of the dogs with this cancer live longer than a year and a half with some living years and most tolerate the chemotherapy very well.