February Case of the Month: Moby
Moby is a handsome and sweet 4 year old male shepherd mix who first visited us at the end of 2014. He was brought in for vague symptoms including hacking and very severe drooling. Moby had previously been under the care of a different veterinary clinic which was working on the issue for a couple months but had been unable to resolve this unusual problem.
Our initial blood and radiology tests did not give us a definitive answer as to the source of Moby's strange symptoms; however "symptomatic" treatments did give him some relief. Unfortunately, symptoms recurred within two weeks.
Our next step was to move on to more specialized diagnostic tests. This started with a contrast esophagram which is a series of X-rays taken after a pet swallows a substance (barium) that shows up white or very bright on X-rays. This "barium series" allowed us to evaluate how the esophagus and GI tract moved food from Moby's mouth into his stomach and eventually into his intestines. While the barium series showed nothing unusual in his esophagus and motility appeared normal, it did reveal foreign material sitting in Moby’s stomach.
The barium series led to us perform an abdominal exploratory surgery to remove the foreign material in Moby's stomach in the hopes that it was the source of the dog's nausea and hypersalivation (and to prevent this material from moving into his intestinal tract where it could cause a blockage). During the procedure, we were unpleasantly surprised to find that the foreign material in his stomach was not substantial— merely wads of paper. The suspicion is that this material in his stomach was not going to be our answer in this case.
During the procedure, however, we did discover that his intestinal tract was thickened and there were some enlarged lymph nodes associated with his intestines—these sites were biopsied and the samples sent to the lab to see if our answer was hiding in these abnormal tissues. When the biopsies came back a few days later, the information was not definitive—a suggestion of inflammatory bowel disease (or IBD). IBD certainly could cause nausea but hypersalivation is not a typical symptom of the disease. The fact that there was foreign material sitting in Moby’s stomach made it extremely difficult to know if the inflammation in his intestines was due to disease (IBD) or a reaction to the material in his stomach.
As feared, in the days after removal of the material from Moby’s stomach his symptoms did not resolve—proving that the paper foreign body was not the answer. At that point, we were considering treating for IBD with prednisone but since the story did not completely add up, we wanted to consider other possible disease processes. After surgery, his salivary glands actually appeared more prominent than in the weeks prior to surgery. This led us down the path of another possible answer in this unusual case—a rare condition called sialadenosis.
Sialadenosis is an unusual disease affecting the salivary glands that is characterized by a noninflammatory enlargement of the salivary glands of unknown cause. In one study, results of an electroencephalogram (a test of electrical activity in the brain) showed changes similar to those seen with epilepsy. Symptoms typically include excessive salivation, retching, gulping, inappetence, and nonpainful swelling of the affected glands. There is no diagnostic test that proves the disorder but a positive response to treatment with phenobarbital, a medication usually used to treat seizures, is typically how we confirm the disease.
We started Moby on phenobarbital and within just a few days of starting the treatment, Moby’s salivary fountain had finally turned off—he and mom were both happy again. It was a long and complicated road to diagnosis and recovery, but Moby is now doing great. We will be keeping him on the treatment for a number of months and hopefully will be able to eventually wean him off the medication (although some dogs need treatment for life).