Intramedullary spinal cord mass presumptively SMALL ANIMALS associated with leishmaniasis in a dog Roberto José-López, DVM; Cristian de la Fuente, DVM, MSC; Martí Pumarola, DVM, PhD; Sonia Añor, DVM, PhD Case Description—A 9-year-old male Miniature Poodle was evaluated because of progres- sive severe right hemiparesis, right forelimb lameness, and signs of cervical pain. Clinical Findings—A low body condition score (2/9) and popliteal lymphadenopathy were detected. Results of a CBC, serum biochemical analyses, urinalysis, cytologic examination of bone marrow and popliteal lymph node aspirates, and serum ELISA were consistent with systemic leishmaniasis. Magnetic resonance imaging of the cervical spinal cord revealed an intramedullary mass extending from the caudal aspect of the C5 vertebral body to the C5-6 intervertebral disk space with a contrast medium–enhanced pattern that had 3 zones (cen- tral contrast medium–enhanced core, intermediate isointense zone, and peripheral contrast medium–enhanced ring). Surgical biopsy of the mass was performed by means of a right C5-6 dorsal hemilaminectomy. Results of PCR assays for detection of Leishmania DNA in CSF and tissue biopsy samples were positive. Treatment and Outcome—Treatment for systemic leishmaniasis was initiated. Two months later, body condition, neurologic signs, and gait of the dog had substantially im- proved; the dog had mild right forelimb paresis at that time. Results of follow-up MRI indi- cated resolution of the cervical spinal cord lesion. Four months after diagnosis, the dog’s neurologic condition was stable. Clinical Relevance—To the authors’ knowledge, this report is the first in which clinical findings, clinicopathologic data, and MRI characteristics of an intramedullary inflammatory spinal cord lesion presumptively attributable to leishmaniasis in a dog have been reported, and the first report of CNS leishmaniasis in a dog with MRI resolution and a successful clini- cal response to treatment. (J Am Vet Med Assoc 2014;244:200–204) A 9-year-old male Miniature Poodle was examined by personnel of the Neurology and Neurosurgery Service of the Veterinary Teaching Hospital at the Uni- was consistent with a right-sided lesion in the C6-T2 spinal cord segments. The primary differential diagno- ses included inflammation (immune mediated or in- versitat Autònoma de Barcelona because of progressive fectious), neoplasia, or lateralized intervertebral disk right hemiparesis, right forelimb lameness, and signs extrusion. of cervical pain of 10 days’ duration. In addition to and Results of hematologic and serum biochemical beginning at the same time as the neurologic signs, the analyses indicated mild, nonregenerative (normocyt- dog had hyporexia and progressive weight loss. Results ic and normochromic) anemia (PCV, 33% [reference of physical examination revealed a body condition range, 37% to 55%]; RBC count, 4.72 X 106 RBCs/µL score of 2 of 9 and popliteal lymphadenopathy. Results [reference range, 5.5 X 106 RBCs/µL to 8.5 X 106 RBCs/ of neurologic examination indicated the dog had severe µL]) and marked hyperproteinemia (9.79 g/dL; refer- right forelimb and hind limb ambulatory hemiparesis ence range, 5.4 to 7.1 g/dL) attributable to severe poly- and postural reaction deficits in those same limbs. Low clonal hypergammaglobulinemia (4.67 g/dL; reference muscle tone and muscle atrophy, most obvious in the range, 0.3 to 0.8 g/dL). Results of thoracic radiogra- supraspinatus and infraspinatus muscles, were detected phy and abdominal ultrasonography were unremark- in the right forelimb. The flexor withdrawal reflex was able. Results of urinalysis indicated mild proteinuria weak in this limb, and the animal had severe signs of with a normal specific gravity (1.036; reference range, pain during palpation and manipulation of the cervical > 1.030) and unremarkable urine sediment. The urine vertebrae. Neuroanatomic localization of clinical signs protein-to-creatinine concentration ratio was 1.4 (refer- ence range, < 0.5). From the Departament de Medicina i Cirurgia Animals (José-López, Results of cytologic examination of a bone mar- de la Fuente, Pumarola, Añor) and the Fundació Hospital Clínic row fine-needle aspirate obtained from a costochondral Veterinari (José-López, de la Fuente, Añor), Facultat de Veterinària, junction indicated abundant Leishmania amastigotes in Universitat Autònoma de Barcelona, 08193 Bellaterra, Barcelona, macrophages. Results of cytologic examination of a left Spain. Dr. José-López’s present address is Willows Referral Service, popliteal lymph node fine-needle aspirate indicated a Highlands Rd, Solihull, West Midlands, B90 4NH, England. predominance of small lymphocytes with a high num- This work was performed at the Departament de Medicina i Cirurgia Animals and the Fundació Hospital Clínic Veterinari, Facultat de ber of plasma cells and intermediate-sized lymphocytes, Veterinària, Universitat Autònoma de Barcelona, Bellaterra, Barce- but no Leishmania amastigotes were detected. Results lona, Spain. of a serum ELISA for detection of Leishmania infantum Address correspondence to Dr. Añor (sonia.anor@uab.es). infection were positive (optical density, > 300% of the 200 Scientific Reports JAVMA, Vol 244, No. 2, January 15, 2014 Brought to you by Universitat Autònoma de Barcelona (UAB) | Unauthenticated | Downloaded 11/23/23 01:35 PM UTC value for a positive control serum sample; cutoff value it was well defined and, in postcontrast T1-weighted for a positive result, 24% of the optical density for a sequence images, had a central contrast medium– SMALL ANIMALS positive control serum sample).1 enhanced core surrounded by an intermediate isoin- One day after admission, MRI of the cervical spi- tense zone and a peripheral contrast medium–enhanced nal cord was performed with a 0.2-T permanent open rim. The MRI findings were considered consistent with magnet.a Transverse, sagittal, and dorsal plane images an immune-mediated or infectious granuloma or intra- were obtained with T2-weighted spin echo sequences medullary neoplasia. (repetition time, 2,800 milliseconds; echo time, 80 mil- Results of analysis of a CSF sample collected from the liseconds) and T1-weighted spin echo sequences (rep- cerebellomedullary cistern indicated a total nucleated cell etition time, 690 milliseconds; echo time, 26 millisec- count in the reference range (2 cells/µL; reference range, onds) before and after IV administration of gadopentate < 5 cells/µL) and a mildly high protein concentration dimeglumineb (0.1 mmol/kg [0.045 mmol/lb]). In the (29.8 mg/dL; reference range, < 25 mg/dL). Results of cy- T2-weighted sequence images, there was a poorly de- tologic examination of the CSF sample indicated 30% of fined, markedly hyperintense intramedullary lesion in the cells were degenerated neutrophils (reference range, the right side of the spinal cord that extended over the < 2% nondegenerated neutrophils).2 The high percent- caudal aspect of the C3 through C6 vertebrae (Figure age of degenerated neutrophils and the mildly high pro- 1). At this level, the spinal cord diameter was slightly tein concentration were considered consistent with mild enlarged, and the signal intensity of the subarachnoid or early inflammation that was suspected to be associated fluid and epidural fat was attenuated. Evaluation of with infection (eg, bacterial [including rickettsial], fungal, precontrast T1-weighted sequence images indicated a or protozoal). Results of real-time PCR assays performed slightly hyperintense, round focal intramedullary mass in the CSF sample were negative for Toxoplasma gondii, that was in contact with the meninges on the right Neospora caninum, and Ehrlichia canis but positive for side. The lesion extended from the caudal half of the Leishmania donovani complex (L donovani and L infantum C5 vertebral body to the C5-6 intervertebral disk space; [including synonymous Leishmania chagasi]). Figure 1—Magnetic resonance images of the cervical spinal cord of a 9-year-old male Miniature Poodle that was evaluated for signs of progressive severe ambulatory right hemiparesis, right forelimb lameness, and signs of cervical pain. Midsagittal (A) and dorsal (B) plane T2-weighted sequence MRI images indicate a hyperintense, right-sided intramedullary lesion that extends from the caudal aspect of the C3 through C6 vertebra. Notice there is a slight enlargement of the spinal cord and loss of the T2-weighted subarachnoid fluid and epidural fat signal intensities from the C4 through C6 vertebrae. A transverse postcontrast T1-weighted sequence image (C) at the level of the caudal aspect of the C5 vertebral body indicates a well-defined, right-sided intramedullary mass with a contrast medium– enhanced peripheral rim, an intermediate isointense zone, and a central contrast medium–enhanced core, resembling a target sign (ar- row). Follow-up MRI was performed 2 months after diagnosis and treatment for systemic leishmaniasis (D, E, and F). Midsagittal (D) and dorsal (E) T2-weighted sequence images obtained at the same level as the images in panels A and B indicate substantial improvement of the lesion with mild, residual poorly defined intramedullary T2-weighted hyperintensity in the spinal cord from the caudal aspect of the C3 through C5 vertebrae. A transverse postcontrast T1-weighted sequence image obtained at the level of the caudal aspect of the C5 vertebral body (F) indicates resolution of the intramedullary contrast medium–enhanced mass and changes secondary to the right C5-C6 dorsal hemilaminectomy performed for collection of a biopsy sample. JAVMA, Vol 244, No. 2, January 15, 2014 Scientific Reports 201 Brought to you by Universitat Autònoma de Barcelona (UAB) | Unauthenticated | Downloaded 11/23/23 01:35 PM UTC Because the intramedullary mass appeared to be in postcontrast T1-weighted sequence images was not de- contact with the spinal cord surface and the meninges, tected. Results of CSF sample analysis were unremark- SMALL ANIMALS surgical biopsy was attempted by means of a right C5-C6 able, and results of a CSF PCR assay for detection of hemilaminectomy by use of a dorsal approach. Durec- Leishmania spp were negative. Four months after deter- tomy was performed, and an intramedullary mass was mination of the diagnosis, the dog’s neurologic condi- identified that was bulging from the spinal cord. The tion remained stable. mass was solid, had gray discoloration, and appeared to be infiltrating the spinal cord parenchyma. A small Discussion amount of the abnormally discolored tissue and the overlying dura mater were resected and fixed in neutral- Leishmaniasis in dogs is a severe systemic disease buffered 10% formalin for histologic examination. caused by the protozoan parasite L infantum. It is trans- After surgery, administration of enrofloxacinc (5 mitted by sandflies of the genus Phlebotomus in the Old mg/kg [2.3 mg/lb], PO, q 12 h for 14 days) and pred- World and Lutzomyia in the New World. In many en- nisoloned (0.5 mg/kg [0.23 mg/lb], PO, q 24 h for 14 demic countries and geographic areas, visceral leishman- days) was started. Treatment for systemic leishmaniasis iasis in dogs is an important cause of zoonotic disease.4 with allopurinole (10 mg/kg [4.5 mg/lb], PO, q 12 h) Determination of a definitive diagnosis of leishmaniasis and meglumine antimoniatef (100 mg/kg [45 mg/lb], is typically made on the basis of cytologic or histologic SC, q 24 h) was also initiated. identification of amastigotes (either inside or outside Results of histologic examination of the surgically macrophages) in routinely stained smears from lymph obtained, paraffin-embedded biopsy sample revealed node or splenic aspirates, skin touch impressions, or a fusiform cell population (fibroblasts and fibrocytes) bone marrow samples. Additionally, the diagnosis can be with some lymphocytes in an eosinophilic matrix cov- confirmed by means of serologic testing, culture of the ered by a thin layer of collagen fibers. No cellular pleo- organism in appropriate medium, or detection of DNA morphism, anisokaryosis, or neovascularization was of the parasite with molecular methods.4 detected. The dura mater was histologically normal. Neurologic signs in animals with Leishmania spp Histopathologic findings for the resected tissue were infection are rare but have been detected in affected hu- consistent with the periphery of a chronic inflamma- mans and dogs.5–12,g Although neurologic signs associat- tory process, most likely a granuloma. However, a tu- ed with visceral leishmaniasis may be obvious in some mor could not be ruled out because of the small size dogs, few data are available regarding the relationship of the tissue sample. Results of real-time quantitative between such signs and nervous system lesions.13 PCR analysis performed on the paraffin-embedded tis- To the authors’ knowledge, the present report is the sue were positive for L infantum.3 first in which the clinical findings, clinicopathologic The presumptive diagnosis determined for the dog data, and MRI features of an intramedullary inflamma- was myelopathy caused by an intramedullary L infan- tory mass presumptively caused by L infantum infection tum inflammatory lesion. One week after the diagnos- in a dog have been reported. The markedly positive PCR tic procedures were performed, the dog was discharged assay results for biopsy samples of this dog indicated it from the hospital with greatly improved motor func- had L infantum in the CNS. Therefore, this is the first tion and postural reactions in the right limbs. Treat- report of CNS leishmaniasis with MRI resolution of the ment with meglumine antimoniatef (100 mg/kg, SC, q lesion and successful clinical response to medical treat- 24 h) was stopped after 1 month, and treatment with ment in a dog. Regarding treatments for this dog, it is allopurinole (10 mg/kg, PO, q 12 h) was continued. At important to note that meglumine antimoniatef is not the time of reevaluation 2 months after determination commercially available in the United States. of the diagnosis, the dog’s body condition score was A vertebral canal extradural granuloma attribut- 4 of 9 and the neurologic condition had substantially able to leishmaniasis causing spinal cord compression improved. The dog’s gait was almost normal, with very has been described in a dog of another report,5 but spi- mild right forelimb paresis. Postural reaction deficits nal cord infiltration was not detected in MRI images were marked in the right hind limb but mild in the right of that dog. A lumbar extradural mass was surgically forelimb. Segmental spinal reflexes were normal in all removed from that dog, and histopathologic analysis 4 limbs, and mild to moderate signs of cervical pain indicated epidural fat extensively infiltrated with in- were detected during right lateral flexion of the neck, flammatory cells and Leishmania amastigotes in and although the dog was able to move its head freely with- outside macrophages. Complete resolution of clinical out signs of discomfort. signs was detected in that dog during recheck examina- Results of hematologic and serum biochemical tions 8 and 12 months after initiation of treatment for analyses performed at this time indicated persistent, systemic leishmaniasis. Information in another reportg mild nonregenerative anemia (PCV, 32%; RBC count, indicates cervical spinal cord ischemic infarctions were 4.44 X 106 RBCs/µL) and mild polyclonal hypergamma- suspected in a dog associated with meningomyelitis globulinemia (1.48 g/dL). The urine protein-to-creati- that was caused by L infantum infection as determined nine concentration ratio had decreased to 0.5. Results on the basis of results of MRI and cytologic examina- of follow-up MRI indicated almost complete resolution tion of bone marrow samples and a positive CSF PCR of the cervical spinal cord lesion. Very mild, poorly de- assay result for Leismania spp. Two weeks after initia- fined intramedullary T2-weighted hyperintensity in the tion of treatment with allopurinol and meglumine an- spinal cord over the caudal aspect of the C3 through C5 timoniate, that dog was euthanized because of lack of vertebrae persisted (Figure 1). However, the intramed- response. Postmortem histologic examination of the ullary mass lesion that had been observed in pre- and spinal cord of that dog indicated vasculitis and malacia 202 Scientific Reports JAVMA, Vol 244, No. 2, January 15, 2014 Brought to you by Universitat Autònoma de Barcelona (UAB) | Unauthenticated | Downloaded 11/23/23 01:35 PM UTC secondary to ischemia, but parasites were not found in with a good outcome.23,24 Because the mass in the dog SMALL ANIMALS nervous system tissue and results of a PCR assay for of this report appeared to be in contact with the spi- Leishmania spp performed for nervous system tissue nal cord surface in MRI images, surgical biopsy was at- samples were negative. tempted to determine a definitive diagnosis. In 2 other studies,13,14 Leishmania amastigotes were The surgically obtained biopsy sample was insuffi- detected in the meninges and choroid plexuses of dogs cient for determination of a histopathologic diagnosis. naturally infected with L infantum. Although dogs in A quantitative PCR assay to detect Leishmania DNA in those studies13,14 had typical features of granulomatous paraffin-embedded skin biopsy samples of dogs is as meningitis and choroiditis, well-defined granulomas sensitive as immunohistochemical analysis for determi- or giant multinucleated cells were not detected. In a nation of a diagnosis.25 Therefore, real-time quantitative recent report12 of a tetraplegic Labrador Retriever that PCR assay was performed with paraffin-embedded tis- died a short time after admission to a hospital, micro- sue samples of the dog, and the markedly positive results scopic examination of nervous system tissue samples for L infantum DNA suggested a presumptive diagnosis indicated Leishmania amastigotes in the spinal nerves, of an intramedullary inflammatory mass attributable to spinal cord, brain parenchyma, and choroid plexuses, leishmaniasis. However, determination of a diagnosis of which induced radiculoneuritis, myelitis, and menin- visceral leishmaniasis in a dog is challenging in endemic goencephalitis in the dog. Results of other studies15–17 areas and, despite the high sensitivity of PCR assays for suggest that failure of the blood-CSF barrier may cause determination of a diagnosis of leishmaniasis in such the transfer of Leishmania antibodies and antigens from animals, false-positive results are a limitation of that blood to the CSF of dogs naturally infected with L in- technique.26 Although the gold-standard methods for fantum or L chagasi. That same mechanism could cause determination of a definitive diagnosis of visceral leish- transfer of Leishmania parasites to the subarachnoid maniasis in dogs are cytologic or histologic observation space and, subsequently, the CNS of a dog. of amastigotes (either inside or outside macrophages), For the dog of the present report, antemortem di- the positive results of real-time quantitative PCR assay agnosis of CNS leishmaniasis was determined on the for an intramedullary spinal cord mass sample of the dog basis of detection of systemic infection, MRI findings, of the present report suggested it had a high parasite bur- and positive results of PCR assays for Leishmania DNA den and the intramedullary mass was an inflammatory in CSF and intramedullary tissue biopsy samples. The lesion caused by L infantum.3 MRI findings for the dog were similar to those for The long-term clinical response to treatment for cats with segmental protozoal myelitis and humans systemic leishmaniasis and the resolution of the intra- with toxoplasmosis (T2-weighted sequence hyper- medullary lesion (as indicated by means of evaluation of intense and T1-weighted sequence contrast medium– follow-up MRI images) were supportive of a diagnosis enhanced, focal intramedullary mass), although in of an inflammatory mass attributable to leishmaniasis in such cats and humans, contrast medium enhancement the dog of this report. To our knowledge, a spinal cord is typically stronger.18,19 In addition, the contrast medi- intramedullary inflammatory mass presumptively attrib- um–enhanced MRI pattern for the dog of this report in- utable to leishmaniasis in a dog has not been previously dicated 3 alternating zones (a central contrast medium– reported, and this diagnosis should be considered a dif- enhanced core, an intermediate isointense zone, and a ferential for dogs with intramedullary spinal cord masses peripheral contrast medium–enhanced ring), which in geographic areas endemic for leishmaniasis. was similar to an MRI target sign detected in humans with cerebral toxoplasmosis.20 Therefore, on the basis a. Vet-MR, Esaote, Genova, Italy. b. Magnevist, Bayer Schering Pharma AG, Berlin, Germany. of the MRI findings and positive PCR assay results for a c. Baytril, Bayer Healthcare, Kiel, Germany. CSF sample of the dog, visceral leishmaniasis–induced d. Dacortin, Merck, Mollet del Vallés, Spain. myelitis was considered a primary differential diagno- e. Zyloric, GlaxoWellcome, Bad Oldesloe, Germany. sis. However, focal intramedullary space-occupying le- f. Glucantime, Merial, Lyon, France. sions in dogs are commonly neoplastic (either primary g. Sanchez D, Navalon I, Font A, et al. Central nervous system spinal parenchymal tumors [eg, astrocytoma, oligoden- involvement induced by Leishmania infantum in a dog (abstr), in Proceedings. 20th Annu Symp Eur Soc Vet Neurol 2007;(A15)9. droglioma, or ependymoma] or intramedullary metas- tases [hemangiosarcoma or lymphosarcoma]). Because the dog of the present report lived in a References geographic area endemic for visceral leishmaniasis and 1. Riera C, Valladares JE, Gallego M, et al. 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