Diagnosis and management of Candida utilis infectious arthritis in a Standardbred filly

A 3‐year‐old Standardbred filly was admitted to the hospital for evaluation and management of previously diagnosed infectious arthritis of the right metacarpophalangeal joint (MCPJ). Candida utilis was isolated from multiple synovial samples submitted for bacterial culture and susceptibility. Following treatment with systemic and intra‐articular fluconazole and regional limb perfusion with amphotericin B and a second arthroscopic debridement the lameness improved and subsequent cultures were negative for bacterial or fungal growth. Infectious fungal arthritis should be a differential diagnosis for atypical or unresponsive joint infections especially in horses previously treated with a combination of intra‐articular corticosteroids and antibiotics.     

Repeatability of subjective evaluation of lameness in horses

Reasons for performing study: Previous studies have suggested that agreement between equine veterinarians subjectively evaluating lameness in horses is low. These studies were limited to small numbers of horses, evaluating movement on the treadmill or to evaluating previously‐recorded videotape. Objectives: To estimate agreement between equine practitioners performing lameness evaluations in horses in the live, over ground setting. Methods: 131 mature horses were evaluated for lameness by 2–5 clinicians (mean 3.2) with a weighted‐average of 18.7 years of experience. Clinicians graded each limb using the AAEP lameness scale by first watching the horse trot in a straight line only and then after full lameness evaluation. Agreement was estimated by calculation of Fleiss' (κ). Evaluators agreed if they picked the same limb as lame or not lame regardless of the severity of perceived lameness. Results: After only evaluating the horse trot in a straight line clinicians agreed whether a limb was lame or not 76.6% of the time (κ= 0.44). After full lameness evaluation clinicians agreed whether a limb was lame or not 72.9% of the time (κ= 0.45). Agreement on forelimb lameness was slightly higher than on hindlimb lameness. When the mean AAEP lameness score was >1.5 clinicians agreed whether or not a limb was lame 93.1% of the time (κ= 0.86), but when the mean score was ≤1.5 they agreed 61.9% (κ= 0.23) of the time. When given the task of picking whether or not the horse was lame and picking the worst limb after full lameness evaluation, clinicians agreed 51.6% (κ= 0.37) of the time. Conclusions: For horses with mild lameness subjective evaluation of lameness is not very reliable. Potential relevance: A search for and the development of more objective and reliable methods of lameness evaluation is justified and should be encouraged and supported.     

The osteopathic treatment of somatic dysfunction causing gait abnormality in 51 horses

Over a 19‐year period, 51 horses showing chronic lameness or gait abnormality that was not fully responsive to veterinary treatment at other referral clinics were referred to us for further treatment. All had either failed to have a diagnosis made, or treatment for the diagnosed conditions had shown only partial response. After further examination, we concluded that they showed abnormal function of the neck or back, but there was no obvious pathological cause. A diagnosis of ‘somatic dysfunction’ was made, characterised by altered muscle tone, tenderness or subtle changes in gait, similar to the condition recognised in human medicine. These cases subsequently underwent osteopathic treatment under sedation. Forty‐six cases (90.2%) responded to treatment in the short term (6 months after treatment). Seventeen (53.1%) were working at the same level or better than previously at least a year after treatment. Ten (31.2%) worked at a reduced level for between 1.5 and 10 years. Nineteen cases were lost to long‐term follow‐up. The findings of this study suggest that neck and back problems may be overlooked when investigating chronic lameness. When no pathology can be pinpointed as a cause of lameness, a diagnosis of somatic dysfunction as a primary problem should be considered. The presence of somatic dysfunction as a secondary complicating factor should not be overlooked. Stiffness and/or low grade pain in the spine of horses can result in persistent abnormal posture, gait, or behaviour, similar to ‘somatic dysfunction’ seen in the human patient. The cause is neuromuscular in origin, rather than resulting from tissue pathology. The diagnosis made clinically can be confirmed with thermography. This study confirms that osteopathic manipulation of the spine of horses can be a valuable treatment for cases of lameness that do not respond fully to standard veterinary treatments.     

Navicular disease in the horse

Navicular disease results in a chronic, progressiveforelimb lameness that is usually bilateral. Although many different horse breeds can be affected, Quarter Horses and Warmbloods appear particularly susceptible. The peak age incidence appears to be in horses aged 6–10 years. The condition has been recognized for many years and has been the source of debate and conflict for at least the last 50 years. Much of the confusion has been caused by different criteria used to establish a diagnosis. In a large series of cases examined at the University of Sydney, only 30 percent of horses that were eventually diagnosed as having navicular disease showed a positive response to hoof testers applied across the middle third of the frog. In contrast, more than 80 percent of horses with navicular disease showed a marked increase in lameness following pastern and fetlock flexion. All horses diagnosed became sound following a palmar digital nerve block and all had positive findings on radiography. However, radiography could not be utilized as a sole diagnostic technique because some horses with radiographic abnormalities of the navicular bone did not show clinical signs of navicular disease.To establish a diagnosis of navicular disease, the following criteria should be met: 1) A chronic progressive unilateral or bilateral forelimb lameness, 2) Pain in areas proximal to the foot has been excluded as a possible cause of the lameness, 3) Other conditions that could cause pain in the palmar heel region are excluded, 4) The lameness is eliminated or substantially improved following a palmar digital nerve block, and 5) There are radiographic abnormalities on upright pedal and/or skyline views of the navicular bone.Treatment of navicular disease has usually fallen into categories of a) pain alleviation, b) drugs with vascular or hemodynamic effects, or c) changing biomechanics either by corrective trimming or corrective shoeing. None of these treatments have been universally accepted and debate about their efficacy is allied to theories about the etiology.     

Efficacy of an Extract of Blue-Green Algae in Amelioration of Lameness Caused by Degenerative Joint Disease in the Horse

Degenerative joint disease (DJD) or osteoarthritis in the equine is largely a result of biomechanical stressors that result in inflammation within the joint, which with continual exposure, leads to progressive degeneration. A myriad of therapies are available for treatment of horses with DJD including nonsteroidal anti-inflammatory drugs, corticosteroids, physiological modifiers, and biological therapies. C-phycocyanin, a protein-bound pigment found in blue-green algae, has been shown to have anti-inflammatory and antioxidant properties and is available as a diet supplement in people, dogs, and horses. Forty-one horses with naturally occurring lameness as a result of DJD were selected for this study. In a blinded study, horses were randomly assigned to either the commercial or placebo product that was fed once daily for 12 months. At selected time points, lameness evaluation was performed through objective gait analysis. Previous medical records for management of lameness were reviewed for all enrolled horses. No statistically significant differences existed within or between the two groups when gait was evaluated objectively nor within individual horses between time points. Review of medical records found that five treated horses had a decreased in frequency of intra-articular injection of corticosteroids. Although this study did not find statistically significant improvement of lameness with oral daily supplementation of C-phycocyanin in equine athletes, there appeared to be a trend of improvement in lameness during the loading period and a decrease in frequency of administration of intra-articular corticosteroids. Further investigations using a higher dose seem warranted.     

Diagnosis and Treatment of Foot Infections

The equine foot is a prime candidate for bacterial and fungal infections. The majority of infections are abscess based and generally are easily managed. Prolonged infections can result in chronic lameness and in severe cases they can be life threatening. A systematic approach to evaluation of the equine hoof can expedite the diagnosis and treatment of foot infections.     

IMAGING DIAGNOSIS—RADIOGRAPHY AND COMPUTED TOMOGRAPHY OF RADIOULNAR ISCHEMIC NECROSIS IN A JACK RUSSELL TERRIER

A 7‐year‐old Jack Russell Terrier with a history of minor trauma was presented for lameness of the left forelimb. Radiography and computed tomography demonstrated a localized radioulnar osteolytic lesion with cortical bone loss and enthesiophytes. Based on results of diagnostic imaging and histopathological examination, the final diagnosis was radioulnar ischemic necrosis (RUIN), complicated by pathologic fracture. A rare disorder of unknown etiology, RUIN may be secondary to tearing of the interosseous ligament and potential ischemia. It should be differentiated from neoplastic or fungal disease. To the authors´ knowledge, this is the first canine case report describing RUIN.     

Articular aspergillosis of hip joints in turkeys

Aspergillosis is an important cause of morbidity and mortality in birds. Turkey poults are known to be particularly susceptible to fungal infection. Although the respiratory tract is the most commonly affected, dissemination can occur into virtually any organ. Here, we report an unusual outbreak of articular aspergillosis in a flock of meat turkeys with clinical signs of lameness. Between 7 and 11 weeks of age, turkeys had severe granulomatous osteoarthritis of the hip joints with necrosis of the femur head. Fungal morphology and PCR amplification and sequencing of the first ITS1-5.8S-ITS2 rDNA region identified Aspergillus fumigatus as the infectious agent. Concurrently, Staphylococcus spp. was isolated from the hip joints, which may have promoted the tropism of the fungus. Mild respiratory tract aspergillosis was observed in only one case. The findings suggest that fungal arthritis may present a specific disease entity in turkeys and should be considered as further cause of lameness in turkeys.     

RADIOGRAPHIC ASSESSMENT OF CRANIAL CRUCIATE LIGAMENT RUPTURE IN THE DAIRY COW

Case records and radiographs of 37 dairy cows presented to the University of Illinois Veterinary Medicine Teaching Hospital with a diagnosis of cranial cruciate ligament rupture were reviewed. Signalment, history, duration of lameness prior to clinical presentation, and physical examination findings were evaluated. Survey radiographs were examined and radiographic lesions were documented. Individual cows were classified into groups (A, B, C) based on the severity of radiographic lesions, with Group A cows having minimal radiographic lesions. Cows in Groups A and B had radiographic lesions similar to Class I in beef bulls reported in another study.^3,4 An attempt was made to relate the severity of radiographic lesions with age and duration of lameness. Group A animals tended to be younger cows (x?= 4.58 years) with a short duration of lameness. Group B cows were older (x?= 7.87 years) with a somewhat longer duration of lameness. Group C cows were slightly younger (x?= 7.30 years) than Group B cows; however, their duration of lameness was much longer (x?= 57.2 weeks vs 6.35 weeks for Group B and 2.54 weeks for Group A). The pathogenesis of cranial cruciate ligament rupture and its associated lameness appeared to differ in dairy cows from beef bulls. The majority of animals in this study had radiographic lesions of mild to moderate severity (Groups A and B). In contrast, based on previous work, beef bulls had a greater tendency to be similar to our Group C designation. Beef bulls became lame with cranial cruciate ligament rupture only after severe lesions of degenerative joint disease had already occurred. It has been stated that lameness associated with cranial cruciate ligament rupture in the beef bull is, therefore, secondary to degenerative joint disease. In contrast, the syndrome in dairy cows, as evidenced here, differs, since they often presented with cranial cruciate ligament rupture with little or no radiographic evidence of degenerative joint disease.     

The use of high-speed treadmills for lameness and hoof balance evaluations in the horse

Examination for lameness remains the most important component of the clinical evaluation for poor performance. Although conventional examinations can be used to diagnose many causes of lameness, treadmill video gait analysis and dynamic hoof balance evaluations have proved to be useful not only for evaluating lameness but also for maintenance of long-term soundness. Treadmill lameness evaluations offer a major advantage compared to conventional evaluations because of the stationary position of the exercising horse relative to the people performing the examination. Lameness is suspected if asymmetric motion is observed or asymmetric sounds of the feet contacting the tread surface are heard during the treadmill evaluation. Localization of lameness to the front or hind legs is the first step in the treadmill gait analysis protocol. In trotting and pacing horses, asymmetric movements associated with foreleg lameness generally are confined to the front end. In contrast to the pacing gait, asymmetric movements associated with hindlimb lameness can involve both the front and rear of the horse at the trot. The evaluation is continued to determine which side of the horse is abnormal. Viewed from the front, horses with primary forelimb lameness appear to have an asymmetric downward rotation of the torso, head, and neck away from the stiffer lame front leg toward the flexed normal leg as it contacts the tread surface. The lame hind leg can appear to be stiff relative to the opposite normal leg. This results in uneven side-to-side oscillations of the pelvis rotating away from the abnormal stiff-appearing hind leg toward the normal, flexed hind leg as it contacts the tread surface. Both front- and hind-leg lamenesses cause dissociation of the normal foot-fall sequence, resulting in the alteration of the normal two beat gait at the trot or the pace to a three-beat gait. The final step of the lameness examination involves the use of diagnostic regional anesthesia to determine the anatomic location of the lameness. Treadmill video gait analysis can be used to evaluate differences in the horse's gait before and after each anesthetic block. Optimal foot balance during exercise is critical for long-term maintenance of musculoskeletal soundness. Combining slow-motion video gait analysis with treadmill exercise provides an excellent method for evaluating hoof balance at a variety of speeds. Optimal hoof balance can be achieved by using the technique of successive trimming and re-evaluation. The principles of hoof balancing include establishing dorsopalmar or dorsoplantar hoof balance.(ABSTRACT TRUNCATED AT 400 WORDS)     

Total Hip Replacement in an Alpaca Using a Cementless Implant

Objective— To report use of a cementless total hip prosthesis in an alpaca.
Study Design— Case report.
Animals— Alpaca (n=1) with chronic craniodorsal coxofemoral luxation.
Methods— A 2.5-year-old Suri alpaca, 3 months pregnant, was admitted for evaluation of acute onset severe left hind limb lameness (grade 4/5) of 6 weeks duration. After diagnosis of craniodorsal luxation of the left femoral head, total hip replacement (THR) using a cementless implant was performed because of the poor prognosis for reduction of a chronic luxation.
Results— A press-fit prosthesis was used and the alpaca delivered a live cria 8 months later. Persistent mild mechanical lameness remained after surgery, with moderate reduction in mobility of the coxofemoral joint. The prosthesis was stable and correctly positioned at 7 weeks and at 9 months. There was mild exostosis surrounding the proximal aspect of the femur at 9 months, and Steinmann pins used to repair the trochanteric osteotomy were removed because of migration. At 1 year, the alpaca has a slight gait abnormality, remains with the herd on pasture and has been re-bred.
Conclusion— Chronic coxofemoral luxation in an alpaca can be managed by THR.
Clinical Relevance— THR is a viable treatment option in alpacas with severe coxofemoral disease.     

The use of sports medicine techniques in evaluating the problem equine athlete

Discovering the cause of poor performance in racehorses can often represent a considerable challenge eluding the more common diagnostic techniques available at the racetrack. Application of sports medicine techniques to these problem cases can aid in the diagnosis of poor performance. Central to the development of this capability has been the use of highspeed treadmills, allowing the racehorse to be evaluated in the controlled laboratory setting, at exercise intensities equivalent to those of racing. Video and cinematographic gait analysis can be used in the diagnosis of subtle lameness conditions. Evaluating hoof balance at high speed has also become an important technique for both lameness diagnosis and prevention. Correcting hoof imbalance normalizes the applied stresses on joints, ligaments, and tendons. Abnormal upper airway function resulting in increased resistance to airflow is major cause of poor racing performance. Often this cause of upper airway dysfunction is difficult to evaluate at rest or after exercise. A definitive diagnosis can be made in these cases using treadmill endoscopy to visualize upper airway function during peak exercise. Lower airway function can also affect performance capability. Radiographic and scintigraphic imaging modalities can be used to evaluate both global and regional lung function in cases of suspected pneumonia, EIPH, COPD, or emphysema. Reduced metabolic fitness can be a primary cause of poor performance due to inherent differences in capability, pathologic changes in the major body systems involved in exercise, or inadequate training. Metabolic stress testing can be used to evaluate the level of fitness in these cases. Orthopedic imaging has also become a valuable diagnostic technique for evaluating musculoskeletal injuries. Scintigraphic evaluation of soft tissue and bone and CT scanning are used to localize the source of lameness and to grade the severity of various orthopedic conditions such as arthritis and stress-induced bone disease that are often difficult to categorize with conventional radiography.     

Assessment of clinical characteristics,management practices,and activities of geriatric horses

OBJECTIVE: To describe the demographic and clinical characteristics, management practices, and owner perception of a population of geriatric horses, and to compare these data with findings in a group of younger horses. DESIGN: Original study. ANIMALS: 218 horses. PROCEDURE: Data were collected via a survey tool from owners of 165 horses that were > or = 20 years of age and 53 horses that were < 20 years of age. RESULTS: Compared with young horses, the geriatric group included a significantly greater number of ponies; geriatric horses were also more likely to have a history of colic, dental disease, tumors, lameness, and pituitary disease, but not laminitis, diarrhea, allergies, respiratory tract disease, thyroid disease, or fractures. Horses that had participated in Western equestrian disciplines were more likely to have a history of lameness. Among old horses, those with pituitary dysfunction were more likely to have a history of laminitis than those without pituitary dysfunction. Geriatric horses were more likely to have long hair and shedding abnormalities than were younger horses. Owners perceived their horses as old at approximately 22 years of age. In horses older than 16.5 years of age, age was a negative factor in the purchase of horses. CONCLUSIONS AND CLINICAL RELEVANCE: Geriatric and young horses share some similar health problems, but old horses have distinct health problems and veterinary medical requirements. The management and athletic history of horses may influence health as they age.     

A moderately severe expression of classical hemophilia in a family of german shepherd dogs

A kindred of German shepherd dogs with a moderately severe form of classic hemophilia was studied. The propositus was presented at five months of age because of a persistent hind limb lameness and swelling of the left stifle joint. Unclotted blood was aspirated from the swelling. A brother of this dog's dam had been diagnosed as a hemophiliac.Hemostatic tests were performed on the propositus and on ten available related dogs. On the basis of pedigree analysis, sex and specific factor VIII related activity levels in their plasmas, the dogs were classified as affected, carriers, or unaffected. The propositus and one male relative were identified as classical hemophiliacs and were classified as moderately severely affected on the basis of apparent bleeding tendency and factor VIII procoagulant levels (FVIII:C 8-10% of normal). The propositus' signs were confined to those of lameness and joint soreness and postmortem lesions were confined to a few joints (hemarthrosis). The affected male relative was asymptomatic up to the time of euthanasia (three months of age) and did not have postmortem lesions attributable to hemophilia.Although classic hemophilia (particularly in large breeds of dogs) is often a severe clinical disease, more moderate forms of the disease do occur. Such forms may be more difficult to recognize early in life.     

Culling rate of Icelandic horses due to bone spavin

A survival analysis was used to compare the culling rate of Icelandic horses due to the presence of radiographic and clinical signs of bone spavin. A follow-up study of 508 horses from a survey five years earlier was performed. In the original survey 46% of the horses had radiographic signs of bone spavin (RS) and/or lameness after flexion test of the tarsus. The horse owners were interviewed by telephone. The owners were asked if the horses were still used for riding and if not, they were regarded as culled. The owners were then asked when and why the horses were culled. During the 5 years, 98 horses had been culled, 151 had been withdrawn (sold or selected for breeding) and 259 were still used for riding. Hind limb lameness (HLL) was the most common reason for culling (n = 42). The rate of culling was low up to the age of II years, when it rose to 0.05 for horses with RS. The risk ratio for culling was twice as high for horses with RS compared with horses without RS and 5.5 times higher for culling because of HLL. The risk of culling (prognostic value) was highest for the combination of RS with lameness after flexion test, next highest for RS and lowest for lameness after flexion test as the only finding. It was concluded that bone spavin affects the duration of use of Icelandic horses and is the most common cause of culling due to disease of riding horses in the age range of 7-17 years.     

Neurologic conditions causing lameness in companion animals.

Animals presented with non-weight-bearing lameness are a diagnostic challenge for the veterinarian. It is extremely important to distinguish between orthopedic and neurologic causes of lameness, because the diagnostic and therapeutic plans can be quite different. Myopathies can be confused with orthopedic disease because of gait abnormalities and associated muscle pain. Common myopathies seen in companion animal medicine include polymyositis, muscular dystrophy, endocrine and infectious myopathies, and myasthenia gravis. Lameness caused by disease of the nerve root or nerve is confused with orthopedic disease because of the disturbances of a nerve's sensory distribution (nerve-root signature) or disruption of the motor innervation. The diseases of the nerve root or nerve discussed are lateralized intervertebral disk disease, spinal cord neoplasia, malignant peripheral nerve sheath tumors, and traumatic neuropathies. The diagnosis of these diseases requires careful attention to the signalment, a complete history, and a thorough physical examination focusing on the neurologic and orthopedic components. Ancillary testing should be selected based on these results and a minimum database. Electrodiagnostic testing, radiography, and advanced imaging may help to localize the lesion more precisely and sometimes to confirm the diagnosis. Surgical exploration and histopathology often provide the definitive diagnosis. These cases of non-weight-bearing lameness are a diagnostic challenge, but when successful resolution can be reached, it is gratifying to the clinician, client, and patient.     

Supraspinatus tendinosis associated with biceps brachii tendon displacement in a dog

A 4-year-old spayed female Australian Cattle Dog (Blue Heeler) was evaluated because of right forelimb lameness of 5 months' duration. Orthopedic evaluation revealed signs of pain localized to the cranial aspects of both shoulder joints. Via magnetic resonance imaging, the mass of the supraspinatus tendon insertion in both shoulder joints was increased, compared with findings in cadavers of clinically normal dogs; additional imaging procedures revealed that, compared with clinically normal tendons, the tendon had increased signal intensity that was consistent with increased fluid content. The increased supraspinatus tendon mass in each shoulder joint was associated with medial displacement of the biceps brachii tendon, which was more severe in the right limb. Arthroscopic evaluations of both shoulder joints revealed no abnormalities. The dog underwent surgery, and the abnormal parts of the tendons were resected. The most prominent finding on histologic examination of excised tissues was severe myxomatous degeneration. The lameness resolved, and at 22 months after surgery, the dog was reported to have had no recurrence of lameness. The clinical signs and histologic appearance of the tendons in this dog strongly resemble findings associated with tendinosis in humans. Decompression of the biceps brachii tendon may have contributed to the successful outcome after surgery in this dog. Supraspinatus tendinosis should be considered among the differential diagnoses in dogs with uni- or bilateral forelimb lameness.     

Prevalence of cranial cruciate ligament rupture in a population of dogs with lameness previously attributed to hip dysplasia: 369 cases (1994-2003)

OBJECTIVE: To determine the prevalence of cranial cruciate ligament rupture (CCLR) in dogs with lameness previously attributed to canine hip dysplasia (CHD). DESIGN: Retrospective study. ANIMALS: 369 client-owned dogs. PROCEDURES: Hospital medical records from 1994 to 2003 were reviewed for dogs in which the referring veterinarian had diagnosed hip dysplasia or hip pain. Dogs were designated as having hind limb lameness because of partial or complete CCLR or CHD. RESULTS: 8% of dogs were sexually intact females, 43% were spayed females, 14% were sexually intact males, and 35% were castrated males. Mean age was 3.8 years (range, 3 months to 15 years). The most common breeds were the Labrador Retriever (21%), German Shepherd Dog (13%), and Golden Retriever (11%). The prevalence of CCLR as the cause of hind limb lameness was 32% (95% confidence interval, 27.2% to 36.8%). The distribution of CCLR among hind limbs was left (29%), right (28%), and bilateral (43%). Of 119 dogs with CCLR, 94% had concurrent radiographic signs of CHD, 92% had stifle joint effusion, and 81% had a cranial drawer sign. CONCLUSIONS AND CLINICAL RELEVANCE: On the basis of the high prevalence of CCLR in dogs referred for lameness because of CHD, it is important to exclude other sources of stifle joint disease before making recommendations for treatment of CHD.     

Temporary remission of disseminated paecilomycosis in a German shepherd dog treated with ketoconazole

Disseminated mycosis caused by Paecilomyces varioti in a female German shepherd dog presented with chronic forelimb lameness is described. Radiographs of the swollen carpal joint revealed geographic lysis of the radial epiphysis. Diagnosis was based on cytological demonstration of fungal hyphae and chlamydiospores, as well as fungal culture of fluid obtained by arthrocentesis. Temporary remission was characterised by markedly improved clinical signs and laboratory parameters, following treatment with ketoconazole. The dog was euthanased 9 months after the initial diagnosis, following the diagnosis of multifocal discospondylitis. This appears to be the longest described period of temporary remission obtained with treatment in dogs with paecilomycosis. Clinical, clinicopathological and necropsy findings of this disease in another German shepherd dog are briefly described.     

CASE REPORT AND CLINICAL REVIEW: Acute lameness associated with osseous metastasis of a peri-renal carcinoma in a horse

We present a case of aggressive metastatic carcinoma in a horse that was initially presented for shoulder lameness. Although radiography and scintigraphy were useful for localising a lesion in the proximal humerus, subsequent development of non-specific signs of systemic disease prompted further evaluation. Haematology and blood biochemistry, urinalysis and ultrasonography were all instrumental in identifying renal involvement. A diagnosis of a peri-renal mass causing secondary renal failure prompted euthanasia of the horse because of the poor prognosis. Antemortem findings were supported by necropsy, with secondary lesions also identified in the spleen, liver, 8th left rib and proximal humerus. Histological examination yielded a diagnosis of undifferentiated metastatic carcinoma.