A 9-year-old male castrated Boxer was presented to the Cornell University Hospital for Animals’ Emergency Service for evaluation of lethargy, inappetence, diarrhea, and vomiting. Two days prior to presentation, the owner had noticed a bleeding blood blister near the patient’s prepuce. Past medical history included hypothyroidism, antibiotic responsive colitis, and bilateral tibial plateau leveling osteotomies (TPLO).

Initial examination revealed petechiae on the penile mucosa, oral mucosa, and pinnae, and ecchymoses on the ventral abdomen. Initial diagnostic testing revealed icteric plasma and zero platelets on blood smear assessment. The patient’s problem list included severe thrombocytopenia manifested by petechiae and ecchymoses, icteric serum, vomiting, diarrhea, lethargy, and inappetence. Additional diagnostic testing focused on differentiating causes of thrombocytopenia and icterus. Clinicopathologic investigation disclosed profound thrombocytopenia, neutrophilia with left shift and toxic changes, increased liver enzyme activities, hypercholesterolemia, and hyperbilirubinemia. Abdominal ultrasound revealed evidence of inflammatory gallbladder disease, which later progressed to extrahepatic bile duct obstruction.

A tentative diagnosis of immune-mediated thrombocytopenia secondary to Cholangiohepatitis was made. Due to the severity of thrombocytopenia, gallbladder aspirate cytology and culture or cholecystectomy could not be safely pursued to achieve a definitive diagnosis. This case presentation reviews differential diagnoses for thrombocytopenia and icterus, and demonstrates the balance required when concurrent clinical problems preclude the pursuit of front line diagnostic and therapeutic interventions.