A Case A Week for Vets

Solution for case 10/25/10

2010-10-29T00:00:00.001-04:00

Tentative diagnosis: Hepatitis. An increase in AP, ALT and total bilirubin is indicative of liver problems. The mild elevation in total bilirubin explains the slightly yellow mucus membranes. The generalized lymphadenopathy and increased globulins could be indicative of a systemic infection that in this case is affecting primarily the liver, causing hepatitis.

Further diagnostic tests:

Paired serum samples
Serology
Immunofluorescence
Ultrasound
Liver biopsy

Differentials:

Infectious hepatitis: bacterial, fungal or other
Leptospirosis
Granulomatous hepatitis
Toxic hepatopathy
Fulminant infectious disease: parvovirus, canine distemper
Portosystemic shunting

Hepatitis can have many different causes. The main disease suspected to be causing the hepatitis is leptospirosis. Leptospira interrogans serovar Bratislava is very prevalent in the area and is not covered by the leptospirosis vaccine. The vaccine only includes serovars Canicola, Icterohemorrhagiae, Grippotyphosa, and Pomona. No cross protection exists between serovars. The typical clinical signs of leptospirosis are fever, depression, lethargy, anorexia, myalgia, vomiting, lumbar pain from renomegaly and nephritis, icterus, bilirubinuria, cholestasis and/or hepatic necrosis, renal failure. It has been reported that many young dogs suffer more from liver problems and not the kidney when infected with leptospirosis.

Extrahepatic bacterial or fungal infections could also cause hepatitis, but this case was not showing clinical signs of having an infection in other body systems that could have traveled to the liver. However, since the owner was not with the dog during the entire summer the patient could have developed a primary infection, that later traveled to the liver, but at the present time is not evident.

Many hepatotoxins such as high amounts of acetaminophen, aflatoxins, blue-green algae, heavy metals; certain herbicides, fungicides, insecticides and rodenticides could cause liver problems. No ingestion or access to any of these was reported by the owner.

Other causes of hepatitis are Canine Adenovirus-1, but this patient vaccinated. Toxoplasmosis is a rare disease because the body is usually able to eliminate the infection. However some young dogs are not able to control the infection and Toxoplasma tachyzoites invade tissues throughout the body and replicate intracellularly until cells burst, causing necrosis. If the Toxoplasma tachyzoites invade the liver clinical signs associated with hepatitis could be seen.

Canine cholangiohepatitis is rare and associated with ascending biliary tract infections (Salmonella sp., Campylobacter jejuni), choleliths, coccidiosis, and surgery of the biliary tract. Clinical signs include anorexia, vomiting, diarrhea, lethargy, PU/PD, fever, abdominal pain, hyperbilirubinemia and elevated AP and GGT. To make a definitive diagnosis samples should be submitted for aerobic and anaerobic cultures and sensitivity.

Idiopathic hepatic fibrosis is a rare disease in young dogs, usually less than 2 years of age, is not associated with any underlying inflammatory conditions. Clinical signs include ascites, hepatic encephalopathy, weight loss, vomiting, diarrhea, portal hypertension, portosystemic shunt, microcytic anemia, elevated AP and ALT and hypoalbuminemia. Microhepatica can be noted on radiographs.

Hepatic amyloidosis is a rare familial disease. Clinical signs include anorexia, PU/PD, vomiting, icterus and hepatomegaly. Diagnosis is made by identifying amyloid deposits in a liver biopsy. Glycogen storage disease is caused by a rare deficiency in glucose-6-phosphatase or in amylo-1,6-glucosidase, this results in a failure of glycogen to be released from the cell. Therefore, glycogen accumulates within the liver and other organs. Enzyme analysis of fresh frozen samples of liver, muscle or skin is needed for diagnosis. Prognosis is poor and most dogs succumb to these diseases at a young age.

Treatment of possible leptospirosis: Administration of 0.9% NaCl fluids IV to prevent dehydration was started along with antibiotic treatment with Ampicillin 500mg orally TID (three times a day). The patient is to be fed three times a day l/d diet in order to prevent any further liver damage and to try to increase body weight. A CBC test is to be repeated in three days to determine if the treatment plan is being effective and assess the health status of the patient.

Need to assess the health and degree of clinical signs in patient's kins. There may be need to look into familial disease.

Case for week 10/25/10

2010-10-25T00:00:00.002-04:00

Presentation:

A six month old, intact, male, mix breed dog (pothound) was presented to AcaseAweek Clinic with a history of anorexia, weight loss and lethargy. The dog has an indoor/outdoor lifestyle, is fed puppy Science Diet, is up to date on its vaccinations and is treated for ectoparasites with Adam’s spray. The owner was away during the summer and upon return found ticks on the dog. There are four other dogs in the household, one of them is showing similar clinical signs and happens to be this patient’s brother.

Physical examination revealed that the patient was mildly depressed, alert and responsive, had a temperature of 100.4ºF, heart rate was 100bpm, respiratory rate was 12bpm and weighted 18.2 kg.

Ears, eyes, nose, throat: mild black, thick, tarry exudate on both ears. No ocular or nasal discharge observed.

Mucus membranes: grey, pale and slightly yellow (icterus). CRT<2>

Lymph nodes: generalized lymphadenopathy.

Laboratory tests:

Snap test: Ehrlichia, Heartworm, Anaplasma and Lyme disease negative.

CBC: unremarkable, except for mild eosinophilia.

Chemistry profile:

AP 1259 U/L (46-337)
ALT 673 U/L (8-75)
Glob: 4.1 g/dL (2.3-3.8)
TBIL: 1.3 g/dL (0.0-0.8)

Urinalysis- unremarkable.

What is your tentative diagnosis? Give list of differentials.

What diagnostic test(s) will you perform to confirm your diagnosis?

How will you treat and manage this case?

Solution to this case will be posted on 10/29/10

Solution for case 10/18/10

2010-10-22T00:00:00.002-04:00

Click here to see this case

Tentative diagnosis: Azotemia due to chronic renal failure (CRF).

Further diagnostic tests:
* Abdominal radiography/ultrasound to demonstrate decreased size of kidneys.

* Urine creatinine:protein ratio.

* Renal biopsy (not commonly performed).

* Blood pressure to demonstrate hypertension.

Isosthenuria is a common finding in chronic renal failure when two thirds of the functioning nephrons are lost.

Azotemia is seen when at least three fourths of the functioning nephrons are lost. Azotemia presents with increased BUN, creatinine, GI, and neurological clinical signs. This patient’s presentation would suggest that she has lost at least three fourths of her functioning nephrons.

Predisposing factors for CRF are age, chronic obstruction, infection, heart failure, and tubular disease. A urine sample taken from this patient, via a cystocentesis, ruled out bacterial infection. Patient’s heart sounded normal on auscultation. The renal failure was attributed to her age.

Management of chronic renal failure is a multifactor process. Most importantly hydration and electrolytes must be maintained with in normal limits. An appropriate renal diet will be low in protein, phosphorous, and sodium. Some other factors which must be addressed in the management of chronic renal failure include anemia, proteinuria, and gastrointestinal processes.

Anemia is due to decreased production of erythropoietin by renal peritubular cells. The anemia could also be from blood loss via GI ulcers, or iatrogenic from blood draws. The anemia is non-regenerative normochromic normocytic.

Treatment of anemia with erythropoietin (EPO) is indicated when the PCV falls below 18% and the patient is showing clinical signs of anemia/hypoxia. Caution must be used with EPO since it is of human origin. Dogs can produce antibodies against it. In severe anemia requiring immediate relief of clinical signs a blood transfusion can be done.

Proteinurea is seen because glomeruli have been damaged enough to allow loss of protein and anti-thrombin III. This decreases oncotic pressure, leading to edema. The loss of anti-thrombin III causes coagulation issues. Many of these patients have pulmonary thromboembolism as a complication.

These patients can be treated with angiotensin converting enzyme inhibitors which decreases the pressure in the glomeruli by dilating the efferent renal artery. This decrease in pressure helps prevent loss of proteins into the urine. Canine patients with CRF and proteinuria tend to have a decreased survival.

GI ulcers and nausea and vomiting are the common clinical signs seen. Uremic toxins activate the chemoreceptor trigger zone which leads to the nausea and vomiting. These uremic toxins also increase gastrin production which increases hydrochloric acid production in the stomach, leading to GI ulcers.

These complications are treated by decreasing the uremic toxins via hydration; protecting the stomach by decreasing acid production, and controlling the nausea and vomiting by blocking the chemoreceptor trigger zone. Acid production can be decreased using histamine blockers or proton pump inhibitors. Sucralfate can be used to protect/coat ulcers. The nausea can be controlled with medication targeted at dopamine antagonism, serotonin, or neurokinin.

Treatment:

Hospitalize patient
– NPO
– Fluid diuresis to decrease azotemia
* * Maintenance: 60ml/kg/24 hours = 2100ml
* * Deficit (5%) = 1715ml
* * Total fluid/day = 3850ml (160ml/hr)
– Decrease gastric acid and control N/V
* * Famotidine 20mg Q12 hours
* * Anti-emetic - Cerenia (maropitant citrate)
– Re-evaluate
* * BUN, Creatinine, Phosphorus every 48 hours
* * PCV and TP daily

The patient remained azotemic.
– After 3 days, fluids increased to 250ml/hr during the day and 160ml/hr during the evening.
– NPO
– Continue H2 blocker and Cerenia
– Continue to monitor BUN, SCr, TP, PCV, Phosphorus
The patient did not improve and was euthanized on consultation with owner.

See following Links for more info on CRF:

http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/130603.htm

http://courses.vetmed.wsu.edu/vm552/urogenital/crf.htm

http://www.marvistavet.com/html/body_chronic_renal_failure.html

http://www.felinecrf.com/what0.htm

Case for week 10/18/10

2010-10-18T00:00:00.001-04:00

A 12 year old spayed female Labrador was presented to AcaseAweek Clinic with one week history of vomiting, decreased appetite and lethargy. Bad breath of the pet was also a complaint. The patient was brought to clinic 4 month back for ehrlichia and mild azotemia. She is currently on Hill’s k/d diet.

Physical exam:

Weight: 34.8 kg
Temperature: 100.7
Pulse: 136
Respiration rate: 28
Mucus membranes: pale
Capillary refill time: > 2 seconds.
Dehydration: ~5%
Abdomen was tender upon palpation.

Lab tests: (Reference Values)

BUN: 112 mg/dl
Creatinine: >13.6 mg/dl
Phosphorous: 16.1
PCV: 25%
USG: 1.011
TP: 6.4 mg/dl
Albumin: 2.7 mg/dl
Non-regenerative anemia was also noted.

What is your tentative diagnosis?

Give differentials for your diagnosis.

What further diagnostic test(s) will be performed to confirm the tentative diagnosis?

How will you treat and manage this case?

Solution for this case will be posted on 10/22/10.

Solution for case 10/11/10

2010-10-15T00:00:00.001-04:00

Problem List:Hemoperitoneum
Cardiac arrhythmia and murmur
Poor peripheral perfusion
Mild anemia with marked regeneration
Moderate leukocytosis due to moderate neutrophilia
Mild lymphopenia
Mild thrombocytopenia
Mild↑ALKP, ALT
Mild↑amylase
Mild↑total bilirubin
Marked↑BUN and creatinine
Marked↑phosphate
Isosthenuria (single reading)
Moderate hematuria and bilirubinuria
Mild proteinuria
Anorexia, depression, lethargy
Vomiting
Marked weight loss and muscle atrophy

Primary problems on this patient are hemoperitoneum and acute renal failure.

Differentials for hemoperitoneumHemangiosarcoma (spleen/liver)
Coagulopathy (rodenticide)
Abdominal trauma

Differentials for acute renal failure
Ischemia due to hypovolemia, hypotension, shock or DIC
Nephrotoxicity (exogenous or endogenous toxins)
Immune mediated glomerulonephritis
Infectious (e.g. Leptospirosis, pyelonephritis)

Regarding the differentials for hemoperitoneum, hemangiosarcoma is the most likely. Hemangiosarcoma is most common in middle-aged to older dogs. Marked weight loss and muscle atrophy noted on physical exam may be suggestive of neoplasia.

The patient’s history and clinical signs are consistent with sudden rupture of splenic hemangiosarcoma causing hemorrhagic effusion into the abdominal cavity. Dogs with ruptured splenic hemangiosarcoma will commonly have abdominal enlargement due to hemoabdomen, pallor and hypotension. Poor peripheral perfusion and hypovolemia are evidenced by increased CRT and pulse deficit on physical exam. CBC with ruptured splenic hemangiosarcoma typically shows evidence of a recent bleed (marked regeneration with a mild decrease in PCV). Leukocytosis due to mature neutrophilia and thrombocytopenia are common CBC abnormalities noted in dogs with hemangiosarcoma of the spleen or liver. Mild lymphopenia may be a ‘stress’ response. High liver enzyme activity may be seen with hemangiosarcoma involving the liver. Mildly elevated liver enzymes are more likely pre-hepatic in origin; secondary to hypovolemia, hypotension and poor perfusion of hepatocytes. The icterus is most likely hepatic in origin, due to impaired uptake and conjugation by the underperfused liver. Mild pancreatic amylase increase is likely also secondary to decreased perfusion.

Regarding other differentials for hemoperitoneium, coagulopathy associated with rodenticide toxicity is less likely than hemangiosarcoma since there was not evidence of intrathoracic bleeding. With hemothorax, clinical signs of coughing, thoracic pain and/or dyspnea would be expected. There was also no history of possible ingestion. Abdominal trauma was ruled out on lack of history or any other evidence of a traumatic event.

This patient’s remaining problems are consistent with acute renal failure (ARF). The patient demonstrated a marked azotemia and hyperphosphatemia due to build up of nonprotein nitrogenous waste products and phosphate which are normally removed by the kidneys. Hypovolemia indicates that there is at least a partial pre-renal component to the azotemia. However if her azotemia was strictly pre-renal with tubular function intact, urine should be concentrated (SG >1.030) in the face of reduced renal perfusion. Patient’s urine SG of 1.013 is in the isosthenuric range, implying that kidneys are unable to adequately concentrate urine despite azotemia. Unlike pre-renal azotemia, renal azotemia is usually irreversible and is caused by extensive morphological or functional glomerular lesions with a loss of more than 75% of functional nephrons. On urinalysis, proteinuria and hematuria are supportive of glomerular damage.

Clinical signs of ARF are mostly caused by severe uremia and include lethargy, vomiting, anorexia and dehydration. The rapid build up of uremic toxins often causes the animal to become profoundly systemically unwell. Severe metabolic derangements are common, particularly hyperkalemia and metabolic acidosis. Electrolytes were not run on this patient, however hyperkalemia likely contributed to the arrhythmia noted on physical exam and being non-tachycardic despite being hypovolemic/hypotensive. Diagnosis of ARF relies on evidence of a sudden elevation in urea and creatinine, but definitive diagnosis would require renal biopsy or post mortem.

The cause of ARF is debatable. The most likely scenario is that this patient had a splenic hemangiosarcoma which ruptured 2-3 days before she was presented. Subsequent uncorrected hypovolemia and hypotension caused secondary insult to abdominal organs and renal failure due to prolonged ischemia. Multiple factors may have contributed to acute renal failure, and it is possible that patient had some degree of renal insufficiency prior to the ischemic insult which merely pushed her over the edge.

Emergency treatment:
IV catheter (20 G) – L cephalic vein
LRS @ 40 mL/hour (maintenance)
Urinary catheter – closed system

Owner did not want any other diagnostic tests performed and requested euthanasia and necropsy.

Further diagnostics (if patient was not euthanized):
Coagulation panel (OSPT to rule out rodenticide toxicity)
Abdominal ultrasound (hemangiosarcoma search)
Cardiac ultrasound (splenic HSA – often concurrent R atrium involvement)
Electrolyte panel (potassium level) → correct imbalances
Repeat urinalysis (confirm isosthenuria, monitor ARF)

Treatment of hemagiosarcoma is supportive and anti-neoplastic drugs. However, prognosis is Grave.

Necropsy findings:
About 500 ml of fluid was reported in abdominal cavity. Ruptured splenic mass of about 12 cm in size was also found and submitted for histopathology. Histopathology confirmed hemangiosarcoma.

Follow these two links for more information about the hemangiosarcomas:

http://www.vet.uga.edu/VPP/clerk/frankhauser/index.php

http://vetpath.wordpress.com/2008/08/12/splenic-hemangisarcoma-in-a-cat/

http://journals.tubitak.gov.tr/veterinary/issues/vet-98-22-5/vet-22-5-13-97199.pdf

https://www.vetconnect.com.au/5min/data/06460647.htm

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Case for week 10/11/10

2010-10-11T00:00:00.001-04:00

A 13 year old, female spayed, mixed breed dog was presented to AcaseAweek Clinic with history of collapse, depression, lethargy and vomiting 3 times the night before presentation. The patient had been anorexic for the past 2 days and appeared healthy previously. The patient lives mostly inside and her owner reported no possibility of accidental ingestion of foreign body or chemicals. Her vaccination status is current and she is on heartworm preventative. She was treated for Ehrlichiosis with doxycycline two months back.

Physical Exam:
Remarkable weight loss and muscle atrophy.
T: 98
P: 88
R: 44
MM: pale pink
CRT> 2 sec

Cardiovascular: murmur, cardiac arrhythmia, pulse deficit.
Respiratory: lungs sound clear
Abdomen: distended, positive succession, moderately painful

CBC/Cytology:
PCV: 23% [37-55]
WBC: 28.9 x103/μL [6-16.9]
Mature Neutrophils: 26.3 x103/μL [3.3-12]
Band Neutrophils: 0.6 x103/μL
Lymphocytes: 0.3 x103/μL
NRBC: 0.9 x103/μL
Smear: Platelets: 1-4/hpf
RBC morph: marked polychromasia, moderate anisocytosis

Biochemistry:
ALKP: 267 U/L [23-212]
ALT: 164 U/L [10-100]
AMYL: 2490 U/L [500-1500]
BUN: 130 mg/dL [7-27]
CREA: 6.1 mg/dL [0.5-1.8]
PHOS: >16.1 mg/dL [2.5-6.8]
TBIL: 1.4 mg/dL [0-0.9]

Urinalysis:
Bilirubin: ++
SG: 1.013
Blood: +++
pH: 5.0
Protein: +

Abdominocentesis:10 mL fluid was withdrawn.
Abdominal Fluid Analysis/Cytology:
Color: red
Turbidity: 3+
Protein: 7.2 g/dL
PCV: 23%
Smear: many RBCs, neutrophils and macrophages, moderate lymphocytes, almost no platelets seen, few reactive mesothelial cells.

What will be your tentative and differential diagnosis?
What further diagnostic test(s) you will perform to confirm your diagnosis?
What will be your treatment plan(s)?

Solution to this case will be posted on 10/15/10.

Solution for case 10/4/10

2010-10-08T00:00:00.001-04:00

Tentative diagnosis: Protein-loosing nephropathy.

Differential diagnosis: Glomerulonephritis, amylodosis, idiopathic glomerulopathy, liver disease, right sided heart failure, protein loosing enteropathy.

Further diagnostic tests:
1. Abdominocentesis: Analysis of fluid revealed transudate nature.

2. Urine Protein:Creatinine ratio: more than 4 (less than 1 is normal)

3. 4DX snap test: Negative in this case.

4. Renal Biopsy: To formulate prognosis by differentiating between glomerulonephritis and amylodosis. Renal biopsy was not done in this case.

5. Fecal float for GI parasites: no parasite eggs were found.

Although there are many causes for abdominal effusion or ascites, hypoalbuminemia, due to protein losing enteropathy or liver failure, can be ruled out at this time based on normal liver enzyme, negative fecal float and balanced diet for this patient. The abdominal fluid sample tested yielded a transudate, a potential cause could include a protein losing nephropathy/enteropathy or liver disease. In this case the hypoalbuminemia, hypercholestrolemia, proteinuria and urinary hyaline casts are hallmark of protein loosing nephropathy (nephrotic syndrome). Thromboembolism is a potential complication in such cases because of the reduced antithrombin III.

Most probable suspected cause here is the idiopathic.

This patient also had severe peridontal disease.

Therapeutic Plan:
Treatment is usually difficult and unrewarding. Prognosis is guarded in this case.
Abdominocentesis to make animal comfortable.
Sodium restricted diet. High quality low quantity protein diet (Hill’s k/d)
Enalapril: Vasodilator, Reduced sodium retention and reduce proteinuria and hypertesion.
Restricted activity and anticoagulants (aspirin) to reduce chances of thromboembolism.

Case for week 10/4/10

2010-10-04T00:00:00.001-04:00

A 12 year old, intact female Pompek canine presented to AcaseAweek clinic for abdominal distention. The owner reported abdominal distention worsening for last one and half week. As the patient was eating, drinking, eliminating and otherwise showing no remarkable behavioral changes at home, the owner was unsure of the exact duration of her condition. The dog is upto date on vaccines and deworming but not on any ectoparasite or heartworm control. Animal is fed Hill’s Science diet for senior dogs.

Physical Exam:
Weight= 5.5 kg
T=100.9 °F
HR/PR=160 bpm
RR=panting/open mouth breathing
EENT: Normal, except right prolapsed third eyelid
Oral: MM pink/moist, CRT<2s, Halitosis, Excessive tartar, gum recession, missing teeth: 101/102, 201/202, 301-303, 401/402
LLN: Normal
Thorax: Heart/Lung auscultate normally, with normal peripheral pulse, no jugular vein distention
Abdomen: Distended, Firm, Unable to palpate internal organs, No pain on manipulation, +ve reaction on Ballotment
U/G: Normal, intact
Skin: Normal
MSk: BCS 2/5
Neuro: Normal

CBC/Chemistry:
PCV= 31.7% (37-55%)
Albumin= 1.2g/dl (2.6-4.0 g/dl)
Total Protein=3.8g/dl (5.5-7.5 g/dl)
Cholesterol= 347 mg/dl (116-254 mg/dl)
All other values WNL

Urinalysis:
Protein= Dipstick protein ++++
Hyaline casts and few RBCs observed in urine sediment.

What is your tentative and differential diagnosis?
What further diagnostic tests you will perform?
What will be your treatment plan?

Solution for case will be posted on 10/8/10

Solution to case 9/27/10

2010-10-01T00:00:00.000-04:00

Click here to see this case.

Radiographic findings:
Globe like cardiac silhouette with distended pulmonary veins.

Ultrasound findings:
Fluid around the heart (pericardial effusion). US also showed the fluid in the abdomen around the spleen, between the diaphragm, the liver and around the bladder.

Tentative diagnosis: Right sided heart failure/pericardial effusion.

Differential diagnoses for pericardial effusion include, tumors (most common especially in dogs greater than 7 years) such as hemangiosarcomas, chemodectomas (most often in brachycephalic breeds), ectopic thyroid carcinoma, mesothelioma, lymphosarcoma. Idiopathic pericardial effusion is the second most common cause and is usually found in dogs 6-7 years old. Others include anticoagulant poisoning such as rat poison and other coagulopathies, pericardial cysts, constrictive pericarditis, infectious disease, atrial tear in small breed dogs, bacteria, FB, fungus, sepsis, trauma, viruses. Top differentials in this case include hemangiosarcoma, Idiopathic, coagulopathy, infectious or constrictive pericarditis.

Anemia and hypoproteinemia due to hypoalbuminemia shown by a low PCV and low TP suggest recent hemorrhage. The nonregenerative anemia is likely due to acute disease within the last 4 days. High BUN and Creatinine are due to dehydration (prerenal azotemia).

Large cardiac Silhouette on radiographs suggests cardiac effusion. Muffled heart sounds are characteristic for pericardial effusion. In cardiac enlargement is heart sounds are louder, pinging heart sounds if the heart was enlarged.

Characteristic findings for pericardial effusion include a large globular cardiac silhouette rounded in all views, enlarged vena cava, and occasionally distended pulmonary veins. With small effusions, these findings may not be evident. Chest x-rays should always be carefully evaluated for evidence of a heart base mass and for metastatic disease. In this case an ultrasound also showed a pericardial effusion and ascities.

Ascites is a common sequel of pericardial effusion. Pericardial effusion can lead to pericardial tamponade and right cardiac heart failure signs such as tachycardia, ascities, swollen limbs and increased respiratory rate.

Ultrasound helps to determine and locate any tumors in the heart. If a mass is found it is important to biopsy the mass or pieces of the pericardium. If mass is determined to be hemangiosarcoma there is a very poor prognosis and only a 3 mo survival period for most dogs without surgery. Chemodectomas carry a better prognosis for 3 years survival with subtotal pericardectomy.

Further diagnostic tests:

1. Coagulation panel
To rule out any coagulopathies and make sure it is safe to perform pericardiocentesis. Also, hemangiosarcoma may lead to minor DIC and coagulopathies.

2. Pericardiocentesis and abdominocentesis
They are more therapeutic than diagnostic.

Pericardial effusion can be differentiated from peripheral blood in that it rarely clots unless it is from very recent hemorrhage and the PCV is significantly lower than that of peripheral blood.

The most common causes of pericardial effusion cannot be diagnosed due to the fact that hemangiosarcomas and chemodectomas do not exfoliate leading to a false negative result. Reactive mesothelial cells may be mistaken for neoplastic resulting in a false positive result.

In this case the fluid in pericardium was blood tinged with PCV <27%.

Abdominocentesis needs to be done to determine the type of the fluid (exudate, transudate or hemorrhagic). In this case abdominocentesis was performed and the fluid was found to be transudate.

3. Blood culture and sensitivity test:
This is required to rule out any infectious etiology for the pericardial effusion. In this case no organism was isolated.

4. 4 DX snap test was negative in this case.

Therapeutic plan:
This case was treated as indiopathic pericardial effuision as no mass was seen on the ultrasound.
The patient was stabilized (iv fluids) and pericardiocentesis was performed and animal was put on predisolone. Recheck was advised in 2 weeks time.
One pericardiocentesis may be enough in idiopathic pericardial effusion in 50% of dogs. However, if more than 2 pericardiocentesis are required a subtotal pericardiectomy is recommended. +/- prednisone for inflammation after pericardiocentesis is performed.
In this case prognosis was fair as there was no recurrence of the pericardial effusion.

Case for week 9/27/10

2010-09-27T00:00:00.005-04:00

A 4 year old intact male pit-bull mix canine was presented to ACaseAweek Clinic for generalised weakness and a swollen left hindlimb since one week. He is both indoor and outdoor and he is fed home made food which is mainly rice and chicken. He is upto date on vaccination, heartworm and ectoparasites control.

Physical Exam:
Weight 25.1Kg
T: 100.9*F
PR/HR: 90bpm
RR: 36bpm
MM: Pale
CRT: >2sec
EENT: Normal
M/S – Swollen hind limb with pitting edema that is not painful.
Thorax: Muffled heart sounds on auscultation, but regular with no arrhythmias or murmurs noted. Possible diminished lung sounds.
Abdominal palpation – Enlarged abdomen, with fluid wave on palpation.
LN: wnl
Neuro, rectal – not examined.
BCS: 2/5

CBC and Chemistry:PCV 27% ( 37-55)
RBC morphology: mild anisocytosis and normochromic – non regenerative
No microfilaria seen,
All other values: wnl
ALB 1.9 g/dl (2.3 -4.0)
BUN 33 mg/dl (7-27)
Creatinine: 1.7 mg/dl (0.5-1.6)
TP 4.8 g/dL (5.2 -8.2)

Urinalysis (free catch):Mild odor,
Color: yellow
SG: 1.020

Radiographs (Click to enlarge):

What are radiographic and ultrasound findings?What is your tentative and differential diagnosis?
What further diagnostic tests you will perform?
What will be your treatment plan?
Solution to this case will be posted on 10/1/10

Solution to case 9/20/10

2010-09-24T00:00:00.002-04:00

Click here to see this case

Tentative diagnosis: FIV/FeLV

Differentials: FIV, FeLV, hemobartonella, cytoxazoon, Eosinophilic granuloma complex, superficial pyoderma, IMHA, hyperthyroidism, renal disease.

Further diagnostic tests:IDEXX Combo FIV/FeLV snap test, blood smear for blood protozoa, impression smear of the oral lesions, skin scraping and bacterial culture and sensitivity for the skin lesions. T4 test. PCR test for hemobartonella is also available.

In this case the IDEXX combo test was positive for FeLV. No blood protozoa was seen on the blood smear. No eosinophils were seen on the impression smear of the oral cavity. Skin scraping was negative. Culture for skin lesions was positive for Staph infection and sensitive to Potentiated Amoxicillin. T4 levels were normal.

Based on the clinical signs and results from CBC and IDEXX snap test, FeLV is at the top of the differential list. Her general appearance, lethargy, skin condition and lymphadenopathy all are signs that the immune system is not functioning optimally. Increase in the BUN/Creatinine and total proteins is due to dehydration.

FeLV is a retrovirus in the same family as HIV/AIDS in humans. It is more common in outdoor cats and kittens. It is transmitted primarily through saliva from sharing utensils or from bite wounds and licking. It can also be transmitted via urine, tears, feces, milk and through placenta. Its main effect is suppression of the immune system thus affected individuals have many other organ system issues. 30% of animals develop cancer (lymphosarcoma). This virus also leads to bone marrow suppression thus this animal had non-regenerative anemia, leucopenia and thrombocytopenia. Animals can live for years with the disease but usually by the time the diagnosis is made, the cat is already viremic. Expected lifespan is 1-2 years after diagnosis.
IDEXX combo snap test for FeLV needs to be repeated in six weeks or Immunoflourecent Antibody (IFA) test needs to be done to confirm the diagnosis.

Treatment Plan:
Blood transfusion was done and supportive therapy was provided as follows:
IV fluids - LRS
Antibiotics - Potentiated Amoxicillin
B-complex
a/d Hills diet (high nutrition diet for recovering sick animals)

Advised to keep the cat indoors and prevent being around others both so they are not possibly exposed to FeLV. Any secondary infections should be treated as soon as possible. FeLV in this case was repeated in six weeks and was still positive thus confirming the diagnosis.

Case for week 9/20/10

2010-09-20T00:00:00.003-04:00

A 2.5 year old female spayed DSH outdoor was presented to the AcaseAweek Clinic with a five week history of lethargy, has not been eating for the past 2 days, and has many areas of alopecia accompanied by pruritis. She is not up to date on vaccines nor is she on heartworm preventative. She was given pyrantel 3 days ago.

Physical Exam:Weight = 2.2kg
Temp = 101.5
HR/Pulse = 204
RR = 36
General appearance: “scruffy” and unkempt
MM: pale but moist
Oral: Halitosis and stomatitis
CV: Tachycardia but strong pulse
Integument: Areas of alopecia on right lateral stifle, along dorsal spine, left abdomen, dorsal neck with associated areas of scabbing and pustules. Entire head had short fur and dry underlying skin.
Musculoskeletal: Thin, BCS 2/5
Ears: Black/brown debris in both ears
Eyes: 3rd eyelids prolapsed
Lymph nodes: Superficial lymph nodes were reactive

CBC and Chemistry:
PCV = 9.8% (24-45)
Hb = 3.1 g/dl (8-15)
Granulocytes = 2.0x109/L (2.5-12.5)
Platelets = 21 x109/L (175-500)
BUN = 41 mg/dl (18-33)
Creatinine: 2.5 mg/dl (1.1-1.2)
Total protein = 9 g/dl (6.6-8.4)
Other values within normal limits

Urinalysis:
Appearance = normal
SG = 1.026
No other abnormality noticed in UA.

What is your tentative and differential diagnosis?
What further diagnostic tests you will perform?
What will be your treatment plan?

Solution to this case will be posted on 9/24/10

Solution for the case 9/13/10

2010-09-17T00:00:00.003-04:00

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Radiographic findings:

Lateral view: New bone formation on ventral aspect of T13, L1, L2 and L3. Intervertebral disc (IVD) space between T13 - L1 and between L3 - L4 is reduced. Osteolytic lesions on the ventral aspect of L3.
VD View: Bone proliferation on the lateral aspect of T13-L1 and L1- L2 and L2 - L3. Reduced intervertebral space between L3-L4.

Tentative Diagnosis: Diskospondylitis.

Differentials: IVD protrusion, Vertebral fractures or luxation, Focal meningomyelitis, Vertebral neoplasia, Spondylosis deformans

Further diagnostic tests:
Myelogram, urinalysis, urine culture and sensitivity, brucellosis test (serology), blood culture for aerobes, anarobes and fungus, CSF analysis.
Urine and blood culture reports showed the Staphylococus spp sensitive to cephalexin. Brucellosis test was negative. CSF tap and myelogram was not performed in this case.

Common infectious agent found in diskospondylitis lesions:
Bacterial: Staphylococcus aureus and Staphylococcus intermedius are most commonly isolated. Other bacteria include Brucella canis, Streptococcus spp, Corynebacterium spp, Escherichia coli, Proteus spp, Pasteurella spp, and Bactericides spp.
Brucella is common in intact males. So unlikely in this case.
Fungal: Aspergillus spp and Coccidioides immitis
Focal meningomyelitis is still possible and a CSF analysis is needed to differentiate.

Intervertebral disk protrusion may cause similar clinical signs but can be differentiated on the basis of radiography and myelography. The lesion seen on radiographs was not consistent with intervertebral disk protrusion.
Vertebral fracture/luxation was not detected on radiographs.

Vertebral neoplasia usually does not affect adjacent vertebral end-plates. This is unlikely in this case due to adjacent vertebral end-plates being involved.

Spondylosis deformans rarely causes lysis of the vertebral endplates.

Treatment plan

Cephalexin 1000mg BID PO for 6 weeks.
Tramadol 50mg 1 capsule BID PO for 5 days.Taper to 50mg SID for another 5 days to gauge the effectiveness of antibiotic therapy.
Recheck after 5days of therapy. If improvement is seen do clinical revaluation every 2 wks and radiographs every 2-4 wks.
If no improvement change the antibiotics and reassess.

Case for week 9/13/10

2010-09-13T00:00:00.016-04:00

A 4.5 year old neutered male large breed mix canine was presented to AcaseAweek Clinic with sudden onset of acute hind limbs weakness for 2 days. The patient is both indoor and outdoor and is current on all the vaccinations, deworming and heart worm prevention.

Physical Exam:

T= 101.9 oF
HR/PR=114
R=panting
Weight= 37.8kg
MM=moist and pink
CRT=<2 sec

Neurological: Mild pain on palpation of spine in thoraco-lumber area.

No other abnormalities noted at this time on P/E.

CBC and Biochemistry: All values within normal limits.

4Dx snap test: Negative.

Radiographs: Pelvic radiograph on this patient was normal. Lateral and VD view of thoraco-lumber area were taken and are as shown below (Click on the images to enlarge):

What are your radiographic findings?
What is your tentative and differential diagnosis?
What further diagnostic tests you will perform?
What will be your treatment plan?

Solution to this case will be posted on 9/17/10

Solution for Case 9/6/10

2010-09-10T00:00:00.005-04:00

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Based on clinical assessment the problem list is as follows:

Lethargy
Dehydration
Putrid smell from oral cavity
Underweight
Mildly elevated platelets
Elevated BUN/CREA
Mildly elevated ALT
Severely elevated GLUCOSE in blood
Glucosuria
Proteinuria
Hematouria
Elevated leukocytes in urine

Tentative diagnosis: Diabetes mellitus.

DDx: Renal glucosuria, stress induced hyperglucemia, acromegaly, hyperthyriodism.

Further Diagnostic tests: Urine culture and sensitivity test for UTI, T4 test.

From history, PE and lab results the confirmatory diagnosis is Diabetes mellitus. The patient’s primary problems are related to his diabetes which accounts for his lethargy, dehydration, and body condition.

The elevated BUN/CREA and total protein are due to dehydration. The hyperglycemia and glucosuria are confimatory findings for the diabetes mellitus. The presence of blood and leukocytes in the urine are likely due to a UTI, urine culture and sensitivity are required.

In stress induced hyperglycemia does not lead to glucosuria. In renal glucosuria or Fanconi syndrome there is not hyperglycemia.

Acromegaly should be suspected in difficult cases of diabetes mellitus. Here acromegaly was ruled out by PE findings. Physical appearnace duing PE and growth hormone assay can confirm acromegaly.

Some of these symptoms (weight loss, PU/PD, vomiting, and weakness etc.) could also be due to hyperthyroidism. But T4 levels were normal in this cat.

The cause of the malodorous oral cavity could be related to diabetes or renal disease or other causes include abscesses, periodontal disease, and pneumonia.

Vomition may be due to hyperglycemia or elevated BUN/CREA.

Treatment Plan:

IV fluids (without glucose or dextrose)
Insulin
Monitor blood glucose levels

The best insulin for cats is ultralente, which is a long acting insulin. The owner is to monitor blood glucose levels at home and regular insulin (fast acting but short duration) is on hand for emergencies.

Dose of insulin is 0.5U/kg Q12h since his BG is > 360 mg/dL, and recheck BG curve weekly for first month. Once BG is <250 mg/dl, insulin can be adjusted to keep BG less than 250mg/dl.

Antibiotics for UTI based on culture and sensitivity should be administered.

The cat should be put on high fiber diet and semi-moist food should be avoided. Some cats can be maintained on oral hypoglycemic agents such as glipizide.

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Case for week 9/6/10

2010-09-06T00:00:00.006-04:00

Dear Readers!!!

We are back again with New Cases on this site. Case will be posted on every Monday and you can comment about the case. Solution to the case will be posted on following Friday. Comments on cases and solutions will be most welcomed.

Here go the case for this week:

A 12 year old male neutered DSH feline was presented to the AcaseAweek Clinic. The cat had two episodes of vomiting and is lethargic for one week. Owner reports that the cat is also PU/PD and inappropriately urinates on the counter and bed. He has been vocalizing more than normal and is showing signs of generalized weakness.

Physical Exam:

Weight: 4 kg

Temperature: 102.1 o F

HR/Pulse: 135 beats/m

RR: 24 breaths/m

CRT: = <2 sec

MM: pink but slightly tacky

BCS: 3/9

ENT: Normal

Oral: Putrid stench from oral cavity

LNN: Normal

Thorax & Abdomen: Normal

U/G: Normal

Skin Turgor: Reduced

MSk: Normal

Neuro: Normal

CBC and Biochemistry:

Platelets: 647 x 109/L [RR: 175 – 500 109/L]
BUN = 51 mg/dL [RR: 16-36]
CREA = 2.8 mg/dL [RR: 0.8-2.4]
ALT = 138 U/L [RR: 12-130]
Total protein = 9 g/dl [RR: 6.6-8.4 g/dl]
GLU = 588 mg/dL [RR: 71-159]
All other parameters within normal limits

Urinalysis:

Sample obtain via cystocentesis

Apparence: Straw colored and cloudy

Glucose = +++

SG = 1.024 (from refractrometer)

Blood = trace

pH = 6.0

Protein = ++

Leukocytes = +++

What will be your tentative and differential diagnosis?

What further diagnostic test(s) you will perform to confirm your diagnosis?

What will be your treatment plan(s)?

Solution for case 2/23/09

2009-02-27T00:00:00.001-05:00

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Tentative Diagnosis: Parvovirus infection

Differentials:

Coronavirus infection
Bacterial gastroenteritis
Foreign body
Hemorrhagic gastroenteritis
Intussusceptions
Intestinal parasites
Toxins

Further diagnostic tests:

ELISA for Parvovirus
Fecal exam
Radiograph

ELISA was positive for this patient and as this patient had no recent history of Parvo-vaccination the test was a true positive.

ELISA can have false negatives and false positives for Parvo. False positives are because of recent vaccination which was not in this case. Supporting the diagnosis of Parvo is the leukopenia which is very commonly seen in Parvo generally due to a neutropenia. It is often common to have an azotemia (increased BUN and Creatine) with Parvo. Icterus can also be associated with Parvo but not commonly.

Parvo is a highly contagious disease and positive dogs should be kept in isolation.

Complications to be aware of are sepsis, shock, disseminated intravascular coagulopathy, intussusception, and acute respiratory distress syndrome. Sepsis prevented by administering antibiotics. Shock and DIC are prevented by fluid therapy. Intussusceptions must be monitored for by doing abdominal palpation and possibly radiographs. These puppies are at a high risk of this because of the hypermotility of the gut.

Treatment and management: There is no cure for Parvo only palliative treatment.

Lactated Ringers solution and antibiotics (Ampicillin and Enrofloxacin) were administered to the patient. Hetastarch was also added to the fluids because of the decrease of Total Protein to compensate for the decrease in oncotic pressure. Metaclopramide was also given to stop vomiting. Nothing per os was prescribed for 24 hr. Once infected and recovered, animals will be immune for life.

Case for week 2/23/09

2009-02-23T00:00:00.001-05:00

Presentation: A 6 week old intact female puppy was presented to AcaseAweek Clinic for vomiting, bloody diarrhea and anorexia for last two days.

Physical Exam:

Quiet Alert and Responsive.
Membranes were jaundiced.
Otherwise Physical Exam was unremarkable.

CBC:

HCT 17.8% (37-55)
HGB 6.5 g/dl (12-18)
MCHC 36.5 g/dl (30-36.9)
WBC 2.4 x109/L (6.0-16.9)
Gran 1.8 x109/L (3.3-12)
PLTs 48 x109 /L (175-500)

Chemistry:

ALKP 841 U/L (46-337)
ALT 10 U/L (8-75)
BUN 102 mg/dl (7-29)
Crea 2.6 mg/dl (0.3-1.2)
Glu 365 mg/dl (77-150)
TP 4.7g/dl (4.8-7.2)

What is your tentative diagnosis?

What are the differentials for this case?

What diagnostic tests will you perform to confirm your diagnosis?

How will you treat and manage this case?

Solution to this case will be posted on 2/27/09.

Solution for case 2/16/09

2009-02-20T00:00:00.003-05:00

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Radiographic findings:

On thoracic radiographs, increased opacity was noted in the ventral portion of the thorax. The opacity, characteristic of fluid seemed to fill up the chest half way, moving the lungs in to the dorsal part of the thorax. The lung lobes were easily visualized due to the fluid surrounding them.

Tentative diagnosis: Pleural effusion.

Further diagnostic tests: Thoracocentasis, cytology, chemistry.

Pleural effusion is an accumulation of fluid in the space between the membrane encasing the lung and that lining the thoracic cavity. The normal pleural space contains only a small amount of fluid to prevent friction as the lung expands and deflates. There are several types of fluids that can accumulate in the pleural space including; transudate, modified transudate, nonseptic exudates, septic exudates, chylous exudates, and hemorrhagic.

Transudate is colorless/ pale yellow clear fluid with protein <1.5g/dl class="Apple-style-span" style="font-style: italic;">caused by hypoproteinemia and rarely early chronic heart failure.

Modified transudate is yellow/pink in color, clear to cloudy fluid with a protein count of 1.5-3.0g/dl and a nucleated cell count of 1,000-5,000/µl. Predominant cells found on cytology are macrophages, mesothelial cells, and possibly neoplastic cells. Modified transudate can develop with the diseases: chronic heart failure, neoplasia, and diaphragmatic hernia.

Nonseptic exudate is yellow/pink in color, clear to cloudy fluid with a protein count of 2.5-6.0 g/dl and a nucleated cell count of 1,000-20,000/µl. Predominant cells found on cytology are non-degenerate neutrophils, macrophages, and possibly neoplastic cells. Fibrin can also be found on cytology. The disease processes causing nonseptic exudates are neoplasia, diaphragmatic hernia, and lung lobe torsion (also FIP in cats).

Septic exudates is yellow/red-brown in color, cloudy to opaque fluid with a protein count of 3.0-7.0 g/dl and a nucleated cell count of 5,000-3000,000/µl. Predominant cells found on cytology are degenerated neutrophils and macrophages. Bacteria and fibrin are also found on cytology. Septic exudates is caused by septic pleuritis and called pyothorax.

Hemorrhagic exudates is a red opaque fluid with a protein count >3.0 g/dl the nucleated cell count is the same as peripheral blood and on cytology RBC’s, WBC’s and fibrin will be found. Hemothorax is caused by trauma, hemostatic disorders, and neoplasia.

Chylous exudate is a milky white opaque fluid with a protein count of 2.5-6.0 g/dl with a nucleated cell count of 500-20,000/µl. The major cells seen on cytology are small mature lymphocytes, with chronicity neutrophils and macrophages can be found. Chylothorax can be caused by an obstructed duct, ruptured duct, chronic right sided heart failure, neoplasia, and heartworm disease.

Chyle can be differentiated from pseudochyle by comparing the triglyceride and cholesterol levels of the exudates to the patient’s serum. Chyle will have a higher triglyceride level and lower cholesterol level than the patients serum while pseudochlye would be opposite with a lower triglyceride level and higher cholesterol level than the patients serum.

Treatment and management:

Thoracocentesis was performed which yielded 1700ml of a chyle like fluid that was whitish pink in color. Post-thoracocentesis radiographs were taken as shown below (click on the image to enlarge):

The treatments suggested for a chylothorax are; thoracentesis, identify and treat underlying cause, chest tubes (only for patients with chylothorax secondary to trauma with rapid accumulation or after surgery), and with unsuccessful medical management surgery is considered. The surgery suggested is a thoracic duct ligation and pericardectomy, if this is not successful pleuroperitoneal or pleurovenous shunts and can be considered.

A change in diet could help; a low fat diet may decrease the amount of fat in the effusion, which may allow the patient to resorb the fluid from the thoracic cavity easier. The prognosis is guarded on these patients therefore euthanasia is often performed on the patients that do not respond to medical or surgical treatment.

The patient was cage rested and monitored for respiratory distress with thoracentesis performed to keep the patient comfortable.

Case for week 2/16/09

2009-02-16T00:00:00.003-05:00

Presentation:

A 2-year-old intact male, mix-breed dog was presented to AcaseAweek Clinic with history of loss of appetite for 2 weeks duration, rapid weight loss, labored breathing, and lethargy. The patient lives in an outdoor/enclosed area. Vaccines are overdue and the patient was de-wormed two months ago with fenbendazole. The patient is not on heartworm prevention. His diet consists of dried kibble mixed with rice fed once daily in the morning.

Physical exam:

BAR
Weight 14.3kg.
Temp: 102.3oF
HR/PR: 140
RR: 40
CRT <2>
MM: pink and moist
Body score: 2/5
Patient showed respiratory distress with mild inspiratory effort, had shallow breathing but no open mouth breathing. The patients lung sounds were decreased ventrally.
Heart sounds were muffled. Abdominal and rectal palpation revealed no abnormalities.

CBC and Chemistry: All values fell within normal limits. The snap test for heartworms, lyme, and ehrlichia was negative. Thoracic radiographs were taken as shown below (click on image to enlarge):

What are the radiographic findings?

What is tentative diagnosis?

What further diagnostic tests will you perform to confirm your diagnosis?

How will you treat and manage this case?

Solution to this case will be posted on 2/20/09.

Solution for case 2/9/09

2009-02-13T00:00:00.001-05:00

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Radiographs: Nephrolith found in renal pelvis of the left kidney.

Diagnosis: Calculi in renal pelvis and secondary cystitis.

Further diagnostic tests:

Ultrasound: Shadow effect from left kidney pelvis suggested of mineralized material present.
Urine Culture and Sensitivity: Proteus and Klebsiella cultured, both sensitive to Clavamox.

Urolithiasis:

The etiology of urolith formation is multifactorial including concurrent urinary tract infection, diet, intestinal absorption, urine volume and frequency, drugs, and genetics. Nephroliths are often asymptomatic unless the patient has a concurrent pyelonephritis. Nephrotomy is indicated for removal of nephrolith.

Cystitis:

The urine had an alkaline pH which favours the formation of struvite crystals. Proteus species are urease producing bacteria which cause the pH of urine to increase thus favouring the conditions for struvite crystal formation.

Treatment and management:

Antibiotic therapy (Clavamox) was initiated and after 3 weeks urinalysis showed that the numbers of bacteria had decreased to few and there was a marked decrease in the amount of blood in the urine showing a positive response to therapy.
The patient’s diet was changed to Hill’s S/D to acidify urine to prevent recurrence and dissolve crystals in urine.
After 3 weeks of antibiotic course, Nephrotomy was performed to remove the urolith from renal pelvis of left kidney.
The patient was continued on another 3 weeks on Clavamox.
Repeat CBC and urinalysis after one month.
Owner advised to monitor the patient at home for stranguria, hematuria, dysuria, appetite and attitude.

Case for week 2/9/09

2009-02-09T00:00:00.002-05:00

Presentation:

A 9 year old spayed female poodle was presented to AcaseAweek Clinic with a one month history of bloody urine which has progressively gotten worse in the past 2 weeks. The owner claims to have seen blood clots passed in the urine recently. The patient has not been eating well for the past 2 days and has vomited 4 times in the past 24 hours. Animal is unvaccinated and has no history of flea or heartworm prevention. Dog is fed home-made food.

Physical exam:

Weight: 7.04 kg
Temperature: 105.2 F
Pulse: 112 bpm
RR: 54
MM: pale
CRT: 2 sec

Complete Blood Count:

Hct: 27% (37-55)
RBC: 5.2 x109/L (5.5-8.5)
Hb: 10.3 g/dL (12-18)
WBC: 3.2 x 109/L (6-16.9)
Grans: 1.7 x 109/L (3.3-12)
PLT: 374 x 109/L (175-500)
TP: 9 g/dL (5.2-8.2)
nRBC : 1%

Biochemistry Profile:

AP: 65 U/L (23-212)
ALT: 35 U/L (10-100)
Glob: 4.9 g/dL (2.5-4.5)
Alb: 2.6g/dL (2.7-3.7)
BUN 33 mg/dL (7-27)
CREA 1.3 mg/dL (0.5-1.8)

Urinalysis:

Colour: Red
Odour: Strong
Turbidity: 3+
G: 1.019
pH: 8.5
Glucose: -ve
Bilirubin: -ve
Ketones: -ve
Protein: 4+
Blood: 3+
RBC: 3+
WBC: 3+
Squamous: few
Transitional epi: -ve
Tubular epi: -ve
Bacteria: 3+
Casts: -ve
Crystals: 2+ (struvite)

Abdominal radiographs were taken as shown below (click on the image to enlarge):

What are radiographic findings?

What is your diagnosis?

What further diagnostic tests will you perform?

How will you treat and manage this case?

Solution to this case will be posted on 2/13/09.

Solution for Case 2/2/09

2009-02-06T00:00:00.002-05:00

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Radiographs show reverse ‘D’ appearance of heart on VD/DV views. Enlargement of right ventricle on lateral view. Enlargement of main pulmonary artery and tortuous appearance of pulmonary arteries.

Diagnosis: Heartworm disease

Differentials for the signs presented:

Dilated Cardiomyopathy
Congestive Heart Failure (Right-sided)

Further diagnostic tests:

Heartworm snap test
Echocardiography
CBC, Chemistry and urinalysis.

Radiographic findings are suggestive of heartworm disease. 2/6 Right AV systolic murmur may be due to heartworm disease. Other causes of the murmur could be dilated cardiomyopathy or congestive heart failure. Murmurs are caused by turbulent blood flow through the heart and vessels, a grade 2 murmur is a faint murmur restricted to a localized area.

Dilated cardiomyopathy (DCM) is an acquired disease characterized by progressive loss of cardiac contractility, ultimately leading to both left and right-sided congestive heart failure. It was ruled out based on radiographic findings.

Congestive heart failure (CHF) results in pulmonary edema (left-sided heart failure) or ascites (right-sided heart failure). With DCM and CHF, tachycardia is usually present. The absence of pulmonary edema and/or ascites rule out dilated cardiomyopathy and congestive heart failure.

Definitive diagnosis is heartworm disease based on thoracic radiographs and a positive heartworm test.

Treatment:

Prednisone 0.5mg/kg PO EOD for 10 days to combat any inflammation and as preventative for pulmonary thromboembolism.
Immiticide treatment- alternative dosing: 1 injection of Melarsomine HCL 2.5mg/kg deep IM, repeat injection in 1 month with 2 injections 24 hours apart.
A month after the third injection, give heartworm prevention.
Heartworm test 4 months after second set of immiticide injections.
Monitor for pulmonary thromboembolism, possibly administer anticoagulants.
Strict cage rest while being treated.
Monitor heart rate, respiration and attitude.

Case for week 2/2/09

2009-02-02T00:00:00.004-05:00

Presentation: 3 year old, spayed female mixbreed canine was presented to AcaseAweek Clinic for occasional coughing and exercise intolerance of one month duration. The patient is not upto date on vaccinations and is not on any flea/tick/heartworm prevention.

Physical exam:

Weight: 18.8kg
BCS: 2.5/5
T: 102.0 F
P: 120
R: panting
CRT: <>
MM: pink and moist
Reactive lymph nodes
Heart- 2/6 Right AV systolic murmur

Thoracic Radiographs (VD, DV and Right Lateral) were taken as shown (Click on the image to enlarge):

What are the radiographic findings and diagnosis?

What are differentials for the signs presented?

What further diagnostic tests will you perform?

How will you treat and manage this case?

Solution to this case will be posted on 2/6/09.

Solution for Case 1/26/09

2009-01-30T00:00:00.003-05:00

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Radiographic findings: Complete fracture of caudal aspect of L6 and ventral displacement of caudal part of L6 and L7. Complete fracture of the left wing of the ilium. A lateral and VD radiographs of thoracic vertebrae were also taken and all appeared unremarkable.

Diagnosis: Spinal cord trauma due to Fracture of L6/L7 (UMN damage to the spinal cord).

Differentials for the signs presented:

Lumbar or sacral spinal trauma
Trauma and fracture of any portion of pelvis

Treatment: Establish an IV catheter and place on twice the maintenance at 4ml/kg/hr fluid rate with lactated ringer solution. Administer buprenophine 0.2mg/kg IV for pain. Treatment options are spinal surgery and devices such as a doggie carts along with possible complications of urinary and fecal incontinence. After all diagnostics were evaluated, all the treatment options including euthanasia were discussed with the owner and the patient was euthanized with pentobarbital (390mg/kg).

Case for week 1/26/09

2009-01-26T00:00:00.001-05:00

Presentation:

A 9 to 10 month old intact female, mixbreed was presented to AcaseAweek Clinic around 2:30pm after being hit by a car approximately 6:40am that morning. Owner said that the patient started biting at her vulva and so blood was seen around the vulva and mouth. The patient was in lateral recumbency and manual manipulation was painful.

Physical exam:

Weight = 10kg,
TPR all WNL,
MM pink
CRT<2 >
EENT all normal
Thoracic auscultation was nonremarkable.
A mild lymphadenopathy was noted in all lymph nodes.
When palpating the caudal vertebrae an obvious defect of the vertebrae could be felt just cranial to the sacrum.

Neurological exam: Hyperreflexia in both right and left hindlimbs. Withdrawl reflex was absent in both. Ischial groove reflex of the left hindlimb produces a reflex in the right limb that was hyperreflexive. Anus was flaccid and showed no tone.

Radiographs of lumbosacral and pelvis region were taken as shown below (Click on image to enlarge):

What are the radiographic findings and diagnosis?

What are differentials for the signs presented?

How will you treat and manage this case?

Solution to this case will be posted on 1/30/09.

Solution for case 1/19/09

2009-01-23T00:00:00.001-05:00

Click here to see this case

Radiographic findings: Thoracic radiographs showed a valentine shaped heart with significant generalized cardiomegaly and enlarged pulmonary arteries and veins. Abdominal radiographs showed homogenous soft tissue opacities with little visceral details which strongly suggest the presence of a significant amount fluid in the abdomen.

Tentative diagnosis: Congestive heart failure (Hypertrophic cardiomyopathy).

Differentials:

Heartworm
Restrictive and Dilated cardiomyopathy
Hyperthyroidism
Feline infectious peritonitis (FIP)
Feline asthma

Hypertrophic cardiomyopathy is common in the cat and is characterized by concentric ventricular hypertrophy in which the ventricular walls become thickened. The heart pumps well but cannot relax well during diastole. In addition, the thickening of the ventricles results in malorientation of the AV valves so the cat may develop mitral regurgitation. The cat may also develop dynamic aortic outflow obstruction secondary to the systolic anterior motion of the mitral valve.

Cat was positive for heartworm, and can be further confirmed by ultrasound which is more reliable in cats.

This patient is suffering from ascites and dyspnea secondary to hypertrophic cardiomyopathy complicated by heartworm disease. Thorax radiograph showed enlarged pulmonary arteries and veins which may be supportive of heartworm disease.

Two possible differentials are dilated cardiomyopathy caused by a taurine deficiency and restrictive cardiomyopathy caused by fibrosis of the endocardium, myocardium, or subendocardial tissues. These can be differentiated from HCM because dilated cardiomyopathy is rare since most cat foods are supplemented with taurine and restrictive cardiomyopathy usually shows enlargement of one or both atria and not a generalized hypertrophy.

A T4 test was done to rule out hyperthyroidism.

In FIP we will see presence of an exudate aspirated from the abdomen as well as an inflammatory CBC.

There was no eosinophilia present in the CBC to support a diagnosis of feline asthma; however, eosinophils in a transtracheal lavage would be more diagnostic.

Treatment:

Due to the dyspnea, the patient was immediately started on oxygen therapy with a pulse oximeter and oxygen levels increased from 80% to 98% oxygen saturation. A catheter was placed, IV fluids were started.

The patient was placed on furosamide (10mg IV twice a day) and diltiazem (10 mg/kg PO q24h) (Ca channel blocker) to treat the hypertrophic cardiomyopathy, pulmonary edema, and ascites. Fluid therapy was continued at twice the maintenance dose (2-3ml/kg/h) for 4 days.

Client education: The patient needs to be on daily heart medications for the rest of its life. Heartworm preventative needs to be given monthly to help prevent the heartworm disease from getting worse.

Case for week 1/19/09

2009-01-19T00:00:00.005-05:00

Presentation:
A 20 yr old neutered male Siamese cat was presented to the AcaseAweek clinic for dyspnea, anorexia, and lethargy. The cat was brought in by people who were watching it while the owners have been away. Vaccination and heartworm prevention status’s are both unknown.

Physical exam:
Weight: 4.5kg
T: 101.2 F
P: 220
R:60
Mouth: severe odontoclastic resorptive lesions and gingivitis
Auscultation: Severe gallop rhythm with grade III systolic murmur with PMI greatest over the LAV valve, respiratory sounds: crackles.
Abdominal palpation: very distended with a fluid wave. No masses were palpated.
Musculoskeletal: Generalized Weakness
General appearance: depressed, dyspneic, weak

CBC and chemistry panel were unremarkable except a mildly elevated BUN and creatinine.

ELISA snap test was positive for heartworm.

Abdominocentesis cytology revealed an obstructive transudate that was mildly cellular, containing mostly round, mesothelial type cells with some neutrophils and few lymphocytes.

Once the cat was stabilized, thoracic and abdominal radiographs were taken and are shown below:

What are the radiographic findings?
What is your diagnosis?
Give differentials for your diagnosis.
How will you treat and manage this case?

Solution to this case will be posted on 1/23/09

Solution for case 1/12/09

2009-01-16T00:00:00.004-05:00

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Radiographic findings:

Skull radiographs showed massive loss of turbinate bones. Loss of alveolar bone on the maxillary side, showing clear tooth roots.

Tentative diagnosis: Tumor (Nasal adenocarcinoma)

Further tests: Nasal biopsy histopathology/cytology, rhinoscopy, bacterial cultures, fungal cultures, nasal swab/lavage, thoracic radiographs.

Differentials:

Bacterial sinusitis
Aspergillosis
Trauma
Tooth root abscess
Foreign body
Coagulopathy

Nasal tumors are rare but found primarily in long-nose breeds. Adenocarcinoma is most common nasal tumors in dogs. The average age for the onset of canine nasal tumors is seven years. The clinical signs typically associated with nasal tumors are sneezing, nasal discharge, epistaxis, exophthalmia, facial swelling, nasolacrimal duct obstruction and, sometimes, neurological disturbances. Deformation of the facial bone, hard palate, or maxillary dental arcade may be visible. These signs are non-specific since they mimic bacterial or mycotic rhinitis, sinusitis, dental diseases, nasal trauma or foreign bodies lodged in the upper respiratory tract. Definitive diagnosis of nasal tumors is achieved by cytology or histopathology. However, the final diagnosis is generally reached at a time when the tumor is already in an advanced stage, and has invaded adjacent nasal structures or more distant organs, such as the brain. The prognosis is generally poor as most nasal tumors are malignant. Radiotherapy and chemotherapy can prolong survival rates and improve the quality of life of dogs. Without treatment, the survival following diagnosis of nasal tumors is usually only a few months.

Aspergillosis, in dogs, is typically localized to the nasal cavity or paranasal sinuses and is usually caused by infection with A fumigatus. Nasal aspergillosis is seen mainly in dolichocephalic breeds. It begins in the posterior region of the ventral maxilloturbinate with signs of lethargy, nasal pain, ulceration of the nares, sneezing, unilateral or bilateral sanguinopurulent nasal discharge, frontal sinus osteomyelitis, and epistaxis. Gross lesions vary considerably with site of infection, but a layer of gray-black necrotic material and fungal growth may cover the mucosa of the nasal and paranasal sinuses. The mucosa and the underlying bone may be necrotic with loss of bone definition on radiographs.

Treatment: The patient was given Cefazolin 500mg (5ml) three times a day. A triple antibiotic ointment was also used when discharge was cleaned off. Tissue biopsy confirmed the adenocarcinoma. As it was a rescued animal, owned opted for euthanasia. If not euthanized we can go for surgery, radiation therapy and chemotherapy, but prognosis is poor.

Case for week 1/12/09

2009-01-12T00:00:00.015-05:00

Presentation: A 3-6 year old intact male pothound canine, rescued with unknown history, was presented at AcaseAweek Clinic for castration. The only abnormality he had was unilateral mucous ocular and nasal discharge from the left side. While at the clinic, patient’s condition worsened over a weekend time. The ocular discharge became mucopurelent and the nasal discharge became bloody. His overall demeanor declined as his condition worsened.

Physical exam was performed, and besides the obvious nasal and ocular discharge he was physically sound. Nose was painful on palpation.

CRT: <2

Weight: 19.8 kg

Temp: 100.8°F

HR: 131bpm

RR: 22rpm

Auscultation revealed abnormal bilateral lung sounds.

The patient was tested for both ehrlichia and heartworm, testing positive for ehrlichia.

Blood chemistry and CBC values fell within normal limits except for Hct (30.5%), HGB (10.6g/dl), EOS (3.1 x 10), GLOB (6.3g/dL), and TP (9.0g/dL).

Under general anesthesia, radiographs were taken as shown below:

What are the radiographic findings?
What is your tentative diagnosis?
Give list of differentials for your tentative diagnosis.
How will you treat and manage this case?

Solution to this case will be posted on 1/16/09

Solution for case 1/5/09

2009-01-09T00:00:00.004-05:00

Click here to see this case

Radiographs show radiopaque foreign body (FB) in pharyngeal region (indicated by green lined boxes/areas).

Differentials for the signs presented:

Rabies
FB
Toxin ingestion
Esophageal stricture
Laryngitis
Congential/Acquired esophageal weakness
Cricopharyngeal Achalasia
Pharyngeal Dysphagia
Esophageal neoplasia

Rabies should always be suspected in all the cases of hypersalivation, dyaphagia and FB.

Esophageal stricture (cicatrix) can form from a prior esophagitis (e.g., subsequent to foreign bodies or severe gastroesophageal reflux) of any cause.

Laryngitis was ruled out due to lack of cough on palpation.

Congenital/Acquired esophageal weakness usually present with regurgitation with or without weight loss and were ruled out from the radiographic findings.

Cricopharyngeal achalasia is usually congenital and there is an incoordination between the cricopharyngeus muscle and the rest of the swallowing reflex which produces an obstruction at the cricopharngeal sphincter during swallowing.

Pharyngeal dysphagia is an acquired disorder related to myopathies, neuropathies and junctionopathies and the inability to form a normal food bolus. This would present most often in an older animal with regurgitation associated with swallowing.

Esophageal neoplasia such as primary sarcomas (due to Spirocerca lupi), primary carcinomas, leiomyomas/sarcomas were ruled out due to the age of the patient and toxin was ruled out due to the absence of more severe clinical signs.

Treatment and Management:

Surgical removal of the bone foreign body was decided to be the best treatment for this patient. The patient was sedated with 3mg/kg Propofol intravenously. Her oral cavity was evaluated with a laryngoscope and the FB was removed with alligator forceps. The FB was positively identified as fish bone vertebrae. The patient was given 2mg/kg ketoprofen subcutaneously for pain management and to reduce esophageal inflammation. After recovering from anesthesia puppy was offered some soft food which she ate immediately.

The patient was given Clavamox 15 mg/kg bid for 7 days and advised the owner to feed the puppy soft diet for 2 weeks. The patient has now made a full recovery.

Case for week 1/5/09

2009-01-05T00:00:00.007-05:00

Presentation:

5 month old, intact female pit mix canine was presented to AcaseAweek Clinic with chief complaint of hypersalivation and retching for few hours. Puppy was up to date on vaccination and deworming. Puppy is indoor/outdoor.

Physical exam:

QAR, slightly lethargic
Weight: 6.1kg
Choking and gagging induced by gentle palpation of the laryngeal region
Hypersalivation
MM pink
Abdomen distended
Fleas and ticks present
Waxy debris in both ears

Radiographs of head and neck region were taken as shown below:

Click here for larger image

Give radiographic interpretation.

What is your diagnosis? Give differentials for the signs presented.

How will you treat and manage this case?

Solution to this case will posted on 1/9/09

Solution for case 12/29/08

2009-01-02T00:00:00.005-05:00

Click here to see this case

Radiographic interpretation: Lateral radiograph shows the loss of cardiac silhouette and loss of continuity of the diaphragmatic line. Gas filled loops of intestine are seen in the thorax. There are also poor thoracic details on the ventral caudal thorax. On VD view we can see fissure lines on the left thorax suggestive of the pleural effusion. On the right side of thorax we can see loops of gas filled intestine.

Diagnosis: Traumatic diaphragmatic hernia / pleuroperitoneal hernia.

Treatment and management: Surgery to repair the ruptured diaphragm after patient has been stabilized is the treatment of choice. Oxygen should be supplied if animal is dyspenic. If pleural effusion is present, thoracentasis should be performed. If animal is in shock, should be treated first for shock. If stomach is herniated surgery should be done at earliest possible as gastric dilatation may further compromise the respiration. Mortality is higher when surgery is performed within 24 hours or after 1 year of the injury.

Click on the Links below for further details:

DH - 1

DH - 2

DH - 3

Case for week 12/29/08

2008-12-29T00:00:00.001-05:00

Presentation:

A 6 month old intact male mix breed canine was presented to AcaseAweek Clinic as an emergency after being hit by car (HBC) the previous night. On physical exam the dog was bright, alert and responsive (BAR), has abrasions distal to the hock and on the metatarsal region of both hind limbs. Mild weight bearing lameness on the right hind limb was observed. Radiographs of the abdomen and pelvic region were normal. The abrasions were cleaned and dog was discharged on Rimadyl 25 mg BID for 5 days. Three weeks later the dog was brought to the clinic again with chief complaint of dyspnea and exercise intolerance.

Physical examination:

Temp: 101.5
HR/PR: 96
Respiration: Laboured breathing
Auscultation of thorax revealed muffled heart sounds and harsh lung sounds.

CBC, chemistry and electrolytes were all within normal range.

Thoracic radiographs were taken (lateral and VD view) and are shown below:

Give interpretation of the radiographs.

What is your diagnosis?

How will you treat and manage this case?

Solution for this case will be posted on 1/2/09.

Solution for case 12/22/08

2008-12-26T00:00:00.002-05:00

Click here to see this case.

Further diagnostic tests:

Paired serum samples
Serology
Immunofluorescence
Ultrasound
Liver biopsy

Differentials:

Infectious hepatitis: bacterial, fungal or other
Leptospirosis
Granulomatous hepatitis
Toxic hepatopathy
Fulminant infectious disease: parvovirus, canine distemper
Portosystemic shunting

Need to assess the health and degree of clinical signs in patient's kins. There may be need to look into familial disease.

Case for week 12/22/08

2008-12-22T00:00:00.003-05:00

Presentation:

Physical examination revealed that the patient was mildly depressed, alert and responsive, had a temperature of 100.4ºF, heart rate was 100bpm, respiratory rate was 12bpm and weighted 18.2 kg.

Ears, eyes, nose, throat: mild black, thick, tarry exudate on both ears. No ocular or nasal discharge observed.

Mucus membranes: grey, pale and slightly yellow (icterus). CRT<2>

Lymph nodes: generalized lymphadenopathy.

Laboratory tests:

Snap test: Ehrlichia, Heartworm, Anaplasma and Lyme disease negative.

CBC: unremarkable, except for mild eosinophilia.

Chemistry profile:

AP 1259 U/L (46-337)
ALT 673 U/L (8-75)
Glob: 4.1 g/dL (2.3-3.8)
TBIL: 1.3 g/dL (0.0-0.8)

Urinalysis- unremarkable.

What is your tentative diagnosis? Give list of differentials.

What diagnostic test(s) will you perform to confirm your diagnosis?

How will you treat and manage this case?

Solution to this case will be posted on 12/26/08

Solution for case 12/15/08

2008-12-19T00:00:00.004-05:00

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Radiographs showed that stomach has ingesta in it with some radiopaque materials. Large amount of gas was found in small intestine. Colon was full of fecal material with some radiopaque material.

Tentative diagnosis: Ehrlichea (because of thrombocytopenia) and foreign body in stomach

Further diagnostic tests:

4Dx SNAP test: Heart Worm - negative, Ehrlichea canis + Positive, Anaplasma – negative, Lyme – negative

Coagulation panel: to rule out the rodenticide poisoning.

Ehrlichea: Active infection confirmed by SNAP test, fever and thrombocytopenia are likely responsible for the epistaxis. Epistaxis is the most frequent hemorrhage due to ehrlichea. Increased BUN suggests the possibility of a GI bleed. The Ehrlichea also accounts for the fever and lymphodonopathy. Trauma and rodenticide poisoning are differentials.

Abdominal pain: With a Hx of being fed chicken bones and the multiple opacities in the lower GIT a foreign body (FB) is suggested. The radiographs showed a substantial amount of feces in the large colon with a large amount of gas in the small intestine which may suggest ileus/obstruction from a FB or constipation.

Treatment:

Doxycyline 10mg/kg (88mg) IV SID to treat Ehrlichea.

20cc warm soapy water enema and repeated later in the day to empty the bowel and see if that helps to evacuate the feces from the bowel and resolve the gas and abdominal discomfort. No fluid treatment was done due to the severe anemia.

Day 2:

The patient is QAR and still seems painful in the abdomen. The epistaxis has stopped.

Good appetite with no vomiting.

40cc warm soapy water enema was given but no defecation.

DAY 3:

QAR. Painful around the abdomen, reluctant to move. Pain seems to have become generalized. No further epistaxis.

Good Appetite without vomiting

Urinated on her own but still without defecation. 60cc warm soapy water enema was given, which in 15-20 minutes produced a moderate amount of liquid/soft feces.

PCV = 8%

TP = 6 g/dL

The patient was radiographed again and showed multiple FB in the stomach and increased gas in the small and large intestine as shown in the figure below:

Evening of Day 3

Temperature decreased sharply to 97.9.

Blood transfusion was given very slowly at a rate of 4mL/hr (0.5mL/kg/hr) for 30 minutes while checking TPR, MM, CRT every 5min as to ensure the patient was not having a transfusion reaction of increased respiratory effort, injected MM, or tachycardia. The only change was the temperature increased by 1 degree from 97.9 to 98.9.

After the initial 30minute transfusion trial the rate was increased to 6mL/kg/hr at 50mL/hr.

Two hours later the patient developed profuse diarrhea and respiratory distress.

The blood transfusion was stopped immediately.

Dexamethasone and Diphenhydramine were given IV in case of a delayed transfusion reaction. However, at night the patient died.

Case for week 12/15/08

2008-12-15T00:00:00.007-05:00

Presentation:
A 7 month old, intact female mixed breed canine was presented to AcaseAweek Clinic as an emergency with epistaxis of one night duration and abdominal pain of about 5 days duration.
The owner has recently placed rat bait (Klerat = Bradisacoum) under the house. The owner does not believe the patient ingested any but is not certain.
The dog is fed people food and chicken bones.
The owner does not and is unable to monitor urination and defecation as the dog lives outside.
The owner does not believe there was any trauma to the patient.

Physical Exam:

Weight = 8.8kg
T = 104
mm = pale
P = 210
R = 40
EENT: Pale conjunctiva, epistaxis x1 day
C/V: Tachycardia, no other abnormalities heard
U/G: Brown/mucoid vaginal d/c.
GI: Very painful on abdominal palpation, mostly caudal abdomen.
LNN: Mildly enlarged pre-scapular and popliteal LN’s
The patient had a “hunched” appearance. The dog was shivering and had bloody nasal discharge (epistaxis). The epistaxis was more pronounced from the Right nare. The dog was also groaning.

CBC:

PCV = 9.0%
TP 6.0
WBC = 3.1
Plt = 41
CBC revealed a severe hemorrhagic regenerative anemia with severe thrombocytopenia, leucopenia and granulocytopenia. MCHC was borderline normal/elevated.

Blood Chemistry revealed hypoalbuminemia along with borderline normal/high BUN and borderline normal/low Creatinine and ALT. All other values were within normal limits.

Radiographs of abdomen were taken as shown in following pictures:
Give interpretations of the radiographs.
What is your tentative diagnosis? Give your differentials.
What further tests you will do to confirm your diagnosis?
How will you treat and manage this case?

Solution to this case will be posted on 12/19/08.

Solution for case 12/8/08

2008-12-12T00:00:00.003-05:00

Click here to see this case

Tentative diagnosis: Leptospirosis; Clinical signs with history of exposure to contaminated urine suggest leptospirosis.

Differential diagnosis:

Immune-mediated hemolytic anemia
Infectious canine hepatitis virus
Canine herpesvirus
Hepatic neoplasia
Trauma/bacteremia
Rocky Mountain spotted fever
Ehrlichiosis
Toxoplasmosis
Renal neoplasia/renal calculi

Leptospirosis is an infectious disease that can cause renal azotemia as the bacteria cause damage to the renal tubules decreasing the capacity of the kidneys to excrete urea. Also Creatinine levels could be high if the glomerular filtration rate of the kidney decreases in a renal failure. Usually dogs with subacute Leptospirosis will present azotemia, high liver enzymes (AP more high than ALT), icterus, dehydrated, mild anemic (Leptospirosis damaging RBC walls and endothelium) and 20% of dog with thrombocytopenia do to vasculitis. High liver enzymes are also observed in dogs with leptospirosis. All these signs make this patient a suspect of subacute leptospirosis. Also clinical signs and history of “rats around the environment” increase the suspicion of leptospirosis.

Urinary tract obstruction, a post renal condition (frequently in male dogs) can also increase BUN/Creatinine levels but usually clinical signs as hematuria and urinary incontinence will be seen in the dog. This was not in this case, as he was urinating with no signs of hematuria and no urinary incontinence.

Further diagnostic tests:

Leptospira isolated from blood and urine after 7-10 days of infection
2 weeks after infection use liquid culture to growth
Dark field microscopic, FA, Silver impregnation technique for tissue (Kidney, liver, lung) with the organism
Serology
Microscopic agglutination test
Not good if the dog was previously vaccinated, or infected or had passive immunity
ELISA (anti-lepto-antibodies), DNA probes, PCR

Treatment:

Supportive therapy (IV fluids) and antibiotics
Ampicillin: Leptospiremia
Dosage 5-10 mg/Kg IV, IM, SQ BID
Ampicillin 300 mg à 0.3 ml SQ BID
Doxycycline: eliminate renal carrier state
Dosage 5-10 mg/kg PO, SID
Doxycycline (100mg)tablets BID
Should be given for 1 month

Prevention:

Vaccination at yearly intervals and more often in enzootic areas
Be aware of new vaccines for Leptospirosis that induce immunity for new serovars

Be concern that it is a Zoonotic disease!!

Owner of the pet should be oriented about how to manage the dog and give the complete dose of antibiotics to eliminate the carrier stage
Clean the cage with bleach or diluted iodine

If the dog does not recover after the treatment further diagnostic test should be performed as kidney and/or liver biopsy, ultrasound, and x-rays.

Case for week 12/8/08

2008-12-08T00:00:00.002-05:00

Presentation:

A 9 months old neuter male pothound dog that was brought to AcaseAweek Clinic for being lethargic, anorexic (not eating since 2 days), and vomiting. On the next day of hospitalization, the patient continued to be lethargic, anorexic, vomiting and became icteric. On detailed history the owner reported presence of rats around the patient’s environment.

Physical examination:

On the day of presentation:

T: 102.1
HR: 104
RR: 40
Tacky mucous membrane
Fleas
Vomiting

Next day:

T: 101.0
HR: 96
RR: 30
CRT: <2sec
Icteric
Lethargic
Not eating

CBC:

HCT: 32% (37.0-55.0)
HGB: 11.5 g/dl (12-18)
MCHC: 35.9 g/dl (30-36.9)
WBC: 10.8 x10⁹/L (6.0-16.9)
Granulocytes: 9.3 x10⁹/L (3.3-12.0)
PLT: 37 x10⁹/L (175-500)

Biochemistry:

ALB: 2.6 g/dl (2.3-4.0)
ALKP: 879 U/L (23-212)
ALT: 184 U/L (10-100)
AMYL: 1260U/L (500-1500)
CREA: 7.9 mg/dL (0.5-1.8)
BUN: 130 mg/dL (7-27)
GlOB: 5.6 g/dL (2.5-4.5)
TP: 8.2 g/dL (5.2-8.2)
TBIL: 9.5 mg/dL (0.0-0.9)

What is your tentative diagnosis?

What are your differentials?

What further tests you will do to confirm your diagnosis?

How will you treat and manage this case?

Solution to this case will be posted on 12/12/08

Solution for case 12/1/08

2008-12-05T00:00:00.005-05:00

Click here to see this case

Tentative diagnosis: Transmissible Venereal Tumor (TVT).

Differentials: Canine Herpesvirus, Lymphoma, or preputial blockage.

Further diagnostic tests: Fine needle aspirate to look at the cells of the lesion.

After the aspirate was stained with Wright’s stain, large round cells with central nucleoli were seen. TVT is related to other round cell tumors such as a lymphoma or a mast cell tumor. The round cell tumors appear microscopically as single cells, usually described as “discrete” because they are separate from each other.

Click this link for cytology of TVT and other Canine Round Cell tumors.

Other diagnostic tests: Impression smear or biopsy of the lesion for histopathology

Transmissible Venereal Tumor is contracted through physical contact between animals. They are found mostly on genitals, but also reported on nose, mouth, and anus. The tumor presents as a cauliflower-like, pedunculated mass that is nodular in appearance, can often be ulcerated, inflamed and bleed easily. Sometimes misdiagnosed as hematuria due to bloody discharge, which is why it is important to look closely at genitals and take appropriate samples. TVT can initially grow quickly, but metastasis is uncommon (5%). A complication of this tumor is urinary retention. The urethra can be blocked and cause urine to retained in the body, which could lead to an acidosis.

On the top of our differential diagnosis list is Transmissible Venereal Tumor, but after that it was possible for this lesion to be Canine Herpesvirus, Lymphoma, or preputial blockage.

Canine Herpesvirus could be ruled out because this is typically a disease of puppies less than 2-3 weeks old. This virus is released in penile or vaginal secretions and could present as a raised sore on the penis, but this is very rare. If it were, the most important thing to do immediately is to keep the pup warm as a low body temperature allows the virus to spread throughout the body.

Lymphoma can be seen in extragenital lesions, but it could be ruled out after doing a fine needle aspirate of the lesion and due to the clinical signs. A lymphoma or lymphosarcoma would show with enlarged lymph nodes and if a CBC would show a leukocytosis, along with the necrosis of the tumor inducing a neutrophilia. Clinical signs would have been much more severe, affecting the spleen, liver or CNS.

Preputial blockage is a problem with intact males. This is an accumulation of urine, secretions and debris in the prepuce which leads to infection and necrosis. This could be ruled out because the lesion was on the penis and even if this infections spread to the penis, then necrosis would look black instead of fleshy and cauliflower-like.

Treatment:

Vincristine sulfate was given weekly, while alternating the left and right cephalic veins. After about 6 injections the lesions have been greatly reduced and once the tumor was resolved, one more injection was given.

Vincristine is a mitotic inhibitor originally derived from the Vinca rosea plant. It has an antineoplastic effect by disrupting and disassembling the microtubules in the cells. It was given intravenously with a catheter in the left cephalic vein. It was important that Vincristine is not administered perivascularly because it causes tissue sloughing. It would cause such severe vesication and ulceration it could be so deep that tendons and bone would be exposed. The other side effects of Vincristine are neurological.

Doxorubicin is another chemotherapy drug used in the treatment of TVT. This is an antineoplastic antibiotic, which destroys DNA. Along with the similar side effect of myelosuppression, this drug can also cause perivascular sloughing as well as phlebitis and urticaria around injection site. But the vesication caused by vincristine will eventually heal with proper bandaging while the damage done with Doxorubicin is beyond repair. Doxorubicin is cardio-toxic too.

Surgery is not recommended for transmissible venereal tumors mostly due to the anatomic locations of the tumors. It would be difficult to excise the lesions and ensure that the entire mass was removed. Likelihood of recurrence is also more after surgery.

Case for week 12/1/08

2008-12-01T00:00:00.007-05:00

Presentation:

One year old male intact Beagle/Pothound Mix was presented at AcaseAweek clinic for dripping of blood in urine. Eating and drinking of the patient was reported normal.

Physical Exam:

Weight: 14.1 kg
Temperature: 101.1°F
Heart rate: 108 bpm
Respiratory rate: 60 rpm
Mucous membranes were pink and moist and CRT was less than 2 seconds.
Popliteal lymph nodes were enlarged.
A growth on the penis was observed as shown in the following picture:

What is your tentative diagnosis? Give differentials for your diagnosis.

What further tests you will perform to confirm your diagnosis?

How will you treat and manage this case?

Solution to this case will be posted on 12/5/08

Solution for case 11/24/08

2008-11-28T00:00:00.011-05:00

Click here to see this case

Tentative diagnosis: Azotemia due to chronic renal failure (CRF).

Further diagnostic tests:

* Abdominal radiography/ultrasound to demonstrate decreased size of kidneys.

* Urine creatinine:protein ratio.

* Renal biopsy (not commonly performed).

* Blood pressure to demonstrate hypertension.

Isosthenuria is a common finding in chronic renal failure when two thirds of the functioning nephrons are lost.

Azotemia is seen when at least three fourths of the functioning nephrons are lost. Azotemia presents with increased BUN, creatinine, GI, and neurological clinical signs. This patient’s presentation would suggest that she has lost at least three fourths of her functioning nephrons.

Predisposing factors for CRF are age, chronic obstruction, infection, heart failure, and tubular disease. A urine sample taken from this patient, via a cystocentesis, ruled out bacterial infection. Patient’s heart sounded normal on auscultation. The renal failure was attributed to her age.

Management of chronic renal failure is a multifactor process. Most importantly hydration and electrolytes must be maintained with in normal limits. An appropriate renal diet will be low in protein, phosphorous, and sodium. Some other factors which must be addressed in the management of chronic renal failure include anemia, proteinuria, and gastrointestinal processes.

Anemia is due to decreased production of erythropoietin by renal peritubular cells. The anemia could also be from blood loss via GI ulcers, or iatrogenic from blood draws. The anemia is non-regenerative normochromic normocytic.

Treatment of anemia with erythropoietin (EPO) is indicated when the PCV falls below 18% and the patient is showing clinical signs of anemia/hypoxia. Caution must be used with EPO since it is of human origin. Dogs can produce antibodies against it. In severe anemia requiring immediate relief of clinical signs a blood transfusion can be done.

Proteinurea is seen because glomeruli have been damaged enough to allow loss of protein and anti-thrombin III. This decreases oncotic pressure, leading to edema. The loss of anti-thrombin III causes coagulation issues. Many of these patients have pulmonary thromboembolism as a complication.

These patients can be treated with angiotensin converting enzyme inhibitors which decreases the pressure in the glomeruli by dilating the efferent renal artery. This decrease in pressure helps prevent loss of proteins into the urine. Canine patients with CRF and proteinuria tend to have a decreased survival.

GI ulcers and nausea and vomiting are the common clinical signs seen. Uremic toxins activate the chemoreceptor trigger zone which leads to the nausea and vomiting. These uremic toxins also increase gastrin production which increases hydrochloric acid production in the stomach, leading to GI ulcers.

These complications are treated by decreasing the uremic toxins via hydration; protecting the stomach by decreasing acid production, and controlling the nausea and vomiting by blocking the chemoreceptor trigger zone. Acid production can be decreased using histamine blockers or proton pump inhibitors. Sucralfate can be used to protect/coat ulcers. The nausea can be controlled with medication targeted at dopamine antagonism, serotonin, or neurokinin.

Treatment:

Case for week 11/24/08

2008-11-24T00:00:00.006-05:00

Presentation:

Physical exam:

Weight: 34.8 kg
Temperature: 100.7
Pulse: 136
Respiration rate: 28
Mucus membranes: pale
Capillary refill time: > 2 seconds.
Dehydration: ~5%
Abdomen was tender upon palpation.

Lab tests: (Reference Values)

BUN: 112 mg/dl
Creatinine: >13.6 mg/dl
Phosphorous: 16.1
PCV: 25%
USG: 1.011
TP: 6.4 mg/dl
Albumin: 2.7 mg/dl
Non-regenerative anemia was also noted.

What is your tentative diagnosis?

Give differentials for your diagnosis.

What further diagnostic test(s) will be performed to confirm the tentative diagnosis?

How will you treat and manage this case?

Solution for this case will be posted on 11/28/08.

Solution for case 11/17/08

2008-11-21T00:00:00.007-05:00

Click here to see the Case before Solution

Diagnosis:

A 4Dx snap test was performed and was positive for Anaplasma. Normal clinical signs seen with Anaplasma are fever, lymphadenopathy, splenomegaly, weight loss with a history of tick infestation. Lab finding are normally thrombocytopenia, non-regenerative anemia and decrease in white blood cells, hyperproteinemia, hyperglobulinemia, hypoalbuminemia, and increase ALT. Lymphadenopathy and polyarthritis is sometimes seen and petechial hemorrhages or epistaxis due to the thrombocytopenia.

The snap 4DX test identifies both IgM (acute exposure) and IgG (chronic exposure) antibody responses to Anaplasma platys (previously known as Ehrlichia platys) and it infects the platelets leading to thrombocytopenia.

Dogs become infected with Anaplasma spp. when a feeding tick inoculates the organisms. The rickettsia enters the granulocytes, platelets, or macrophages, where it survives and multiplies, and spreads throughout the body. Anaplasma is maintained in a tick vector/vertebrate reservoir host system.

Other diagnostic tests:

Urinanalysis, bone marrow or lymph node biopsy, abdominal radiographs. We can also go for blood smear stained with Giemsa stain. PCR has also been developed for this condition.

Differentials:

Rocky mountain spotted fever, multiple myeloma, chronic lymphocytic leukemia, lymphoma, ehrlichia and immune mediated thrombocytopenia. But, since this patient was positive for Anaplasma on the 4Dx snap test, the differentials can be ruled out.

Treatment:

Anaplasma species infections in dogs usually respond to treatment with doxycycline, a treatment regimen of 10mg/kg for 28 days is currently recommended. This patient was admitted to the clinic and IV LRS fluids were given at 180 ml/hr. He was also given doxycycline at 200 mg PO BID for 28 days. This will help clear the infection, but some side effects you must watch out for are nausea, diarrhea, vomiting, upset stomach, loss of appetite, dysphagia, and a possible hypersensitivity to the drug.

Protective immunity does not develop and re-infection may occur following treatment, which would require additional courses of therapy. Vaccines are not available to prevent infections. Therefore, control and prevention of ticks is the key. Brown dog ticks transmit this infection.

Click here to see image of Anaplasma morula in a Neutrophil and diagnostics.

Click here for a case report of Anaplasma in young dog.

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Case for week 11/17/08

2008-11-17T00:00:00.003-05:00

Presentation:

A 5 year old castrated male Rottweiler Labrador mix canine was presented at AcaseAweek Clinic for lethargy and inappetence for the past 4 days. He was still drinking water, and urinating normally. The diet consists of adult dry food, Alpo, of which he is eating less of. He has also lost a lot of weight recently. Vaccinations were giving 12 days ago, and the dog is currently on ivermectin.

Physical Exam:

The patient weighed 20 kg (44 lbs) on physical exam, he was lethargic. His temperature was 103.2, pulse rate was 100 and respiration rate was 40. Mucus membranes were pink, and CRT was less than 2 seconds. On physical exam there were enlarged pre-scapular and popliteal lymph nodes. All other systems were within normal limits.

CBC and Blood Chemistry:

On general blood chemistry, all the values fell within normal limits except for ALT which was slightly increased, 166 (10-100). The complete blood count revealed a hematocrit of 28.1 (37.0 – 55.0), hemoglobin of 10.2 (12.0 – 18.0), granulocytes of 3.1 (3.3 – 12.0), neutrophils of 1 (2.8 – 10.5), eosinophils of 2.1 (0.5 - 1.5) and platelets of 36 (175 – 500).

What is your tentative diagnosis?

Give differentials for your diagnosis.

What further diagnostic test(s) will be performed to confirm the tentative diagnosis?

How will you treat and manage this case?

Solution to this case will be posted on Nov. 21, 2008.

Solution for case 11/10/08

2008-11-14T00:00:00.008-05:00

Click here to see the Case before Solution

Problem List:
Hemoperitoneum
Cardiac arrhythmia and murmur
Poor peripheral perfusion
Mild anemia with marked regeneration
Moderate leukocytosis due to moderate neutrophilia
Mild lymphopenia
Mild thrombocytopenia
Mild↑ALKP, ALT
Mild↑amylase
Mild↑total bilirubin
Marked↑BUN and creatinine
Marked↑phosphate
Isosthenuria (single reading)
Moderate hematuria and bilirubinuria
Mild proteinuria
Anorexia, depression, lethargy
Vomiting
Marked weight loss and muscle atrophy

Primary problems on this patient are hemoperitoneum and acute renal failure.

Differentials for hemoperitoneum
Hemangiosarcoma (spleen/liver)
Coagulopathy (rodenticide)
Abdominal trauma

Differentials for acute renal failure
Ischemia due to hypovolemia, hypotension, shock or DIC
Nephrotoxicity (exogenous or endogenous toxins)
Immune mediated glomerulonephritis
Infectious (e.g. Leptospirosis, pyelonephritis)

Follow these two links for more information about the hemangiosarcomas:

http://www.vet.uga.edu/VPP/clerk/frankhauser/index.php

http://vetpath.wordpress.com/2008/08/12/splenic-hemangisarcoma-in-a-cat/

http://journals.tubitak.gov.tr/veterinary/issues/vet-98-22-5/vet-22-5-13-97199.pdf

https://www.vetconnect.com.au/5min/data/06460647.htm

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Case for week 11/10/08

2008-11-10T00:00:00.006-05:00

A 13 year old, female spayed, mixed breed dog was presented to AcaseAweek Clinic with history of collapse, depression, lethargy and vomiting 3 times the night before presentation. The patient had been anorexic for the past 2 days and appeared healthy previously. The patient lives mostly inside and her owner reported no possibility of accidental ingestion of foreign body or chemicals. Her vaccination status is current and she is on heartworm preventative. She was treated for Ehrlichiosis with doxycycline two months back.

Physical Exam:
Remarkable weight loss and muscle atrophy.
T: 98
P: 88
R: 44
MM: pale pink
CRT> 2 sec

Cardiovascular: murmur, cardiac arrhythmia, pulse deficit.
Respiratory: lungs sound clear
Abdomen: distended, positive succession, moderately painful

CBC/Cytology:
PCV: 23% [37-55]
WBC: 28.9 x103/μL [6-16.9]
Mature Neutrophils: 26.3 x103/μL [3.3-12]
Band Neutrophils: 0.6 x103/μL
Lymphocytes: 0.3 x103/μL
NRBC: 0.9 x103/μL
Smear: Platelets: 1-4/hpf
RBC morph: marked polychromasia, moderate anisocytosis

Biochemistry:
ALKP: 267 U/L [23-212]
ALT: 164 U/L [10-100]
AMYL: 2490 U/L [500-1500]
BUN: 130 mg/dL [7-27]
CREA: 6.1 mg/dL [0.5-1.8]
PHOS: >16.1 mg/dL [2.5-6.8]
TBIL: 1.4 mg/dL [0-0.9]

Urinalysis:
Bilirubin: ++
SG: 1.013
Blood: +++
pH: 5.0
Protein: +

Abdominocentesis:
10 mL fluid was withdrawn.
Abdominal Fluid Analysis/Cytology:
Color: red
Turbidity: 3+
Protein: 7.2 g/dL
PCV: 23%
Smear: many RBCs, neutrophils and macrophages, moderate lymphocytes, almost no platelets seen, few reactive mesothelial cells.

What will be your tentative and differential diagnosis?
What further diagnostic test(s) you will perform to confirm your diagnosis?
What will be your treatment plan(s)?

Solution to this case will be posted on 11/14/08.

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Soluton for case 11/03/08

2008-11-07T00:00:00.010-05:00

Click here to see the Case before Solution

Diagnosis: Tentative diagnosis is hyperadrenocorticism (cushing disease) based on the typical presenting signs. Click here to see image of the case from merck vet manual site.

DDx: Hypothyroidism, diabetes mellitus, renal diseases and other causes of PU/PD.

Diagnostic tests:

Low Dose Dexamethasone Suppression Test (LDDS):

Basal cortisol: 5.1 µg/dL

4-hour post test: 2.2 µg/dL

8-hour post test: 6.5 µg/dL [<1.0>

These values indicate the hyperadrenocorticism, but to differentiate the adrenal tumor from pituitary dependent hyperadrenocorticism (PDH) we need to perform HDDS test.

High Dose Dexamethasone Suppression Test (HDDS):

Basal cortisol: 4.8 µg/dL

8-hours post test: 0.8 µg/dL [<1.0>

(The ACTH stimulation test is a screening test for diagnosis of hyperadrenocorticism, but was not done in this case.)

Definitive diagnosis: Pituitary dependent hypheradrenocorticism.

Treatment:

Mitotane is a commonly used drug in hyperadrenocorticism. Ketoconazole can be used in dogs which are unable to tolerate mitotane at the required dose.

This patient was started on 60 mg of Trilostane (Vetoryl®) once daily and his status will be monitored with an ACTH stimulation test in 1-2 weeks time. If he has still not achieved a hypoadrenal response at this time or has achieved a response but is still exhibiting clinical signs, we can consider increasing his dose or increasing to a BID regime. After achieving therapeutic stability, the patient should have an ACTH stimulation test every 3-4 months to monitor cortisol response to therapy.

Trilostane tends to be better tolerated by dogs. Trilostane is a competitive inhibitor of 3-β-hydroxysteroid dehydrogenase. This enzyme mediates the conversion of pregnenolone to progesterone in the adrenal gland, with the net effect being inhibition of cortisol production.

With PDH treatment, it is important to achieve a hypoadrenal response but avoid the complete adrenal suppression to a point that glucocorticoids and mineralocorticoids are deficient. Specifically, mineralocorticoid deficieny and hypoaldosteronism have the deleterious effects of cardiac disturbances (due to hyperkalemia and hyponatremia), hypovolemia and hypotension.

See detailed information about the Cushing Disease

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Case for week 11/03/08

2008-11-03T00:00:00.007-05:00

A 9-year old neutured male Wirehaired Dachsund was presented to AcaseAweek Clinic with history of lethargy, generalized bilateral symmetrical alopecia of increasing severity, potbellied appearance and complaint of polyuria/polydipsia for one month duration. The patient is current on vaccinations, heartworm preventative, de-worming, and flea and tick control.

Physical Exam:

T: 102.8

P: 100

R: 32

MM: pink/moist

CRT <2

Bilateral symmetrical alopecia, rat-tail, comedones over ventrum, bruising on left lateral thorax. Potbellied abdomen, weakness, muscle wasting (esp. semitendinous, semimembranous muscles).

CBC and Biochemistry: all values within reference range

Urinalysis:

Color : pale yellow

pH : 8.0

SG (refractometer): 1.015, SG (dipstick): 1.010 [1.015-1.060]

Protein (dipstick): 2 + (100-300 mg/dL) [negative-trace]

Blood (Dip stick): Moderate

Sediment exam: small number of cocci

What will be your tentative and differential diagnosis?

What further diagnostic test(s) you will perform to confirm your diagnosis?

What will be your treatment plan(s)?

Post your answers in the comments section of this site.

Solution for this case will be posted on 11/07/08

Anouncement !!!

2008-11-01T00:00:00.000-04:00

Dear readers,

We are going to start a new website named A Case A Week. In this series we will be posting a veterinary case every Monday and will ask readers to comment on the case about the diagnosis and line of treatment, or in general how they will follow the case. On the Friday of the same week will post our own follow-up about the case and will again ask the users to comment on this. Purpose of preparing this site is to share our experiences and generate good discussion for the benefit of veterinary community in general.
Users can also get the cases in their email, for this there is subscribe box on the right hand side of the website. You can also make the cases to appear on websites like i-google, my-yahoo, thefreedictionary etc. automatically by subscribing to get the cases in reader of your choice.

Best Wishes

Dr Saul and Dr Banga