Case help please icteric saluki

Re: Case help please icteric saluki

Rajat — Mon, 25 Jun 2012 14:58:59 GMT

Sorry to hear that Nicola

I suppose another bacterial infection/toxin could be responsible. True shame we didn't get an answer but I bet the owner will be vaccinating her dogs all the same in the future.

Re: Case help please icteric saluki

Nicola Lawlor — Thu, 21 Jun 2012 13:47:30 GMT

Very sadly the dog took a turn for the worse and died this morning. His platelets gradually dropped so that he ended up with a transfusion a couple of days ago, but despite this he continued to deteriorate.

The lepto titre came back to us about 2 hours after he died, negative, however it did say on the report that it is possible to still have a negative titre as far as 10 days after the clinical signs start so it doesn't rule lepto out still. Shame we didn't get the answer for sure one way or the other.

Re: Case help please icteric saluki

Rajat — Tue, 19 Jun 2012 18:16:36 GMT

Hi Nicola

I have no personal experience of this but a google and pubmed search did show up some papers. Given the organism affecting the endothelium I suppose any organ involvement is possible, along with the seoncdary inflammatory response affecting organ function secondarily (SIRS)

http://www.ncbi.nlm.nih.gov/pubmed/17488910

http://www.ispub.com/journal/the-internet-journal-of-surgery/volume-20-number-1/leptospirosis-as-a-rare-cause-of-acute-pancreatitis.html

http://www.ncbi.nlm.nih.gov/pubmed/14762628

Hope the dog carries on improving

Best wishes

Raj

Re: Case help please icteric saluki

Nicola Lawlor — Mon, 18 Jun 2012 20:16:52 GMT

Dog is still icteric but stable re this, Urea/Crea/Phos still high but also stablised out. Dog definately has more energy now though still clearly not right yet. Given how poorly it was last week (could hardly even lift his own head Vs now trying to bolt out of the kennel door with occasional energy burst) I am not expecting a miracle improvement overall. The only thing that is throwing me a little now is that the blood glucose has for the past 3 days been high (in the low 20's mmol/l). We stopped any additions in the iv fluids in case this was affecting our readings (and we are getting oral nutrition syringed in anyway now) but the levels have persisted. No signs of ketonuria at present but I did give a low dose of caninsulin today just to keep a bit of a check on the levels.

Can multiorgan failure include pancreas? I guess maybe but if anyone has any experience that would be appreciated.

Re: Case help please icteric saluki

Rajat — Fri, 15 Jun 2012 15:15:59 GMT

Hi Nicola

Certainly does seem more and more consistent with lepto - do you have any evidence for hypotension or poor perfusion/pre renal issues? I think its difficult to answer re how long you'd expect to see increases in renal values. I had a pup 2 weeks ago with lepto- had severe azotemia and severely elevated liver values including bilirubin. Renal values took about 1 week to normalise.

I'm sure you know already but good fluid management, ins and outs measurement, daily /twice daily weighing can help guide fluid therapy (dont wanna sound patronising at all). Doxycycline is useful, I would use IV abs for a few days on this one. My pup also had NO tube feeding, but it was a rescue from a traveller who by the looks of it hadnt fed it for a week, was 7 months old and looked about 2.5 months old based on size!

Oh and phos binders if there is hyperphosphatemia ;)

Best of luck

Raj

Re: Case help please icteric saluki

Nicola Lawlor — Fri, 15 Jun 2012 14:12:19 GMT

Thanks all.

Dog is a little brighter today, liver values have stabilised out and jaundice only very slightly increased on blood readings. The bad news is renal values are now climbing up and Urea and Crea are both elevated now too. This is looking more like a leptospirosis clinically from what I can find out about it. So, we push on and see how things go over time now.

Anyone have any idea how long renal parameters keep climbing for in lepto cases before we might start to see an improvement again (assuming appropriate fluid therapy support etc). ???

Thanks

Re: Case help please icteric saluki

Bob Russell — Fri, 15 Jun 2012 09:16:41 GMT

I tend to use penicillins (Co-amox usually) where liver infection is possible. I will try preds if all else has failed and resources are limited. Both of these may be outdated but have worked for me in the past. Penicillins should be good for Lepto as well.

I don't rule out steroids for pancreatitis either but not first line.

Re: Case help please icteric saluki

Kirsten Simpson — Fri, 15 Jun 2012 08:26:47 GMT

Just as a test for IMHA. Is his PCV normal? 2 drops 0.9% saline and one drop of blood mixed on a slide and gentle move about to check for obvious clotting. Most likely not but cheap and easy test to see. Not always 100% reliable though

Re: Case help please icteric saluki

Nicola Lawlor — Thu, 14 Jun 2012 20:05:58 GMT

[quote user="Kirsten Simpson"]Have you done a slide saline agglutination test?

[/quote]

No - please tell me more...

Re: Case help please icteric saluki

Kirsten Simpson — Thu, 14 Jun 2012 15:08:15 GMT

Have you done a slide saline agglutination test?

Re: Case help please icteric saluki

james herriot lied — Thu, 14 Jun 2012 13:17:53 GMT

[quote user="Lorna McHardy"]

Nurse on call with me got it from the last one I had in, despite barrier nursing... they reckoned she'd breathed it in! I didn't know that was possible.

[/quote]

Infective dose with lepto can be as little as 100 organisms - and yes, it can cross an intact mucous membrane. Aerosol spread may be significant - a farmer up the road sadly died about 25 years ago (pre-PCR etc) from what was probably lepto, picked up from the cows in the parlour. All that wee splashing on concrete at head height.

Lepto diagnosis is fairly rare, but disease is definitely under-diagnosed - mainly because it actually causes a spectrum of disease, from almost undetectable to liver failure. What I would say is that even if diagnostic tests come back apparently negative, don't remove it from the differential list.

I'd also be inclined to get an external PL done - I've never been convinced by the in-house tests - and to scan the back of the liver to look for post-hepatic blockage. If you're uncertain as to whether you're looking at a dilated biliary tree and gall bladder, why not scan a couple of other staff dogs for comparison.

Some good advice given on the parallel thread going at the moment.

Re: Case help please icteric saluki

Lorna McHardy — Thu, 14 Jun 2012 12:24:42 GMT

[quote user="Nicola Lawlor"]

Dog is not vaccinated as staff member believes she had a vaccine damaged dog previously...long story.

[/quote]

<sigh> The power of personal anecdote over a sensible risk assessment. Oh well, I can't claim to be immune to that phenomenon myself. However... I certainly wouldn't have an unvaccinated dog.

Re: Case help please icteric saluki

Nicola Lawlor — Thu, 14 Jun 2012 11:22:24 GMT

oh and stopped cerenia too! Thanks for that one.

Re: Case help please icteric saluki

Nicola Lawlor — Thu, 14 Jun 2012 11:21:39 GMT

Update - abdo radiographs normal. cPL snap test this morning is negative (I was not convinced was read properly last night as amylase was normal and stayed normal this am on bloods.) Biochem shows deteriorating liver ;arameters (ie increased TBIL/ALT and ALP levels) even in last 12 hours though not huge changes. Despite being on IV fluids renal parameters have increased now to high normal ranges so I am a little suspicious these may go above normal with time? Dog is mildly hypothermic now so working to improve that with heat pad/bubble wrap etc.

Dog is not vaccinated as staff member believes she had a vaccine damaged dog previously...long story.

I have started barrier nursing, taken bloods for Lepto MAT with Axiom and started on Ronaxon in addition to other meds. Have taken off the preds. Time.....and will keep you updated.

Thanks for the advice.

Re: Case help please icteric saluki

Hannah Wynne Richards — Thu, 14 Jun 2012 10:34:33 GMT

Lepto til proven otherwise

Wynne

Re: Case help please icteric saluki

Lorna McHardy — Thu, 14 Jun 2012 10:32:11 GMT

I would definitely keep Lepto on the differential list, and make sure everyone treats it as though it were until the bloods get back!... you don't want any more people at risk than necessary. Don't see many, but maybe one every 2-3 years or so does come in. Nurse on call with me got it from the last one I had in, despite barrier nursing... they reckoned she'd breathed it in! I didn't know that was possible. I was ok, but didn't spend as much time with him as she did.

P.S. why isn't it vaccinated? Staff dog... just wondering.

Re: Case help please icteric saluki

Rajat — Thu, 14 Jun 2012 10:12:15 GMT

Hi Nicola

Lepto while rare does occur, what are renal values like?

Pancreatitis could certainly be a possibility, I'd get the snap CPLI sent to idexx for the quantitative analysis done. The abdo scan is definitely a good idea, check the pancreas, liver, gall bladder and bile ducts.

I'd definitely avoid prednisolone, you dont want to be causing any immunosuppression and tough to see how it will be helpful in any of these scenarios (and plenty of ways to see how it would cause harm)

I'd get a blood smear examined, see if you have a regenerative/degenerative left shift.

Blood and protein- these on free catch or cysto? Lepto affects the endothelium so if this is free catch and you also have raised renal values with raised liver values it greatly raises my suspicions for lepto. If so, I'd be tempted get a sterile urine sample for cultrue and start broad spectrum antibiotics. Bloods for lepto take 1 week at least so depending on index of suspicion (access to rats, farms, stagnant water, cases in your area etc) tx should be started before results are back.

I guess I don't worry about cerenia with liver issues unless in liver failure. You can always use metoclopramide if that worries you.

Staff pets are tough! Emotionally and because they seem to have weird stuff happen to them!

Best wishes

Re: Case help please icteric saluki

James Laidlaw — Thu, 14 Jun 2012 09:22:18 GMT

Has he never had vaccines or just out of date with a booster? I think cerenia is contraindicated with liver dz, could metoclop be an option if vomiting persists? I'd be checking x-rays, treating for pancreatitis primarily I guess. No doubt others will chip in. Good luck.