Tricky case

Re: Tricky case

Alicia Gonzalez — Tue, 09 Jul 2013 20:56:59 GMT

If the dog never left the UK is unlikely if not impossible to be leishmania, because the vector, phlebotomus is not present at that latitude, or maybe it would be a first case ... leishmania was a problem a few years ago only on the Mediterranean coast but now is spreading throughout Spain because of climate change.

And what about vaccins? in despite of his age, this case also reminds me distemper, which is one of the differentials of leishmania (crusty nose, ocular / nasal discharge ... and In this case maybe some ataxia if I have well Understood)

Re: Tricky case

Helen Wallace — Mon, 08 Jul 2013 22:12:18 GMT

Dog had never been out the UK and no known contact with one that had- but you're right it looked like leishmania. We had a case in my old job dx by our spanish vet at a glance and that's exactly what this girl's face looked like. I might ask the lab if they could look at the samples they've aleady got.

Re: Tricky case

mariette asselbergs — Mon, 08 Jul 2013 18:00:35 GMT

Even though dog is dead, [quote user="Alicia Gonzalez"]

Hi Hellen,

Ask the O if the dog has been (even for a short period) or come from a southern/mediteranean country. If yes, ask your lab for Leishmania antibodies testing and serum protein electrophorese.

crusting nose, ocular/nasal discharge, weight loose, mild anaemia, renal failure, all these together -and much more- can occur after infection by this blood parasite...

[/quote]

Even though the dog is dead, this is still very relevant since Leishmania is a zoonotic disease.

Mariette

Re: Tricky case

Alicia Gonzalez — Mon, 08 Jul 2013 01:55:14 GMT

Hi Hellen,

Ask the O if the dog has been (even for a short period) or come from a southern/mediteranean country. If yes, ask your lab for Leishmania antibodies testing and serum protein electrophorese.

crusting nose, ocular/nasal discharge, weight loose, mild anaemia, renal failure, all these together -and much more- can occur after infection by this blood parasite...

Re: Tricky case

Helen Wallace — Sun, 07 Jul 2013 21:46:04 GMT

Thanks for all the replies and advice.

Her owners finally decided to euthanase tonight after she continues to get duller. Crea hadn't dropped and urea had risen again on fluids. I still don't know what the underlying issue was. I'll try to post rads tomorrow. Unfortunately biopsies weren't taken at time of scoping but I just can't see any form of nasal disease causing all the other effects.

Glad none of you have come up with anything obvious I should have done.

Re: Tricky case

Andrew Kent — Sun, 07 Jul 2013 19:49:36 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Andrew Kent"]just blind biopsies.[/quote]

I can't agree, really. Like dipping your hand blindly into a sack of corn to see if it's got a few ball bearings in it. You might get a useful result, but the chances are you won't.

But I don't think this is nasal disease anyway.

[/quote] It depends on the disease process but some things have a reasonable chance of a diagnostic sample. It's not ideal but in the absence of other options it can be worth a go. But I agree that primary nasal disease unlikely.

Re: Tricky case

John Flynn — Sun, 07 Jul 2013 19:15:03 GMT

[quote user="Helen Wallace"]

Fungal culture on nasal discharge also -ve. No aspergillous titre.

Atill crusting in nose- bilateral- when removed airflow seems reasonable bilat and I can't get pain on palpation.

Bloods done post endoscopy 1wk ago no azotaemia, not on fluids at that point.

36hr ago Urea 44 Crea 330 SG 1.014 all before fluids. After drip for 24hr urea 21.7 Crea 333. Urine production seems to be close to fluid intake but I don't have indwelling cath to measure exactly.

Lab report neuts 36.74 bands 2.45 Lymp 1.22 Mono 0.41 Eos 0.0 Described as neutrophils showing slight toxicity with a mildly toxic left shift. Unfortunately lab closed at same time the report came through so couldn't speak to the pathologist further.

[/quote]

I'd continue as you are really. If you're missing something, then I don't know what it is.

Fluids maybe at 3 x maintenance hartmanns and keeping rough eye on urine production; broad-specturm antibitoics; equiavelnt of 1mg/kg pred q12 hrs; maybe keep eye on electrolyes also; any nutrition that I can realistically get in got to help also.

Realistically, you're not going to get any biopsy results back before Thursday, and by that stage I'm guessing the dog will either have improved a little on treatment or been euthanased if its still not eating and feeling awful, so I'd discuss it with the owner for tomorrow, but I wouldn't push it. I think FNA of kidney for lymphoma sounds a reasonable minimally-invasive diagnostic that might be an outside chance, but quite easy to check so I might do that.

Re: Tricky case

Evelyn Barbour-Hill — Sun, 07 Jul 2013 15:56:54 GMT

[quote user="Andrew Kent"]just blind biopsies.[/quote]

I can't agree, really. Like dipping your hand blindly into a sack of corn to see if it's got a few ball bearings in it. You might get a useful result, but the chances are you won't.

But I don't think this is nasal disease anyway.

Re: Tricky case

Andrew Kent — Sun, 07 Jul 2013 14:50:42 GMT

[quote user="Helen Wallace"]

Fungal culture on nasal discharge also -ve. No aspergillous titre.

Atill crusting in nose- bilateral- when removed airflow seems reasonable bilat and I can't get pain on palpation.

Bloods done post endoscopy 1wk ago no azotaemia, not on fluids at that point.

36hr ago Urea 44 Crea 330 SG 1.014 all before fluids. After drip for 24hr urea 21.7 Crea 333. Urine production seems to be close to fluid intake but I don't have indwelling cath to measure exactly.

[/quote] What fluid rate are you giving? Ultimately if the creatinine continues to increase despite fluids the prognosis looks pretty poor.

Re: Tricky case

Andrew Kent — Sun, 07 Jul 2013 14:48:16 GMT

I agree with others that excluding significant nasal disease on rhinoscopy is not possible. Were any biopsies taken? Ideally advanced imaging of the nose would be a good idea but failing that just blind biopsies.

were any bloods taken prior to the initial GA?

perhaps something like a nasal/renal lymphoma would be possible so FNA's of the kidneys may be useful if you are finding nothing else. Is the blood pressure normal?

Re: Tricky case

Evelyn Barbour-Hill — Sun, 07 Jul 2013 14:38:01 GMT

It does seem in general picture to look like metabolic disease, organ failure, rather than anything specifically nasal. Kidney failure can present exactly like this in signs and symptoms.

(But I wonder if you could post the radiographs?

And, I am not being rude, but are we positive the endoscopy was conclusive? Nasal endoscopy can be quite difficult especially in a small animal especially when there's discharge fouling everything up.)

Re: Tricky case

Helen Wallace — Sun, 07 Jul 2013 13:52:02 GMT

Fungal culture on nasal discharge also -ve. No aspergillous titre.

Atill crusting in nose- bilateral- when removed airflow seems reasonable bilat and I can't get pain on palpation.

Bloods done post endoscopy 1wk ago no azotaemia, not on fluids at that point.

36hr ago Urea 44 Crea 330 SG 1.014 all before fluids. After drip for 24hr urea 21.7 Crea 333. Urine production seems to be close to fluid intake but I don't have indwelling cath to measure exactly.

Re: Tricky case

An On MRCVS — Sun, 07 Jul 2013 12:23:10 GMT

Whtas the wbc differential?

Re: Tricky case

Helen Wallace — Sun, 07 Jul 2013 12:19:04 GMT

Thanks guys- I can't see a liver abscess on echo. Haven't scanned the heart as no edema on rads but that's a thought.

Urea has come down with dripping- I'd expect to see some clinical improvement if renal failure but maybe not....

Was initially pyrexic, now prone to bouts of hypothermia.

Re: Tricky case

John Flynn — Sun, 07 Jul 2013 12:18:51 GMT

SOunds like a puzzler...

Any airflow down each nostril? Discharge unilateral / bilateral / unclear?

Original bloods tken 4wks ago didn't show azotaemia - correct? Were these taken after GA and if so was patient on high fluid rate during GA?

If there's still a nasal discharge, you could try cytology on it (but if on antibiotics probably won't see any bacteria even if there were some initially) - negative culture makes me think this was sterile pus, so +1 for autoimmune/inflammatory disease. I'm guessing bacterial culture negative, but would there have been a fungal culture also (unlikely to be relevant, but just clarifying)?

Levels for current crea/urea and I assume these were while on intravenous fluids at perhaps 2-3X maintenance? Urine done at same time?

The UPC certainly isn't sky high, but glomerulonephritis could be a differential, so I'd try to check the (fresh) urine sediment for any hints if possible. Also measuring urine output compared to fluid input (even roughly) might be helpful today.

Did the lab report the neutrophilia to be a mature neutrophilia or were there elevated numbers of bands or signs of neutrophil toxicity?

Kidneys looked OK on abdominal scan I assume, and no evidence of enlarged lymph nodes. Any pyrexia at any point?

I think I would have continued fluids aggressively, iv antibiotics, and I would have started steroids (probably equivalent of 1mg/kg pred q12hrs) myself over the weekend also, though with the knowledge that I might screw with further diagnostics potentially and there's no firm diagnosis of auto-immune/inflammatory disease as yet.

biopsies aren't going to give you any information any time soon unfortunately...

Re: Tricky case

Robin Grimmer — Sun, 07 Jul 2013 12:17:26 GMT

I think nasal tumour still possible despite normal rads. CT scan?

Re: Tricky case

Francisco Gomez — Sun, 07 Jul 2013 12:11:11 GMT

Sorry, i missed nasal rads nad

Re: Tricky case

Francisco Gomez — Sun, 07 Jul 2013 12:09:07 GMT

I can think: Abscess somewhere, behind eye? Cant remember now if you get Aspergyllus w those signs... Tumor somewhere? I agree alkp is fairly high, I dont find it too useful enzyme these days, unless accompanied by ALT... What's the temperature?

Re: Tricky case

Michael Woodhouse — Sun, 07 Jul 2013 12:04:02 GMT

Some weird haematogenous spread of the dental infection to heart valves/liver abscess?

If urea and creat now up with USG of 1014 could the anaesthetic have put kidneys under final strain and pushed dog into renal failure?