2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

mariette asselbergs — Fri, 07 Feb 2014 12:01:15 GMT

Ha, today got through to a very sensible person at Weybridge and have sent off smear.

Through the post, since it weight less than 50 grams.

The hoops to jump through!

Mariette

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

mariette asselbergs — Thu, 06 Feb 2014 22:55:57 GMT

Update

Today I phoned AHVLA through their central telephone number asking to talk to a vet in the lab in Shrewsbury.

Was connected to the duty vet at AH (not the lab), discussed a bit and he was of the opinion that they would only accept material for culture.

But he gave me the number of the lab in Shrewsbury, which I am mostly familiar with.

Phoned them, but they no longer do ziehl neelsen staining of slides. Only Weybridge does that.

Phoned Weybridge, but no vet was available to talk to me and nobody else could decide if they would accept a smear to stain and examine (I would pay for it if necessary). They would phone me back.

Still waiting......

Don't think our lab responsiveness has improved or maintained its standards since the recent cuts and closures/centralisation. Poor ex State Veterinary Service and staff....

Mariette

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

John Flynn — Thu, 06 Feb 2014 05:57:57 GMT

A little aside:

I had a cat that I removed a rather large, deep cervical mass from and thought might be a mycobacterial LN lesion.

Felt compelled to send for mycobacterial culture at local government lab (no charge), but also sent for histopath and culture to usual lab.

Usual lab results:

Neutrophilic inflammation and overall consistent with botryomycosis (and culture backed up this suspicion).

Turned out that histopath was done routinely as well as mycobacterial culture at government lab:

Eosinophilic inflammation consistent with allergic reaction.

I don't often send histopath to 2 different labs where 2 different experieinced pathologists both have a look at same specimen - good reminder that even basic desciriptions can be wildly different, let alone interpretative points - you honestly wouldn't have thought the 2 reports could have come from same sample.

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

Michael Woodhouse — Thu, 06 Feb 2014 00:16:01 GMT

We had a cat once with massive lymphadenopathy. Took some FNAs and sent to Idexx. Cat deteriorated and died. By weird coincidence the chap collected the bodies late that afternoon. When the samples came back they had acid fast bacteria suspicious of TB. The cats body had already been cremated.

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

mariette asselbergs — Wed, 05 Feb 2014 21:28:35 GMT

Thanks for your understanding Gillian. It is true that the owners went to A&E fearing a heart attack from the shock, so, no, I haven't (yet) added more on their plate. Tomorrow I will contact AHVLA where I know some people personally and discuss it, and they may look at the smear if they share my suspicion. (We took photographs of the pathology). Only if it turns out to be a real suspicion do I want to take it to the further level.

I did post this case initially because we were so puzzled about what was happening with this dog.

I now think it presents the other aspect of thinking what you would do in a situation of suspecting something like TB.

Thanks all for your comments! (so far)

Mariette

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

Gillian Mostyn — Wed, 05 Feb 2014 18:01:53 GMT

A stressful situation- and only you know what you saw in that dog. But in the absence of a more likely/common diagnosis in a 2 year old, TB has to remain a strong possibility.

As far as deciding whether to be on the safe side vs raising alarm, I would probably have erred on the side of caution with this one. But you're the one in the midst of what sounds like a difficult situation so it is difficult for anyone else to call it.

Are the owners aware of the possibility of TB?

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

mariette asselbergs — Wed, 05 Feb 2014 17:50:44 GMT

Well.....about coughing alpacas being a zoonotic risk I have a totally different opinion/fear/and am very careful. I would like to see the evidence for that second email!! AHVLA frown upon and actively discourage post mortems on alpacas on farm because of all the risk.

Mariette

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

Anthony Dennison — Wed, 05 Feb 2014 17:47:09 GMT

Anecdote alert:

At university we had an email that went around to a few people that had been on their public health rotation at the time that there had been a post mortem on an alpaca that had nodular lesions. These lesions turned out to be TB, which caused some concern.

This concern brought forward another email saying not to worry too much, the only way anyone could have contracted TB from the alpaca was if they had lived in close proximity with it for months (ie in a stable) with the animal coughing into your face.

So I should imagine transmission risks will be low, unless there was anyone that was immunocompromised.

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

mariette asselbergs — Wed, 05 Feb 2014 17:41:43 GMT

I wouldn't mind about the costs (AHVLA would take care of that in case they would agree to test).

But 1) I think that this would be an extremely unusual presentation of TB in a dog, specially bovine TB. Although, if this dog grew up as a puppy drinking tb contaminated milk it would not be unthinkable.

However 2) the owners were in such a state of distress that they went to A&E themselves, and they were adamant that they did not want any other investigations. Therefor I did not feel I could go in further and look at lungs etc. We had done chest and abdominal x rays and there were no signs of calcified lesions in the thorax. In the abdominal x ray you could not see anything because of all the fluid. But the lumps we cut did not show calcification. The dog had never had a cough had no skin lesions, and I don't think could be a zoonotic risk to its owner/family unless it would have had open lung lesions.

In such a case, I think you have to be careful to raise extra false alarm. Also I know from experience that older tb lesions often do not show up acid fast red rods with ziehl Neelsen, a negative smear does not really mean much, only a positive one is a definite diagnosis.

I did make one smear and will find a way to get it tested, then we see from there. The dog has been cremated.

I know not an ideal perfect solution. It could have served on the ethical issue in In Practice discussing the balance between un uneasy feeling more than a straight forward diagnosis/ the choice between safety first or false alarm/and a situation of high emotions.

Mariette

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

Gillian Mostyn — Wed, 05 Feb 2014 14:36:06 GMT

I'd say this is one case where I would happily absorb the cost of confirmation - the repercussions of ignoring this, to then have a member of the family fall very ill, don't bear thinking about!

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

Christopher Saul — Wed, 05 Feb 2014 14:17:25 GMT

Yes Gillian is right; TB is a notifiable disease and as such should be reported to DEFRA on suspicion

herein lies the issue: do you really suspect TB? or is it just a niggle?

One suggestion which may help you decide if you really suspect it or not: send a sample to the lab for ZN stain for acid fast organisms ( you may decide to absorb the cost if the owners won't give permission). If the ZN stain is -ve then TB would be highly unlikely and therefore I wouldn't worry. If it is positive then you may put TB higher up your list and raise the alarm

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

Gillian Mostyn — Wed, 05 Feb 2014 13:59:28 GMT

TB is a human health risk. Do you still have the carcase? If TB is a clinical suspicion you should have contacted DEFRA - pathology costs etc are met by them.

http://www.defra.gov.uk/animal-diseases/a-z/bovine-tb/animal-keepers/other-species/

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

mariette asselbergs — Wed, 05 Feb 2014 11:30:16 GMT

We went in and initially drained 1.3 litres of bloody fluid, then opened up wider and found spleen and liver absolutely riddled with yellow lumps, from 2mm to 15 mm diameter. Also a golfball size mass attached to the liver.

The dog was euthanized on the table. The owner did not want to have anything sent off.

I suppose they were tumours (in a 2 year old!!), but I also have a nagging question/suspicion:

The dog came from a farm as a puppy, and when you google "tuberculosis in a dog's liver images", you see just what it looked like.......

Mariette

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

Christopher Saul — Tue, 04 Feb 2014 14:26:46 GMT

Oh, another quick tip- measure the fluid glucose on a glucometer and compare it with that of the circulating venous blood. If the fluid glucose is lower than that of blood then there is increased index suspicion of septic peritonitis

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

Christopher Saul — Tue, 04 Feb 2014 14:23:04 GMT

Hi Mariette

Sorry this reply is going to be a bit less detailed than I would like - I'm on my phone and in a bit of a rush. I'll reply in more depth later

A few first thoughts include septic peritonitis, non-cirrhotic portal hypertension (given the abnormal appearance to the liver) - you can get portal vein hypoplasia/non-cirrhotic portal hypertension presenting at this age - and neoplasia (given the mass)

So the albumin was only very slightly low? If this is correct then the ascites won't be a transudate secondary to the hypoalbuminaemia - you don't normally see this until you get down to 14 or so (dependant upon how quickly it falls). So this leaves exudate ( most likely ddx a septic peritonitis) or modified transudate (most likely ddx portal hypertension or neoplasia)

I would get analysis done on the fluid sample urgently. Send to a reference lab of course but in house you could do Total solids, SpG and microscopy.

If there are degenerate neutophils and intracellular bacteria - then you have a septic peritonitis and the dog will need an ex lap.

if you don't have an immediate reason to ex lap and the dog is cardiovascularly stable, I would get the folioing diagnostics done:-

*cytology and culture of the fluids

*Bile acid stimulation test, PT and APTT.

*cytology of the mass via ultrasound guided FNA

Any chance of referral for ultrasound of the liver/tru cut biopsies??

Hope this helps

Chris

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

Gillian Mostyn — Tue, 04 Feb 2014 14:13:16 GMT

I would expect that if I saw a mass in the abdomen, with signs of peritonitis, I'd be doing radiographs and then probably an ex lap ASAP.

The fact that it had a cruciate repair could be a red herring!

Re: 2 year old spaniel with sudden ascites after cruciate repair 2 weeks earlier

mariette asselbergs — Tue, 04 Feb 2014 13:29:41 GMT

Sorry GPT not GGT 7x increased.