Shifting lameness in a 15th month old Cocker Spanial

Re: Shifting lameness in a 15th month old Cocker Spanial

Neil Wheadon — Fri, 12 Sep 2014 16:14:10 GMT

Result time

Having thrown the fishing rod away and hired the trawler

Culture negative after 48 hours

ANA -ve

Rheumatoid factor 1:20 - Yippee (well for me anyway)

Talking to TDDS, there are 3 diagnostic signs, this, neutrophilia (have this) and a decreased joint space on X-ray and osteophyte reaction (can anyone really see this on X-Ray, especially where both may be affected so can't compare)

So steroids here we come.

Unless people know better

Neil

Re: Shifting lameness in a 15th month old Cocker Spanial

Neil Wheadon — Fri, 05 Sep 2014 18:09:16 GMT

OK an update

Has been on meloxicam and Amoxycillin/Clavulanate for 5 days

Swelling on the left elbow much reduced and he is better in himself. though still lame

Temperature 102.8 today, but as I'm at a branch has just had a 10 mile car drive (previously 101)

The heart sounds fine and his demeanour is good

Of interest is that before the last 2 attacks the parents had him for the day and went for 2 hour walks rather than the normal 30 minutes (honest owners) the day before the lameness.

I have discussed all the options and was well armed thanks to Andrew and Malcolm and has gone away with 6 weeks of Metacam.

The ANA test and rheumatoid factor are being run today and i'll post these with the haenmatology (which got missed to send to me) when I get them

I've found this really helpful and the client was really pleased today, and i'm checking again in 7 days to assess lameness, temperature and demeanour

Neil

Re: Shifting lameness in a 15th month old Cocker Spanial

Malcolm Ness — Fri, 05 Sep 2014 14:56:17 GMT

[quote user="Michael Woodhouse"]Not forgetting we can rationalise with a human [/quote]

...... now, there's a sweeping statement!!

see homeopathy thread ............

Re: Shifting lameness in a 15th month old Cocker Spanial

Michael Woodhouse — Fri, 05 Sep 2014 14:47:56 GMT

Not forgetting we can rationalise with a human and tell them to take some ibuprofen if it hurts, not the case with the stoic animals under our care.

(I'd rather give analgesia when not absolutely need it, than possibly withhold it when there may be a benefit).

Re: Shifting lameness in a 15th month old Cocker Spanial

Andrew Kent — Fri, 05 Sep 2014 10:59:27 GMT

[quote user="Malcolm Ness"]I always hesitate to draw comparisons with the human caseload, but a very common cause of polyarthropathy in that species is [presumed] post-viral reactive arthritis, which is usually self-limiting and receives nothing more than pain-control. I strongly suspect that the situation is similar in dogs[/quote]

I think that is very likely in the same way humans get other post-viral immune-mediated disease (for example thrombocytopenia) which they monitor rather than treat. I guess we are just not brave enough or don't have enough evidence about these diseases to not treat them!

Re: Shifting lameness in a 15th month old Cocker Spanial

Malcolm Ness — Fri, 05 Sep 2014 10:16:37 GMT

[quote user="Andrew Kent"]Thinking about the difference in caseload the other difference from a medicine point of view is that 90+% of our cases will have already had NSAIDs and failed to respond. I'm sure we never see the many cases that improve.[/quote]

I think that is probably true - there is certainly a difference in the caseload I see arriving through our own primary care practice and that arriving by secondary or tertiary referral.

I always hesitate to draw comparisons with the human caseload, but a very common cause of polyarthropathy in that species is [presumed] post-viral reactive arthritis, which is usually self-limiting and receives nothing more than pain-control. I strongly suspect that the situation is similar in dogs (I have absolutely no evidence other than cases seen) but there seems to be a feeling amongst vets that polyarthropathy is always a bad diagnosis calling for nasty drugs and a poor prognosis. I don't think that that is always the case. It is possible that some cases will improve without definitive diagnosis - a lot of stiff dogs get a "diagnosis" of "arthritis" and given NSAIDs without the kind of detailed clinical/orthopaedic examination that would reveal subtle joint effusions and without synovial cytology so cases could be being missed.

Re: Shifting lameness in a 15th month old Cocker Spanial

Andrew Kent — Fri, 05 Sep 2014 07:38:16 GMT

Thinking about the difference in caseload the other difference from a medicine point of view is that 90+% of our cases will have already had NSAIDs and failed to respond. I'm sure we never see the many cases that improve.

Re: Shifting lameness in a 15th month old Cocker Spanial

Malcolm Ness — Thu, 04 Sep 2014 22:19:17 GMT

[quote user="Andrew Kent"]and wouldn't view these dogs as having a guarded prognosis.[/quote]

I wrote "a more guarded prognosis" Provided there is no evidence of erosive arthropathy most immune mediated polyarthropathy cases I see which don't resolve with time can be sent into apparent permanent remission with early, aggressive immunosupression.

Don't get too trigger-happy with the immunosuppression. Over the years I have seen three cases (all labradors) of polyarthropathy and prednisolone poisoning that despite a diagnosis of immune mediated polyarthritis at St Elsewhere's turned out to be bilateral elbow dysplasia with a more recent bilateral cruciate failure superimposed. They were reportedly pyrexic (?? pain related) and lethargic (they didn't have a good leg to stand on).

Re: Shifting lameness in a 15th month old Cocker Spanial

Andrew Kent — Thu, 04 Sep 2014 16:48:33 GMT

[quote user="Malcolm Ness"]In my experience, the cocker spaniel is the breed at the top of the list for idiopathic inflammatory arthropathy. My approach to the case mentioned here would be a full dx work up (probably without the synovial biopsy at first or second presentation) then try treating with extended (12 weeks or so) NSAID in the first instance. A significant number of these cases will sort themselves out given time and the NSAID probably does little more than making the dog feel better while it sorts itself out. In the face of a worsening clinical picture, I would repeat the dx testing and include biopsy with a view to immunosupression along with a more guarded prognosis.[/quote]

It's an interesting discussion here, and I am sure that there is a difference in the cases that are referred to an internal medicine department compared to an orthopaedic surgeon. But we would tend to reach for immunosuppressive medication quite early on in these cases (but then we love immune-mediated diseases) and wouldn't view these dogs as having a guarded prognosis.

But then most of our dogs will be pyrexic and lethargic as well where as perhaps the dogs that are only lame would be sent to an orthopaedic surgeon? And therefore perhaps the caseload and therefore underlying pathology is slightly different.

Andy

Re: Shifting lameness in a 15th month old Cocker Spanial

Neil Wheadon — Thu, 04 Sep 2014 15:59:09 GMT

[quote user="Malcolm Ness"]Unfortunately, there is something of a diagnostic vacuum around polyarthritis and inflammatory arthropathy in dogs with many/most of these dogs that actually get a full diagnostic work up (clinical exam, rads, joint fluids, serology,synovial biopsy) arriving back at idiopathic inflammatory arthropathy.[/quote]

I feel so much better for those words![quote user="Malcolm Ness"]In my experience, the cocker spaniel is the breed at the top of the list for idiopathic inflammatory arthropathy[/quote]

Getting better

[quote user="Malcolm Ness"]try treating with extended (12 weeks or so) NSAID in the first instance[/quote]

Sounds like a plan

Thankyou

Neil

Re: Shifting lameness in a 15th month old Cocker Spanial

Malcolm Ness — Thu, 04 Sep 2014 08:42:44 GMT

I think Lyme disease as a cause of lameness in dogs is rare. I see a lot of lame dogs and we are in a big tick area and I have yet to see a convincing case of lameness and arthropathy caused by Lyme disease. Certainly, seroconversion is not uncommon and unsurprisingly, some polyarthritic dogs will have seroconverted or might even be seroconverting.

Unfortunately, there is something of a diagnostic vacuum around polyarthritis and inflammatory arthropathy in dogs with many/most of these dogs that actually get a full diagnostic work up (clinical exam, rads, joint fluids, serology,synovial biopsy) arriving back at idiopathic inflammatory arthropathy. Whenever there is that level of diagnostic inaccuracy, there is first a need for further investigation and understanding but in the interim, there is space for candidate diagnoses to fill the void. I think it likely that in the fullness of time Lime disease will be shown to be a real cause of problems in dogs but at a very low incidence.

In my experience, the cocker spaniel is the breed at the top of the list for idiopathic inflammatory arthropathy. My approach to the case mentioned here would be a full dx work up (probably without the synovial biopsy at first or second presentation) then try treating with extended (12 weeks or so) NSAID in the first instance. A significant number of these cases will sort themselves out given time and the NSAID probably does little more than making the dog feel better while it sorts itself out. In the face of a worsening clinical picture, I would repeat the dx testing and include biopsy with a view to immunosupression along with a more guarded prognosis.

Re: Shifting lameness in a 15th month old Cocker Spanial

Andrew Kent — Wed, 03 Sep 2014 21:39:29 GMT

Hi Neil,

If you are taking some blood I like to measure c-reactive protein on these dogs as I find it helpful for monitoring response to therapy and in relapses.

It's always interesting to measure ANA but regardless of the result I would be leaning towards getting some steroids on board at this stage, especially if the dog remains painful. It would also be interesting to know if it has ever been pyrexic?

Andy

Re: Shifting lameness in a 15th month old Cocker Spanial

Bob Russell — Wed, 03 Sep 2014 16:35:30 GMT

Not sure I can answer the question as to how most present. I have found testing less than informative so don't bother. I tend to be quite liberal with antibiotics in the vague PUO's and malaise cases.

I am sure I may miss loads but I do have doubts about how many clinical cases there are in dogs!

Re: Shifting lameness in a 15th month old Cocker Spanial

Neil Wheadon — Wed, 03 Sep 2014 14:57:56 GMT

PCR for Lyme disease negative on joint tap

Awaiting culture and I'll order the ANA and rheumatoid factor tests, as well as run a haematology

Re-seeing Friday, so will listen to the heart

Neil

Re: Shifting lameness in a 15th month old Cocker Spanial

Neil Wheadon — Wed, 03 Sep 2014 11:19:13 GMT

Thanks for the input so far

Lyme's disease is interesting as this practice has loads of ticks in a popular dog walking area. Out of interest Bob, how do yours present?

As Alex Gough said to me a few years ago 'The more you look, the more you find' In the case of Lyme's disease I seem to recall a retrospective serological survey a few years ago on I think 1200 dogs and 12/22? were positive to Lyme's. Doesn't sound like a lot but that's 1% which in my book is quite a lot, considering all these samples weren't for lame dogs.

The lab recommended PCR on the joint fluid so will post the result.

I'm trying this as genuinely unsure which way to go on this and suggestions very much appreciated

Neil

Re: Shifting lameness in a 15th month old Cocker Spanial

james herriot lied — Wed, 03 Sep 2014 10:40:59 GMT

[quote user="Neil Wheadon"]

What would you do?

Neil

[/quote]

Any heart murmur present? Any blood changes consistent with a systemic inflammatory / infectious response?

Unlikely bacterial endocarditis, but a quick scan might be in order.

Re: Shifting lameness in a 15th month old Cocker Spanial

Andrew Kent — Wed, 03 Sep 2014 07:33:54 GMT

[quote user="David Mills"]Lyme disease is almost impossible to diagnose[/quote]

I'm not sure I agree with this. It can certainly be difficult to diagnose and it is certainly true that there is no one diagnostic test that will prove it causes your clinical signs but it is possible. Clearly how far you pursue it depends on the prevalence in your area. There are some useless serology tests but also some that are less so and it is about building a weight of evidence in support of the diagnosis. The final part of the diagnosis is response to therapy which is usually fairly rapid. And we have seen dog's present in exactly this way with borrelia (they really can mimic a polyarthritis even if uncommon).

I would regard a septic arthritis as being less likely in a shifting lameness, with non-degenerate neutrophils and involving multiple legs. I also don't hold out much hope of getting a positive culture even in the presence of infection from joints. Which is why I would use the few days to assess response to doxy.

But this choice definitely depends on the diseases you see in your area. The only problem we have had with interpreting response to doxycycline is a couple of immune-mediated polyarthritis dogs who have shown a partial improvement on this, we suspect due to the immunomodulatory effects rather than anything else.

Re: Shifting lameness in a 15th month old Cocker Spanial

David Mills — Wed, 03 Sep 2014 01:13:32 GMT

Lyme disease is almost impossible to diagnose - see Malcolm Ness's deconstruction of it in another thread about 12m(?) ago. Serology means very little, and is possibly an expensive folly (like most serology, I personally believe). Lyme disease, in the cases I've suspected, rarely causes acute purulent joint effusion to the extent you describe. Part of it depends on the tick prevalence in your area, of course. I would start treating with a broad spectrum antibiotic, something like amoxicillin or amoxiclav, awaiting culture.

Re: Shifting lameness in a 15th month old Cocker Spanial

Andrew Kent — Tue, 02 Sep 2014 22:02:24 GMT

Hi Neil,

Sounds a fun case! I think how hard you look for Lyme disease probably depends on your area - is there much around you? If there is then I might test serology (C6 antibody) as well as PCR (I assume you have done this on the joint fluid?)

Has the dog ever been pyrexic? Any 'interesting' recent history - illness, vaccinations, travel?

I have to say I tend not to run ANA on suspected polyarthritis dogs unless I see evidence of another immune-mediated disease (e.g. thrombocytopenia, anaemia, glomerulonephritis, skin disease etc) and I am not sure it gives me anything extra otherwise!

If I am in a Lyme area then I might start doxycycline whilst I await the PCR results.

Andy

Re: Shifting lameness in a 15th month old Cocker Spanial

Bob Russell — Tue, 02 Sep 2014 17:30:24 GMT

Lyme disease, would be a classic presentation. A big problem I have is that living in the heart of Lyme disease territory I have yet to see a classic presentation!

Not had much luck with Lyme blood tests either.

Treat for it anyway?