Inconsistent pyrexia of unknown origin

RE: Inconsistent pyrexia of unknown origin

Anthony Todd — Fri, 09 Oct 2015 17:59:32 GMT

[quote user="Anthony Todd"]Let me know what happens[/quote]

Should have been a steroid response by now?

RE: Inconsistent pyrexia of unknown origin

Anthony Todd — Wed, 07 Oct 2015 17:26:43 GMT

[quote user="J Monz"]Any input greatly appreciated because I'm stumped!![/quote]

You'd expect me to suggest a high dose of steroid, so here it is.

No point, IMHO, in starting off with a low dose 'cos it won't be definite enough.

At least I can almost guarantee the dog will feel much better, certainly the pruritus, which may be separate anyway, in 6 hours or less, which used to be the primary aim. Warn of polyuria is probably a good idea, so give it in the morning.

Let me know what happens, privately if you like; public ridicule makes me cry.

RE: Inconsistent pyrexia of unknown origin

J Monz — Tue, 06 Oct 2015 19:30:15 GMT

Hi all,

Thank you for all your replies and input on this case.

This case was back in to me this evening, presenting now with different symptoms - quite extreme pruritis, all over his body, sneezing. Looks like allergy so pxd piriton and metacam for discomfort. Non steroidal in case something up with the immune by any odd chance! But am still inexperienced so perhaps being over cautious.

Scooting, chewing paws and whipping head around to chew vigourously on his tail, running away from pain in tail region. When he whips round to chew he is weak on his hindlimbs.

Hopping test - didn't hop with the hindlimbs, just stayed in same place and leaned.

Knuckling over test: sluggish on both hindlimbs

Deep pain perception present.

Spinal pain seems to have eased but much weaker when prompted to move rather than reacting in pain. Still bit tender in thoracolumbar region.

Peripheral lnn enlargement still evident (all of them, but in particular submandib and prescap).

Quick reminder of his case to date for those that are able to tackle another bizarre case at the end of a long day!

(I referred this case on, but he is now back with me after NAD).

4 year old male neutered Labrador that presented for further investigation following an episode during which the dog was off back legs and urinated on himself. The episode occurred 4 days before presentation and lasted 10 seconds. The dog was conscious during the episode and appeared normal before and after. Elevated temperature (40.1°C) was found at your practice following this episode. One episode of haematochezia was observed the day of the episode although it was not persistent. Additionally, frequent ear twitching was reported 4 days before presentation. Beside this, the dog was reported to have good appetite and to be in good form.

Physical examination

The dog was bright, alert and responsive. Physical examination revealed elevated temperature (40°C) as well as mildly enlarged submandibular, prescapular and popliteal lymph nodes. Abdominal palpation did not reveal any discomfort or abnormal structure. Auscultation was unremarkable.

Neurological examination revealed a normal mentation, gait and posture. Moderate proprioceptive deficits were present on the right pelvic limb. Cranial nerve examination did not reveal any abnormality. Mild thoracolumbar and lumbar pain were present.

Investigation

Investigation included haematology, biochemistry, urinalysis, urine culture, thoracic imaging, and abdominal ultrasonography:

- Haematology was unremarkable
- Biochemistry revealed a low urea concentration (1.6 mmol/L ; ref: 3.6 – 8.6)
- Urinalysis revealed a specific gravity of 1.023. Notably, no evidence of inflammation was present
- Urine culture did not reveal any growth
- Thoracic imaging revealed a diffuse, mild interstitial pattern (possibly exacerbated by expiration)
- Abdominal ultrasonography was unremarkable

Fine needle aspirates of peripheral lymph nodes were performed. The right popliteal lymph node and both prescapular lymph nodes were cytologically benign.
As spinal pain and elevated temperature were present, radiography was performed in order to investigate the presence of discospondylitis. No abnormality could be seen. However, discospondylitis can be missed on radiography during the acute stage.
Because the urea concentration was low, a bile acid stimulation test was performed to investigate the presence of liver dysfunction. The bile acid stimulation test was consistent with adequate liver function (post bile acid: 1.4 umol/L ; ref: 0 - 15).

The dog’s temperature decreased shortly after admission and did not increase during hospitalization. This raises concerns that there was ever true fever. Certainly cases of true fever can have fluctuating rectal temperature but are typically dull, anorexic and lethargic during times when elevated rectal temperature is documented. As Bubba does not have this history, we are slow to add true fever to his problem list. Additionally, further investigation of pyrexia of unknown origin would have included joint taps and CSF tap. False negative results can be obtained if these procedures are performed while the dog is not pyrexic. This was discussed with the owners and it was decided to monitor temperature at home if the dog was dull.

The reason Bubba acutely presented to you off his back legs is unclear. The episode reported may be explained by acute spinal pain. In the absence of significant neurological findings (other than mildly delayed proprioceptive deficit in the right hindlimb), it was difficult to encourage an extensive investigation. Main causes of spinal pain associated with proprioceptive deficit include intervertebral disc disease, inflammatory diseases, neoplasia and haemorrhage. Intervertebral disc disease is the most frequent cause of spinal pain and a large proportion of dogs improve with conservative management. This was discussed with the owners and it was decided to start a conservative management, including pain relief and strict rest (during 4 to 6 weeks), was started. The dog was discharged with the following medications:

- Gabapentin 300 mg: Give 1 tablet twice daily for five weeks (9.95 mg/kg SID)
- Tramadol 50 mg: Give 2 tablets twice daily for five weeks (3.3 mg/kg BID)

Should the dog be dull and have an elevated temperature (> 39.5 °C) at home, the owners were asked to contact me. Further investigation may be considered at that point. Should the dog deteriorates neurologically (eg, more pronounced paresis, paralysis) during conservative management, advanced imaging +/- surgery should be considered.

At the end of the conservative management period, an appointment should be planned at your practice. Assessement of the gait, proprioception and spinal pain should be performed. Should improvement be documented, the owners should be made aware than 1/3 of cases will relapse following the end of the conservative management period.
Should absence of improvement or deterioration occur, the dog should be referred to the surgery department.

Any input greatly appreciated because I'm stumped!!

Thanks

Justine

RE: Inconsistent pyrexia of unknown origin

Robin Grimmer — Mon, 31 Aug 2015 00:13:01 GMT

You are right Virginia in that discospondylitis needs a long course of antibiotics:

If clinical improvement is seen within two weeks of starting antibiotic therapy – such as resolution of fever, improved appetite or reduction of apparent spinal pain – medical treatment should be continued for at least six weeks, and vertebral radiographs should be performed every four to six weeks to monitor progression/regression of a lesion, and to monitor for development of new lesions.

RE: Inconsistent pyrexia of unknown origin

Anthony Todd — Sun, 30 Aug 2015 23:29:30 GMT

[quote user="Virginia Campbell"] I might give it a bit longer than the usual 48hours though,[/quote]

Yeah, fair do's, as usual was a bit exaggerating but I'm glad the point was taken.

RE: Inconsistent pyrexia of unknown origin

Virginia Campbell — Sun, 30 Aug 2015 21:14:41 GMT

Ok fair point. I might give it a bit longer than the usual 48hours though, especially as some of the signs are episodic and some- the lymphadenopathy for example- would likely take longer to noticeably improve.

RE: Inconsistent pyrexia of unknown origin

Anthony Todd — Sun, 30 Aug 2015 20:34:14 GMT

[quote user="Virginia Campbell"] long antibiotic trial[/quote]

Why "long"? I reckon if you have had no response in a maximum of 48 hours, not a cure mind you, just a positive response then you won't get one after 48 days.....

When do you reassess? Does the owner only come back in 6-8 weeks or what? could be lots of wasted money and tablets....

No steroids concurrently either, unless you are very sure, cos they'll give you an "improvement" in virtually any condition you like to meet.

Add your steroids if a nice response which will help recovery, appetiite etc.

RE: Inconsistent pyrexia of unknown origin

Martin Atkinson — Fri, 28 Aug 2015 15:55:56 GMT

[quote user="GrooveJet"]

Would the Avacta Lymphoma blood test be of any use in this case?

[/quote]I had suggested lymphoma biomarker tests as a possibility but TBH I lost faith in Avacta. I embraced this bio-technology as the future when it first came out something like 10 years ago although there were some teething problems but of the last 6 tests I sent to them a couple of years ago IIRC 3 were false positives, 2 were false negatives and one was never confirmed one way or another as the case was lost to follow up. In all the time I've used their test I think I only had one that I can recall which was confirmed on biopsy or PM examination. I am prepared to accept it cannot be 100% but not that I was so unlucky I got all the dodgy ones. A near zero specificity isn't a lot of use. Maybe it has improved since but I think someone else offers a similar test now.

RE: Inconsistent pyrexia of unknown origin

Miriam Lodewyks — Fri, 28 Aug 2015 12:49:34 GMT

Would the Avacta Lymphoma blood test be of any use in this case?

RE: Inconsistent pyrexia of unknown origin

Virginia Campbell — Thu, 27 Aug 2015 22:54:50 GMT

Are you absolutely sure it's lumbosacral endplates were super perfect on Xray? If I see spinal pain and pyrexia they go on amox-clav forthwith and stay on it for 6-8weeks. Have a grope of its prostate too. You can excise a popliteal or prescap l.n. but be prepared for lab to say, dunno we want to do immunohistochemistry which would add to cost. Presumably if money limited then no chemo anyway if had lymphoma, but I'd definitely want long antibiotic trial first before I'd reach for pred if you are stuck with empiricial tx with no more diagnostics, in case you have infection wedged somewhere ...disks, kidneys (negative culture doesn't rule out), prostate. Zebra case would be the likes of a grass awn that has found its way to somewhere like sublumbar muscles. I'd get Os to learn how to take temp and use paracetamol 10mg/kg for pyrexia as appropriate.

RE: Inconsistent pyrexia of unknown origin

Martin Atkinson — Thu, 27 Aug 2015 13:08:55 GMT

[quote user="Justine D"]FNA came back as possibility of lyphoma but could not be comfirmed.[/quote]My primary DD was already lymphoma before I got this far, it's not called the great pretender for no reason. As suggested you really need a lymph node biopsy and although they are unreliable you could consider one of the blood tests for lymphoma biomarkers.

RE: Inconsistent pyrexia of unknown origin

Laura Marshall — Thu, 27 Aug 2015 12:52:52 GMT

I think I'd want to pursue the lymphoma line first, as this has not been excluded and would be very high up my list of differentials.

If FNAs not useful then I'd look towards a biopsy. What was the feed back from the pathologist on the FNAs? I sometimes find that I get better lymph node aspirates without suction.

Laura

RE: Inconsistent pyrexia of unknown origin

Andrew Kent — Thu, 27 Aug 2015 12:48:57 GMT

Hi Justine,

With a lymphadenomegaly and the possibility of lymphoma on cytology I would suggest a biopsy of a lymph node. Either surgical excision of an entire node or a tru-cut biopsy (which could be done under sedation so not that expensive?). This, for me, is a lymphoma until proven otherwise.

The other major differential for this would be certain infectious diseases - in the UK these are relatively uncommon but perhaps there are more in Budapest? I am thinking about things like leishmania, ehrlichia etc.

Andy