Pyrexic dog - advice/help please

RE: Pyrexic dog - advice/help please

Anthony Todd — Thu, 23 Feb 2017 15:42:08 GMT

[sigh] Who do you believe??

Conclusion

Early use of NSAIDs is associated with a reduction in postoperative adverse events following major gastrointestinal surgery.

from:

View issue TOC
Volume 101, Issue 11
October 2014
Pages 1413–1423

RE: Pyrexic dog - advice/help please

Thomas Johnson — Wed, 22 Feb 2017 17:23:30 GMT

[quote user="Anthony Todd"]

Here's another one against NSAIDs and surgery:

Dan Med J. 2012 Mar;59(3):B4420.

Postoperative non-steroidal anti-inflammatory drugs and colorectal anastomotic leakage. NSAIDs and anastomotic leakage.

[/quote]

I think you would find a consensus of opinion that NSAIDs shouldn't be given to any animal having GI surgery.

RE: Pyrexic dog - advice/help please

Anthony Todd — Wed, 22 Feb 2017 16:50:15 GMT

Here's another one against NSAIDs and surgery:

Dan Med J. 2012 Mar;59(3):B4420.

Postoperative non-steroidal anti-inflammatory drugs and colorectal anastomotic leakage. NSAIDs and anastomotic leakage.

and this

Could nonsteroidal antiinflammatory drugs (NSAIDs) enhance the ...

https://www.ncbi.nlm.nih.gov/pubmed/8645850

by DL Stevens - ‎1995 - ‎Cited by 180 - ‎Related articles

Could nonsteroidal antiinflammatory drugs (NSAIDs) enhance the progression of bacterial infections to toxic shock syndrome? ... Though NSAIDs are frequently used to relieve pain or reduce fever, they also attenuate granulocyte functions such as chemotaxis, phagocytosis, and bacterial killing.

[but, to be fair, other references say the opposite....

RE: Pyrexic dog - advice/help please

Anthony Todd — Wed, 22 Feb 2017 16:49:06 GMT

[quote user="Thomas Johnson"]That isn't the conclusion that I would draw. While the paper you referenced obviously shows some risk from NSAIDs with a particular type of bacteria, it's a human paper so several questions follow: Is the risk the same in animals? Are the bacteria mentioned a cause of disease in our patients? And would appropriate antibiotics prevent it from happening?[/quote]

Come on, we extrapolate all sorts of procedures etc. from human medicine when it suits us and, if you do a search there's others, ie contraindications for NSAIDs and steroids in PUOs, UTIs being one example, to say nothing of gloves and gowns when the bugs are different etc. etc.

It sounds to me very likely that either steroids or NSAIDs probably aren't a good idea with a PUO and no one has contested [yet] a shot of a BS AB.... or I suppose the modvet way is to start the complete diagnostic protocol at the initial consult for every undiagnosed PUO?

RE: Pyrexic dog - advice/help please

Anthony Todd — Wed, 22 Feb 2017 09:11:28 GMT

[quote user="Thomas Johnson"]That isn't the conclusion that I would draw.[/quote]

But it's the only evidence we've got, AFAIK, and with informed consent and all that.....

What are the contraindications for the shot/course of BS ABs?

[I think the NSAID current flavour-of-the-month is a spin-off from humans where, 9 times out of 10, the cause is a developing URTI viral infection which must be rare in animals, and just needs "palliative" treatment]

You're right though, I can't really justify steroids in this scenario, and it's probably lazy pre-historic medicine.

Continue the ABs if obvious response; reassess if no change.

RE: Pyrexic dog - advice/help please

Thomas Johnson — Wed, 22 Feb 2017 09:00:18 GMT

[quote user="Anthony Todd"]

[quote user="Thomas Johnson"]My reading of that would be that steroids shouldn't be given to an animal with pyrexia of unknown origin, as if it is a viral infection you may make the it more unwell.[/quote]

True, so we're back to square one with just a BS antibiotic, which, it sounds, is better than either the NSAID or the steroid, and, often, does the trick.

[/quote]

That isn't the conclusion that I would draw. While the paper you referenced obviously shows some risk from NSAIDs with a particular type of bacteria, it's a human paper so several questions follow: Is the risk the same in animals? Are the bacteria mentioned a cause of disease in our patients? And would appropriate antibiotics prevent it from happening?

RE: Pyrexic dog - advice/help please

Anthony Todd — Tue, 21 Feb 2017 18:51:16 GMT

True, so we're back to square one with just a BS antibiotic, which, it sounds, is better than either the NSAID or the steroid, and, often, does the trick.

RE: Pyrexic dog - advice/help please

Thomas Johnson — Tue, 21 Feb 2017 16:34:31 GMT

[quote user="Anthony Todd"] Thus, NSAIDs may contribute to the sudden onset of shock, organ failure, and aggressive infection by inhibiting neutrophil function, augmenting cytokine production, and attenuating the cardinal manifestations of inflammation. [my bold][/quote]

Of course there are risks with NSAIDs, but there are also risks with giving steroids, from the Dexadreson datasheet:

"Corticosteroids may delay wound healing and the immunosuppressant actions may weaken resistance to or exacerbate existing infections. In the presence of bacterial infection, antibacterial drug cover is usually required when steroids are used. In the presence of viral infections, steroids may worsen or hasten the progress of the disease."

http://www.noahcompendium.co.uk/publications/-454557/dexadreson-solution-for-injection

My reading of that would be that steroids shouldn't be given to an animal with pyrexia of unknown origin, as if it is a viral infection you may make the it more unwell.

RE: Pyrexic dog - advice/help please

Cool — Tue, 21 Feb 2017 16:21:55 GMT

[quote user="Rebecca MacMillan"]The thing that has upset me most about this thread is that yet again I've ended up feeling berated and silly about posting. I've had this happen on this forum previously, where I had to stand up for myself and say that I work sole charge (with some locums helping when I'm off), and have no colleagues to just casually ask for a 2nd opinion in passing or over tea break. Instead I rely on email support, speaking with local referral centres or posting on here for some of my more obscure and confusing cases. More often than not I'm just looking for a bit of reassurance. And yes I may have done things differently to you, but there are ways of phrasing things or being supportive and making suggestions to a fellow professional, regardless of experience/age. I can do without the stress and additional aggro of battles on here to be honest, and this thread has pushed me close to quitting the forum. However it is worth mentioning that the main instigator of this has since sent me a private apology after failing to read my initial post properly. But anyway, thanks again for all the useful posts, they have given me some food for thought and as mentioned we will be keeping a close eye on her.[/quote]

Take no notice of the criticism. I know it is not easy to ignore but such abound in our profession sadly. It is only those who are not busy doing something that do not make mistakes. Please dont leave the forum

RE: Pyrexic dog - advice/help please

Anthony Todd — Mon, 20 Feb 2017 11:19:16 GMT

As the subject of the last post I have to say I have never knowingly and certainly not intentionally criticised any post via a personal attack or approach. There's no point, I've never thought of doing it, and it doesn't help.

I still can't understand why contrary advice suggestions or opinions are taken personally particularly when there is absolutely no "personal" angle to the post.

However, as someone who would have found the forum invaluable, when I was bumbling along. on my own, with only a telephone and journals to help I know how "alone" it can feel.

Interesting, though, that there's usually quite a useful spin-off from the most mundane of posts and the downside of the ubiquitous NSAIDs came as a surprise to me, even though I couldn't see the point in effectively masking symptoms when there were drugs that may have treated the cause.

Going back through the thread there was a fair few suggestions from others which were contrary to other advice, and which agreed with my approach so it's not just me.

As Michael Winner famously said "Calm down dears; it's only a forum".

RE: Pyrexic dog - advice/help please

Rebecca MacMillan — Sun, 19 Feb 2017 21:58:22 GMT

Thanks to all who contributed with useful comments and anecdotes. We're certainly keeping an eye on this dog, but thought it was worth giving people an update on the case in case there was interest. I'm usually bad at doing this after I've posted a question initially, so was pleased with myself for actually getting round to doing it! However what I can do without is some of the backlash...

In all honesty on the afternoon I posted I didn't know what else to do to bring this dog's temperature down other than IVFT and keeping her covered on broad spec ABs, so reverted back to the antipyrexic effects of NSAIDs, after sh'd had a couple of days off of them following the lack of response to the initial injection. I was nervous about going down the steroid route because of the pyo red herring and also in case of some other focus of infection that I'd missed, and as some of you have mentioned it may interfere with subsequent tests. As the dog was showing no GI signs and was on IVFT I felt an NSAID was an appropriate risk to take.

On googling pyrexia/fever of unknown origin just now, Merck (the first page that comes up) lists the work up as follows -

History/physical exam

CBC/Biochem

Urine culture

Survey radiographs/advanced imaging

Ultrasound

(it then goes on to mention further tests)

Of which I did all of these tests. The only thing I would have done differently with hindsight is taken some xray views of the cervical region at the same time, especially after some of your stories about migrating foreign body.

They also go on to state 'It is also likely that fever itself has some beneficial effects, particularly in infectious diseases. However, fever can lead to anorexia, lethargy, and dehydration. Thus, animals with FUO may benefit from IV fluid therapy or antipyretic medications. Examples include NSAIDs such as aspirin, carprofen, ketoprofen, and meloxicam in small animals, and flunixin meglumine or phenylbutazone in large animals.'

http://www.merckvetmanual.com/metabolic-disorders/fever-of-unknown-origin/overview-of-fever-of-unknown-origin

As with all cases there will always be a difference of opinion about exact management, especially on forums where none of you have the actual animal and owner in front of you to assess.

The thing that has upset me most about this thread is that yet again I've ended up feeling berated and silly about posting. I've had this happen on this forum previously, where I had to stand up for myself and say that I work sole charge (with some locums helping when I'm off), and have no colleagues to just casually ask for a 2nd opinion in passing or over tea break. Instead I rely on email support, speaking with local referral centres or posting on here for some of my more obscure and confusing cases. More often than not I'm just looking for a bit of reassurance. And yes I may have done things differently to you, but there are ways of phrasing things or being supportive and making suggestions to a fellow professional, regardless of experience/age. I can do without the stress and additional aggro of battles on here to be honest, and this thread has pushed me close to quitting the forum. However it is worth mentioning that the main instigator of this has since sent me a private apology after failing to read my initial post properly. But anyway, thanks again for all the useful posts, they have given me some food for thought and as mentioned we will be keeping a close eye on her.

RE: Pyrexic dog - advice/help please

Elisabeth Knappett — Sun, 19 Feb 2017 18:38:22 GMT

[quote user="Anthony Todd"]

[quote user="Elisabeth Knappett"]I had a very similar case, turned out to be a migrating foreign body,[/quote]

Come on, there are always cases that don't follow the rules and which, on here, become support for an alternative and contradicting solution.

Pretty rare and unusual I would have thought although it would be unusual if there wasn't at least some local pain and swelling.

What do the notes say? Surely the dog had a "sore neck"?

I remember the daily Moan's "vomiting kitten" that had a Yale key in it's stomach, not something you'd see every day....

[/quote]

Of course there are the cases that don't follow the rules and I absolutely wouldn't expect to consider a migrating foreign body for every PUO that comes through the door, but on one such as the OP describes it could certainly be a differential now.

There was mention in the OP that the owners noted coughing/gagging at home, which was the only indication in the case I saw as there was no pain on throat/neck palpation on it's initial presentation, which was 3 days after the stick playing incident (from the notes). It received NSAIDs and a/bs. Which it didn't respond to completely. Hence my mentioning it now.

I agree completely that PUO often are that, UO, but occasionally there are alternative solutions...especially to those that don't respond to medication as expected.

RE: Pyrexic dog - advice/help please

Anthony Todd — Sun, 19 Feb 2017 14:01:21 GMT

[quote user="Emily Rainbow"]You yourself haven't read the original post, this was a case that returned 24hrs later with no improvement. Why bang on about what you would do on initial presentation when this isn't on initial presentation?????[/quote]

Sorry, I apologise profusely to the OP, you're quite right, I should have read it more carefully.

One star deserved!

Er, but further on it came back improved on the ABs which was what put me off the track.......

RE: Pyrexic dog - advice/help please

Anthony Todd — Sun, 19 Feb 2017 13:46:23 GMT

[quote user="Robin Grimmer"]But you're missing the point.[/quote]

I don't think so.

As far as I understood the OP had done the full monty on the initial presentation and anyone, including me who treated an initial presentation of pyrexia and NAD with an AB +- a steroid was cast into outer darkness.

A NSAID was regarded as good practice, although the logic escapes me [and the contraindications appear significant so I hope the client was also warned of those....]

RE: Pyrexic dog - advice/help please

Anthony Todd — Sun, 19 Feb 2017 13:39:05 GMT

[quote user="robloxley"]

[quote user="Anthony Todd"]I cannot see the logic in a NSAID which has been posted[/quote]

Pyrexia; inflammation; anti-inflammatory drug?

[/quote]

Even a reference in my support.... bloody 'ell, hate to get involved in "informed consent" every time I gave it....

Anecdotal reports suggest an association between the use of nonsteroidal antiinflammatory drugs (NSAIDs) and the progression of invasive group A streptococcal infections to shock and multiorgan failure. There is a biochemical rationale that could support this theory. Though NSAIDs are frequently used to relieve pain or reduce fever, they also attenuate granulocyte functions such as chemotaxis, phagocytosis, and bacterial killing. In addition, findings in recent studies involving human volunteers injected with endotoxin suggest that pretreatment with NSAIDs enhances production of tumor necrosis factor, which leads to higher blood levels of this cytokine, probably by preventing feedback inhibition by prostaglandin E2. Thus, NSAIDs may contribute to the sudden onset of shock, organ failure, and aggressive infection by inhibiting neutrophil function, augmenting cytokine production, and attenuating the cardinal manifestations of inflammation. [my bold]

from:

Clin Infect Dis (1995) 21 (4): 977-980.

DOI:

https://doi.org/10.1093/clinids/21.4.977

Published:

01 October 1995

RE: Pyrexic dog - advice/help please

Robin Grimmer — Sun, 19 Feb 2017 13:36:56 GMT

[quote user="Anthony Todd"]

[quote user="Emily Rainbow"]I'm sorry but this attitude really pisses me off.[/quote]

Well me too, particularly when I'm totally misquoted and misunderstood....

What you don't mention is how many cases "given the old-fashioned treatment" do improve, and never need to come back.

[/quote]

Undoubtedly true. But you're missing the point. If someone is posting a PUO case on here, then I think it's fairly safe to assume that it's not one of the cases that would get better with symptomatic treatment. I think it's also safe to assume that a full history and probably several full clinical exams have been done. So it's not very helpful when you say things like have you palpated the abdomen, and in my day would have got better with clam la and bets etc.

RE: Pyrexic dog - advice/help please

Emily Rainbow — Sun, 19 Feb 2017 13:32:56 GMT

[quote user="Anthony Todd"]

What you don't mention is how many cases "given the old-fashioned treatment" do improve, and never need to come back.

Should all of these have had the full monty every time on first presentation? [which was my point?]

[/quote]

You yourself haven't read the original post, this was a case that returned 24hrs later with no improvement. Why bang on about what you would do on initial presentation when this isn't on initial presentation?????

[quote user="Anthony Todd"]

How often does this happen and how often does this "more experienced vet" miss something that needs more than the B12, AB and Bets etc.?

[/quote]

I would average 2-4 cases a week when I worked with them myself, and I'm sure the other assistants had some too. The numbers aren't the problem as I'm not disputing that a lot of cases would 'recover', it was the severity of the cases I was seeing that was more of an issue.

Edit: its left such a lasting impression that if I ever lose my passion for medicine and just take that approach with everything myself I know it's time to leave the profession.

RE: Pyrexic dog - advice/help please

Anthony Todd — Sun, 19 Feb 2017 13:19:25 GMT

[quote user="robloxley"]Pyrexia; inflammation; anti-inflammatory drug?[/quote]

So for an infection, say a dog bite?? Or the quoted wood FB deep in the neck somewhere??

Not too good, I'd say, although the animal might feel better while the infection progressed.

RE: Pyrexic dog - advice/help please

Rob Loxley — Sun, 19 Feb 2017 12:47:59 GMT

[quote user="Anthony Todd"]I cannot see the logic in a NSAID which has been posted[/quote]

Pyrexia; inflammation; anti-inflammatory drug?

RE: Pyrexic dog - advice/help please

Anthony Todd — Sun, 19 Feb 2017 11:57:19 GMT

[quote user="Elisabeth Knappett"]I had a very similar case, turned out to be a migrating foreign body,[/quote]

Come on, there are always cases that don't follow the rules and which, on here, become support for an alternative and contradicting solution.

Pretty rare and unusual I would have thought although it would be unusual if there wasn't at least some local pain and swelling.

What do the notes say? Surely the dog had a "sore neck"?

I remember the daily Moan's "vomiting kitten" that had a Yale key in it's stomach, not something you'd see every day....

RE: Pyrexic dog - advice/help please

Anthony Todd — Sun, 19 Feb 2017 11:50:47 GMT

[quote user="Emily Rainbow"]I'm sorry but this attitude really pisses me off.[/quote]

Well me too, particularly when I'm totally misquoted and misunderstood....

What you don't mention is how many cases "given the old-fashioned treatment" do improve, and never need to come back.

Should all of these have had the full monty every time on first presentation? [which was my point?]

How often does this happen and how often does this "more experienced vet" miss something that needs more than the B12, AB and Bets etc.?

I would highlight the post about the young beagle with meningitis; not everything is dismissed with a shot of whatever.......

BTW I cannot see the logic in a NSAID which has been posted. Fine for humans, where most "un-wells" are early viral infections so NSAIDs would be indicated but, AFAIK, dogs and cats, when vaccinated, don't get many of these so I can't see the logic in NSAIDs.

They aren't actually doing anything therapeutic, so if they don't relieve symptoms the animal is 48 hours further down the disease process.

RE: Pyrexic dog - advice/help please

Elisabeth Knappett — Sat, 18 Feb 2017 12:45:23 GMT

Totally off topic - where is the cut off between dino and mod vet? I'm not sure which category I fall into as I seem to do a mixture of both!

And as a response to OP - I had a very similar case, turned out to be a migrating foreign body, thought to be plant material. Suspected old stick injury which migrated from pharynx to (eventually) axilla, where it was removed. Had 3 courses of ab/nsaids or steroids (depending which vet saw him) over a period of 5 months before it eventually headed. Owners were offered the option for referral for CT to ensure all was removed, but preferred to stay in house and come back if recurred! 3 years on and still waiting!

RE: Pyrexic dog - advice/help please

Joyce Whitehead — Fri, 17 Feb 2017 21:13:29 GMT

And my PUO this week was a steroid responsive meningitis - I just had a feeling there was something odd and he had a little bit of back pain (young beagle) so I referred and it was confirmed. Long acting antibiotic and steroid may have caused a temporary improvement but wouldn't have got the right diagnosis or treatment. And I'm a dinovet. (Hate that expression btw, nearly as badly as mod vet, both seem derogatory to me).

RE: Pyrexic dog - advice/help please

Emily Rainbow — Fri, 17 Feb 2017 19:40:37 GMT

I'm sorry but this attitude really pisses me off.

This dog was given the 'old fashioned' treatment and didn't improve. Therefore the OP looked into it. My last PUO like this last week was an acute leukaemia!! In an otherwise 'well' normal on exam dog.

i had a more experienced vet I worked with and I have to mop up all their cases where the standard Dex, B12 and clamoxyl La hasn't fixed them. It's just bloody frustrating and often interferes with my testing e.g. If it's cushings, has something that need culturing or something surgical.

yes working something up should be within reason, which comes with experience, but don't you dare belittle someone who has worked something up further even if no diagnosis was reached.

RE: Pyrexic dog - advice/help please

Anthony Todd — Fri, 17 Feb 2017 19:03:26 GMT

[quote user="robloxley"]Surely just 'alternative facts'![/quote]

I'll settle for an alternative dinosaureal opinion....