Unusual pyometra

RE: Unusual pyometra

Thomas Johnson — Thu, 26 Oct 2017 08:55:43 GMT

[quote user="Michael Woodhouse"]I think this case is interesting as we have evidence the bitch was in a true oestrous. Clearly something is going on and I think its interesting and worth talking about. It's not a pyo.[/quote]

The report on the fluid is back, but I don't think it adds a huge amount:

CLINICAL SUMMARY
Septic peritonitis due to ruptured pyometra, fluid collected by ultrasound guided abdominocentesis.
SITE
Abdominal effusion
CYTOLOGICAL INTERPRETATION
Septic peritonitis with mixed bacteria
CYTOLOGICAL DESCRIPTION
Slightly bloodstained, watery, moderately cloudy medium brown fluid, with particles.
NCC 24,930 cells/L. RBC: 130,000 cells/L. TP: 64 g/dL.
The slides are of high cellularity with poor preservation. There is abundant smeared chromatin
present. Cells are rarely intact and are most consistent with highly degenerate neutrophils. Within
the background are myriad mixed bacteria, consisting of a minimum 2 types of rods and a potential
population of cocci.
COMMENT
The cytologic profile is compatible with the clinical history and diagnosis provided. There are a
minimum of two types of rods observed and occasionally the impression of a population of cocci, though these latter may represent fragments of rods. Culture is pending and will be reported separately.

Aerobic Culture - Profuse growth of Escherichia coli. Sensitive to all the antibiotics tested.

Anaerobic Culture - Profuse growth mixed anaerobes.

RE: Unusual pyometra

Michael Woodhouse — Sun, 22 Oct 2017 16:48:34 GMT

[quote user="David Mills"]

So were you right or not??

I had unshakeable faith in you til this point my deity!

[/quote]

If his memory is correct then it's not a pyo, it's something else.

I think this case is interesting as we have evidence the bitch was in a true oestrous. Clearly something is going on and I think its interesting and worth talking about. It's not a pyo.

RE: Unusual pyometra

David Mills — Thu, 19 Oct 2017 18:50:31 GMT

[quote user="Martin Atkinson"]

[quote user="villagevet"]Please explain how you categorise this as pyometra and not a congenital defect, clotting disorder etc? It is unlikely the cystic change was progesterone initiated unless there was a hormonally active lesion somewhere also?[/quote]Sorry but this was 42 years ago, 2 weeks into my first job straight out of uni. It is possible that this bitch had even had one season I honestly can't remember but she certainly didn't fit the phenotype. My limited knowledge of this is that cystic endometritis is the precursor to pyometritis.

[/quote]

So were you right or not??

I had unshakeable faith in you til this point my deity!

RE: Unusual pyometra

Martin Atkinson — Thu, 19 Oct 2017 18:36:57 GMT

RE: Unusual pyometra

Lindsey Edwards — Thu, 19 Oct 2017 17:14:09 GMT

[quote user="Martin Atkinson"]I saw one in my first job in a 6 month old lab that hadn't even been in oestrus. The more experienced vets said it was impossible and stopped me from operating. The bitch subsequently died. On PM examination it had a cystic endometriits that was hemorrhaging rather than filling with pus.[/quote]

Please explain how you categorise this as pyometra and not a congenital defect, clotting disorder etc? It is unlikely the cystic change was progesterone initiated unless there was a hormonally active lesion somewhere also?

RE: Unusual pyometra

Thomas Johnson — Thu, 19 Oct 2017 13:29:28 GMT

[quote user="Clive Ansell"]

[quote user="Thomas Johnson"]I have a sample of the fluid from the abdomen, but the client isn't insured and I don't feel I can ask her to pay the lab fee for bacterial culture on top of an already substantial bill for investigations and surgery.[/quote]

I know the client has now requested a post mortem anyway, but why could she not have been asked if she wanted a swab sending off for culture? she could say yes or no?

Also, for the sake of academic interest, the £20 or so lab fee, could be "lost" within the rest of the bill, or the practice could pay for it?

[/quote]

Another change of plan, the owner has now decided against the post-mortem, but has agreed to sending the fluid for culture and sensitivity.

As an assistant I'm reluctant to spend the practices money if the client's not going to pay for it, it's one thing to give up my own time as I was going to to take the dog to the pathology centre, it's another to make even a small reduction in the profitability of the practice, if you get in to the habit of doing it it's surprising how it can accumulate.

RE: Unusual pyometra

Clive Ansell — Thu, 19 Oct 2017 12:49:35 GMT

I know the client has now requested a post mortem anyway, but why could she not have been asked if she wanted a swab sending off for culture? she could say yes or no?

Also, for the sake of academic interest, the £20 or so lab fee, could be "lost" within the rest of the bill, or the practice could pay for it?

RE: Unusual pyometra

David Mills — Thu, 19 Oct 2017 12:33:25 GMT

[quote user="Martin Atkinson"]That taught me a valuable lesson: that if I thought I was right I was right even if everyone else said I as wrong and have held that conviction to this day.[/quote]

https://en.m.wikipedia.org/wiki/God_complex

What about when you were shown your arse on here last month? Why QUEST for perfection when you already are?

Should we talk about use of ACEis in asymptomatic cats with murmurs?

RE: Unusual pyometra

Anthony Todd — Thu, 19 Oct 2017 12:14:02 GMT

[quote user="Martin Atkinson"]The more experienced vets said it was impossible and stopped me from operating.[/quote]

Again a turboed quick 20minute ex-lap would give you a definitive, life-saving diagnosis.

Ironically my daughter-in-law is doing her Consultant exam in A&E and one of the questions was:

List the conditions indicating an emergency ex-lap......

RE: Unusual pyometra

Martin Atkinson — Thu, 19 Oct 2017 11:47:47 GMT

[quote user="Thomas Johnson"] there are a number of published cases of pyometra in young bitches that haven't been mated.[/quote]I saw one in my first job in a 6 month old lab that hadn't even been in oestrus. The more experienced vets said it was impossible and stopped me from operating. The bitch subsequently died. On PM examination it had a cystic endometriits that was hemorrhaging rather than filling with pus. That taught me a valuable lesson: that if I thought I was right I was right even if everyone else said I as wrong and have held that conviction to this day.

[quote user="Thomas Johnson"]And also of pyometras immediately after the season.[/quote]It certainly happens but I would say in most cases it was an incorrect observation of a perceived oestrus and that the 'season' was the start of the pyo.

RE: Unusual pyometra

Thomas Johnson — Thu, 19 Oct 2017 11:10:22 GMT

[quote user="Michael Woodhouse"]

[quote user="Thomas Johnson"]there are a number of published cases of pyometra in young bitches that haven't been mated. And also of pyometras immediately after the season.[/quote]

I feel that's sloppy review and lax editing of journals. It doesn't fit with the accepted aetiology and I suspect people are using it rather lazily as "puss in womb" rather than to describe a specific but unrelated condition. I don't believe these are 'classic' pyos and perhaps if someone had been more pedantic about this we'd have learnt more about this by now.......

[/quote]

The owner has requested a post mortem, which I am organising at the University of Surrey Veterinary Pathology Services, I'll let you all know when I get their report.

RE: Unusual pyometra

Michael Woodhouse — Wed, 18 Oct 2017 23:18:29 GMT

[quote user="Thomas Johnson"]there are a number of published cases of pyometra in young bitches that haven't been mated. And also of pyometras immediately after the season.[/quote]

RE: Unusual pyometra

Lindsey Edwards — Wed, 18 Oct 2017 19:23:07 GMT

The dog owner may wish to however, especially if the male is potentially carrying a virulent strain of something? A non blame conversation with the stud owner or their vet may be beneficial to future bitches?

RE: Unusual pyometra

Thomas Johnson — Wed, 18 Oct 2017 15:11:42 GMT

[quote user="Michael Woodhouse"]

I don't think using the term pyometra is particularly helpful here. That is a specific condition with specific aetiology and that doesn't fit.

[/quote]

You may be right, though having said that there are a number of published cases of pyometra in young bitches that haven't been mated. And also of pyometras immediately after the season.

[quote user="Michael Woodhouse"]A culture would be interesting to see if a likely source of infection could be traced and we could hypothesise whether it was inoculated at insemination or via another route (eg haematogenous spread).[/quote]

I have a sample of the fluid from the abdomen, but the client isn't insured and I don't feel I can ask her to pay the lab fee for bacterial culture on top of an already substantial bill for investigations and surgery.

RE: Unusual pyometra

Martin Atkinson — Wed, 18 Oct 2017 14:24:09 GMT

Clearly the vaccine caused it all - obvious innit?

RE: Unusual pyometra

Michael Woodhouse — Wed, 18 Oct 2017 14:06:18 GMT

I don't think using the term pyometra is particularly helpful here. That is a specific condition with specific aetiology and that doesn't fit.

This sounds like an acute purulent metritis in the post mating period. Likely as the oestrodiol declined and progesterone increased. A uterus under the influence of oestrodiol is relatively resistant to infection cf one under progesterone influence.

A culture would be interesting to see if a likely source of infection could be traced and we could hypothesise whether it was inoculated at insemination or via another route (eg haematogenous spread).

RE: Unusual pyometra

Thomas Johnson — Wed, 18 Oct 2017 08:55:38 GMT

[quote user="intelligenteaser"]

where work I see we pyometras almost daily unfortunately. I have seen one ruptured at 2cm before - was scanned 24hrs prior to surgery and 1.5cm on scanner. spoken to a certificate holder in surgery recently who said he had also seen similar (think the case he described had started discharging. I hate the term open pyo for this reason..is it really open and discharging with no issues or is it just because its about to/has burst and is just being squeezed out because of the amount of pressure. I find most pyos if left long enough will discharge whether they are "closed" or not!) Is the breeder quite experienced...I have had clients telling me they had ascribed potential clinic signs eg. lethargy inappetance and vomiting on morning sickness eg. extrapolating from humans.

[/quote]

She hadn't eaten her breakfast that morning, but that isn't unusual for her since the owner's other dog was euthanased 4 months ago. She'd was very bright that morning, hadn't been pu/pd and had no vomiting before the sudden onset at about 2pm.

RE: Unusual pyometra

intelligenteaser — Tue, 17 Oct 2017 20:07:58 GMT

RE: Unusual pyometra

Thomas Johnson — Tue, 17 Oct 2017 18:56:04 GMT

[quote user="villagevet"]

How close to cervix was rupture and was it natural mating or was she inseminated? Would be interested in smear/culture to determine type of infection? A no-blame discussion with dog owner may be worthwhile?

Open cervix during oestrus can potentially allow ascending infection or may be haematogenous - any previous clinical history of bacteraemia? I have seen acute metritis symptoms after mating but not diagnosed rupture, normally pyrexic and inappetant, + fluid in uterus on scan but not distended like a pyo. Generally responded to medical abortion and antibiotics if unwilling to spay

[/quote]

The rupture was on the right uterine horn, 3-4cm from the bifurcation, it was natural mating and I can't see how the uterus could have been traumatised that far up. I had mentioned metritis to the owner when I first examined the dog. She was treated for a superficial pyoderma in June, and was seen on 8 September as she was a bit pruritic, examination of her skin was unremarkable and she was treated with Bravecto in case the pruritis was due to parasites (though none were seen). The owner didn't mention the pruritis at any of the appointments during her season.

RE: Unusual pyometra

Lindsey Edwards — Tue, 17 Oct 2017 18:48:43 GMT

RE: Unusual pyometra

mariette asselbergs — Tue, 17 Oct 2017 18:24:58 GMT

Well yes, that sounds very convincing. I have seen another closed pyo a year ago in a 3 year old spaniel. Luckily she was in good shape otherwise and surgery was uneventful, but she did have a large uterus full of pus. I was surprised to find that at her age and it played a role in getting my own 5 year old bitch spayed....!

Mariette

RE: Unusual pyometra

Thomas Johnson — Tue, 17 Oct 2017 18:20:23 GMT

[quote user="mariette asselbergs"]So was possibly not in season the 23rd of September? Or became infected during mating?[/quote]

I'm fairly certain she did come in to season on 23 September, I examined her on 25 September as the owner was worried she'd missed the start of the season as she was only lightly bleeding. Vaginal cytology was consistent with pro-oestrus and progesterone was low. Vaginal cytology on 29 September still consistent with pro-oestrus and on 3 October consistent with oestrus. Progesterone had started to come up on 3 October and increased further on 5 October. Progesterone levels were all run at Idexx and they recommended mating on 7 October (or if 2 matings, on 6 and 8 October).

I did wonder if she could have become infected during mating, but I can't imagine the chances of that are very high, and I wouldn't have expected a 2 year old bitch to have the cystic endometrial changes likely to predispose to a pyometra.

RE: Unusual pyometra

mariette asselbergs — Tue, 17 Oct 2017 18:03:23 GMT

So was possibly not in season the 23rd of September? Or became infected during mating? I also saw a bitch (10 years old) with a ruptured pyo two weeks ago, and she did not show anything until the day she presented (closed pyo diagnosed with ultrasound and not ruptured at that moment) and then developed septic shock while on IVF awaiting surgery the same day, same findings as you, and did not even survive the surgery but arrested on the table. Uterus had ruptured in 3 places. Did not look very distended (I have seen them miles worse). Sad and scary cases.

Mariette