Old Amazon with lots going on!!

RE: Old Amazon with lots going on!!

Marie Kubiak — Fri, 01 Mar 2019 11:29:46 GMT

[quote user="Sheryl Calway"]

With regard the compounding with pharmaceutical syrup - I have glycerol from pharmacy...is this what you mean?

Is it a case of 250mg tablet into known volume to make known strength solution and then dose at 15mg/kg bid. And solution stays stable 3-4 weeks...?...in fridge...??

[/quote]

Yes, glycerol will work well for compounding. Refrigeration may prolong stability but it tends to make it more viscous and difficult to administer so I have always advised room temperature. It is very unscientific I'm afraid as there is no data on whether it is stable for 5 mins or 5 years! However, it does seem to be effective where I've used it like this and tablets invariably fail when owners are trying to get them into birds daily.

Marie

RE: Old Amazon with lots going on!!

Sheryl Calway — Fri, 01 Mar 2019 09:58:52 GMT

Thank you (again!)

With regard the compounding with pharmaceutical syrup - I have glycerol from pharmacy...is this what you mean?

Is it a case of 250mg tablet into known volume to make known strength solution and then dose at 15mg/kg bid. And solution stays stable 3-4 weeks...?...in fridge...??

RE: Old Amazon with lots going on!!

Marie Kubiak — Thu, 28 Feb 2019 16:03:50 GMT

Proventriculus is enlarged (non-specific and may simply be hypocalcaemia/debilitation but would be prudent to consider heavy metal ingestion and bornavirus for differentials) - my very rough estimations using the work computer and a cracked ruler (!) give a value of 70% keel height for the proventricular height (should be <48%).

There are poorly defined soft tissue opacities in the mid and caudal coelom, liver doesn't look dramatically enlarged but is more radiodense than expected. I would definitely want to carry out air sac endoscopy to get a better idea of prognosis as it may not be worth persisting with this bird if there is marked asper/neoplasia and allows for biopsy collection for ambiguous findings.

Clinical comments on the blood sample sum up results nicely! Bile acids are higher than I would consider 'normal' but liver changes of this level are expected with diet issues. Ionised calcium at that level is clinically significant but you already have changes in place.

Terbinafine will be better orally as crushed tablets have been shown to be less useful with nebulisation than using the original powder ingredient and effective levels are short-lived. I use 10-15mg/kg bid, though up to 60mg/kg is apparently non-toxic in Amazons. The tablets we have are 250mg and I compound them in pharmaceutical syrup every 3-4 weeks (though I have also used Ky jelly and water made up weekly when this was unavailable to no apparent ill effect) and dose the liquid for easier, accurate dosing than splitting tablets and trying to force fragments into a parrot. As a heads up, there is a licensed form of itraconazole for parrots - Fungitraxx.

Marie

RE: Old Amazon with lots going on!!

Gillian Mostyn — Thu, 28 Feb 2019 12:01:41 GMT

[quote user="Sheryl Calway"]arranging GA to remove mass for history[/quote]

Any chance of a concious FNA or even just an impression smear?

What a complicated chronic case. From those rads, I would also be worried that there is something pretty nasty lurking in the coelom. Especially with your non-existant white cells....

RE: Old Amazon with lots going on!!

Sheryl Calway — Thu, 28 Feb 2019 11:47:46 GMT

I think these rads are a bit clearer!

I started the little guy on F10 nebuliser yesterday and itranfugol orally...have also ordered some terbinafine...though I've not a clue how to administer this...I was thinking via nebuliser but am not sure how well the crushed tablets we have got on order will dissolve and how stable they will remain in solution in order to vaporise them.

Also, have got him on ZolCal D, changed diet (readily accepted so far!) and got him under UV light. Owner is very much on board with what needs to be done.

I was thinking about treating this way for a week or so and then possibly arranging GA to remove mass for history +/- heavy metal toxicosis tests.

RE: Old Amazon with lots going on!!

Sheryl Calway — Thu, 28 Feb 2019 11:38:31 GMT

RE: Old Amazon with lots going on!!

Sheryl Calway — Thu, 28 Feb 2019 11:37:56 GMT

RE: Old Amazon with lots going on!!

Sheryl Calway — Thu, 28 Feb 2019 11:30:17 GMT

BIOCHEMISTRY

Albumin 15 g/L (12.0 - 22.0)

Total Protein 46 g/L ( 33 - 53 )

Uric Acid 171 umol/L (77.7 - 333 )

Bile Acid 60.2 umol/L

AST * 251 IU/L High ( 35 - 200 )

Creatine Kinase * 1501 IU/L High (64 - 322 )

Sodium * 141 mmol/l Low (149 - 164 )

Potassium * 5.9 mmol/l High (2.2 - 3.7 )

*Overnight sample*

Calcium * 1.82 mmol/L Low (1.87 - 2.42)

Ionised Calcium 0.83 mmol/l

Cholesterol * 4.5 mmol/L Low (4.68 - 8.01)

Triglyceride 2.0 mmol/L

Amylase 750 u/l

*GROSSLY HAEMOLYSED SAMPLE*

HAEMATOLOGY

White Cell Count * 0.4 10^9/l Low (5.0 - 17.0)

Haemoglobin * 12.6 g/dl Low (12.7 - 16.5)

PCV * 32 % Low (41 - 53 )

MCHC 39.4 g/dL

WBC Differential

Film Comment No polychromasia within erythrocyte series. It is

impossible to do an accurate differential with a total

white cell count this reduced and only two unremarkable

heterophils found on which to comment. Thrommbocytes

appear normal in structure and number on film.

MICROBIOLOGY

Culture To follow

CLINICAL COMMENTS

Haematology demonstrates a marked leucopaenia which may be a feature of viral

disease, toxicosis or underlying chronic disease with sequestration of

leucocytes at an inflammatory/necrotic focus. There is also a mild apparently

non regenerative anaemia consistent with that of chronic disease and/or

haemorrhage. I believe also of significance are increases in AST/CK which may

reflect skeletal muscle injury/catabolism associated with described lesions and

a hypocalcaemia which likely reflects the described sub optimal husbandry in

this case.

RE: Old Amazon with lots going on!!

Marie Kubiak — Tue, 26 Feb 2019 15:47:55 GMT

No worries, let me know what comes up on bloods or if anything else is seen on rads,

Marie

RE: Old Amazon with lots going on!!

Sheryl Calway — Mon, 25 Feb 2019 21:55:14 GMT

Marie...not sure how to thank you enough! I must admit, I was feeling a bit "oh my...where on earth do I start with this case..??..!!" .....so can only begin to let you know how much your hugely detailed answer both helps and reassures in equal measure! I thought it was going to be complex, so your response has confirmed this and I think some long conversation with the owner is in order!! I'll await the labs reporting the blood results...hopefully by tomorrow evening...and will play with the radiography settings...I think the pictures I posted are a pretty poor representation of what I was looking at on our digital viewer....taking a photo and posting from my phone may have played a part in the appearance presented here...? I'll have a look at the rads tomorrow with your queries and see if I can be more specific with regards the questions you raised...would you be interested in me updating on this patient? However, having spent, I imagine, a significant amount of time writing your reply, I appreciate that you may have had enough of this knackered old bird! (the patient..not me..although after the day I've just had...could be either of us I was referring to!!!)

RE: Old Amazon with lots going on!!

Marie Kubiak — Mon, 25 Feb 2019 20:02:53 GMT

Re: vent haemorrhage, (I'd forgotten about this by the end of my monologue!) beware apparently minor papillomas in Amazons (and other neoptropical species) as there is often an underlying herpes virus responsible and there is a strong link to induction of hepatic/biliary malignant neoplasia. Cloacoscopy and biopsy for histo and Psittacid-herpes PCR would be prudent for any lesions. Renal/reproductive and GI causes also possible. Amazons seem to respond oddly to lead intoxication and develop GI bleeds but it rarely presents as fresh bleeding of the lower GIT, more as older blood mixed in faeces. Could also be traumatic, from inability to perch/defaecate properly due to foot issues and secondary irritation/abrasion of the vent.

Marie

RE: Old Amazon with lots going on!!

Marie Kubiak — Mon, 25 Feb 2019 19:55:36 GMT

Not a nice Monday case!!

The smily face looks from the lateral view to be opacities within the cervical air sacs.

Humeral medullary cavity/air sac extensions are mottled in appearance. The more extended wing on the lateral view looks to have a very unclear distal humerus, is this where the mass lies? Could be artefact as the VD view of the left (if the same wing) looks much less dramatic.

The ‘mass’ on the VD view looks like intestinal loops to me, which suggests it is impinging on air sac space, partly due to slight rotation, probably exacerbated by an increase in coelomic soft tissue of unclear origin. I’d want to scope to be sure it wasn’t an aspergilloma though with all the predilections this bird has been subjected to.

The coelomic soft tissues on the image are over-exposed (or the digital xray algorithms are confused by air filled creatures!), can you tweak the radiograph on the DICOM software to reduce this and get some more info on liver/proventricular region? Usually Amazons (frugivores) fed on seed chronically end up with an almost spherical cirrhotic/fatty liver the size of my fist!

Atherosclerosis of the ascending aorta is present for a significant stretch over the lungs.

L stifle looks to have osteoarthritic change on VD – could be evaluated further on lateral again if settings can be played with. Neither inter-tarsal joint looks entirely normal either.

Increased opacity over clubbed foot at distal tarsometatarsus, gout/OA/neoplasia with secondary tendon contracture? Do the other limb joints move freely? Can you manually uncurl the toes?

That mass also looks pretty nasty! I can’t tell clearly from image but am assuming axillary location? If so there is a strong predilection for squamous cell sarcoma at this site, and occasionally fibrosarcoma (usually secondary to chronic moist dermatitis), but bacterial/yeast dermal granulomas can look very similar. Also bear in mind Mycobacterium avium cases seem over-represented in Amazons!

Assuming the bird is externally appearing stable, I would stick with your plan to sit and wait for results for now as everything looks chronic. This bird has been permanently compromised by the terrible husbandry and you are unlikely to fix most/all of its problems. If bloods are ok, I would look to scope it and see what horrific things lie inside, plus biopsy/remove the mass. Cervical air sac lesion is tricky – there is no easy way to access this site, without risking significant issues with sc emphysema post-intervention so hard to say whether fungal/bacterial/nutritional/historic/all of the above! I would be looking at haematology to help guide whether I went in with all guns blazing (terbinafine, itraconazole, nebulisation with F10), or just sorted the diet and hoped for the best.

Marie