'Challenging' Rads

Re: 'Challenging' Rads

Martin Jones — Fri, 11 Sep 2009 13:41:08 GMT

ps which means it probably had lungworm. Funny thing, lungworm.

Re: 'Challenging' Rads

Martin Jones — Fri, 11 Sep 2009 13:39:41 GMT

Further (and hopefully final) update:

Dog's been living at my house since Tuesday, and has made a remarkable recovery. Now eating like a train (5-6 tins of Chappie, a few eggs, plenty of bread, chicken, crumpets, the plates in the dishwasher, the chickens' food, and anything else it could scam out of the kids).

It's been off all meds since Weds morning, its temperature hasn't risen above 38.5 at any time - previously, it hadn't dropped below 39.5 for weeks. Yesterday, a 2 mile walk at brisk pace was fine. Today I repeated haematology, and found wbc at 12 (from 31 last week), platelets fine, and a very marginally low pcv at 35% (from 36 last week).

So I sent it home (with antibs - I'm a coward). Any of you who may have experienced earthquakes and rains of frogs last night, rest easy: for a merest fraction of a second there I was the World's Best Vet, and the earth reacted accordingly. Natural order will be restored on Monday morning.

We still have a way to go with this dog, and there's every possibility of a relapse - but right now we're all a bit elated. Many thanks to all those who ventured an opinion, both on the thread and through private conversations: we should do a lot of this kind of thing. Any of you that I meet in person will definitely be on the end of free drinks.

Martin

Re: 'Challenging' Rads

Martin Jones — Tue, 08 Sep 2009 15:18:42 GMT

As an update:

Owners presented first thing this morning with fitting dog. In consult, showing opisthotonus and nystagmus, but apparently conscious and stable underneath. temp 39.4. Resolved with 4mg of diazepam, and followed through with 5ml duphacort.

Eosinophilic meningitis? Currently at the top of my list. She hasn't shown any mentation or specific CNS signs prior to this, so I'm viewing it either as part of a lungworm, or other process reactive to the current treatment. Dog has been aware, but quiet all day and lying out in her kennel. I'm preparing to bring her home, having negotiated a 24 hour extension with family - who are understandably at their limit.

Steroids it is, with the usual prayers.

Re: 'Challenging' Rads

james hunt — Mon, 07 Sep 2009 23:26:45 GMT

Re. the inexplicable lameness..might be worth clipping the hair over the joints the have a look for joint effusion (carpi especially) in case some kind of immune mediated arthritis causing the recurrent/persistent pyrexia?

Re: 'Challenging' Rads

Martin Jones — Mon, 07 Sep 2009 19:02:39 GMT

Wynne + Uttetcetc

Yes to all of the above - we're equally inundated with lungworm down here, although I think we have less issues with post-advocate probs (interestingly, in my previous life as a cattle vet, I never had corresponding problems with Dictyocaulus, and always used ivermectin without mishap).

I think my main concern is with the persistent pyrexia, and the possibility that it suggests something else entirely. Having advocated on Saturday, I'm seeing the dog again tomorrow. A quick check with the owner today initially elicited the response that she wasn't really better - but then we did establish that she was more lively, eating better and had a cold nose (moot point) - which, to me, would be a bit better really. But she is also on clav-amox and enrofloxacin, with lashings of meloxicam - and has been on clav-amox for quite some time.

We see the usual run of lungworms - this evening a classic nasal bleeder with scavenging tendencies - but this one is either just a bit complicated, or is off on another tangent entirely.

The last rad is contrast. Some pooling, but not marked, and no sudden pinching a la PRAA with aspiration; no prev symptoms of megaoesophagus either - but I have seen a couple of young collies with PUO leading back to early oesophageal dysfunction and aspiration, the first picked up at a referral centre, and the second myself.

Thanks for the reassuring comments that I'm not the only one who admits to problems with chest films - I think I may trawl for a bit of CPD on this one, as it's clearly needed

Martin

Re: 'Challenging' Rads

Hannah Wynne Richards — Mon, 07 Sep 2009 11:54:22 GMT

I agree with Sarah that Angiostrongylus can't be ruled out, and caudal lung lesion is definitely suspicious, as is RHS cardiac enlargement in young dog. Lameness could be joint haemorrhages. I find that clinical cases of angio respond best to 50mgs/kg fenbendazolre for 21 days (not licensed, but this is one where I would be prepared in the patient's interest to defy the cascade. I would also treat with high doses of antibiotic for same time-treat 2y pneumonia from dead lungworm and bacterial endocarditis same time. I haven't seen the dog, but if I was certain it was angio, not endo I would also give steroid, as dead lungworm seem even more antigenic than live ones, so can produce a fulminating pneumonia without it

Wynne

Re: 'Challenging' Rads

Martin Jones — Sun, 06 Sep 2009 22:35:42 GMT

Dear All

Thanks for the comments (and keep them coming).

For the record, I think there's a good chance this dog has lungworm, but I also realised that I left out a bit of history - the dog went transiently and inexplicably lame on right fore a couple of days ago, so I'm also concerned re bacterial endocarditis, although there are no overt signs of cardiac failure

Like most vets most of the time, I'm slightly frustrated in terms of finances etc, but I did perform an FOC echocardiograph and abdo ultrasound. Abdo is clear, and I'm confident re that, but we're not experienced in heart scanning and don't have colour flow doppler. Having taken advice, I'd confirm the right sided enlargement, but no further on that one.

Wish I had done a BAL for cytology/parasitology, as it's comething I could have done even with the labs shut. In the event, I did advocate, and fully prepped the OOH centre, just in case.

The rads don't really give the full picture, as they're compressed and reduced copies of digital photos from a viewer. Some of the changes - for example the lucency over craniodorsal aspect of the heart, which appears to compress oesophagus - may be lost in translation. There was also a marked pattern in the caudal lung field which hasn't reproduced well.

We'll see how we're doing tomorrow.

Re: 'Challenging' Rads

Utlendigur — Sun, 06 Sep 2009 22:35:12 GMT

Ditto not great with reading rads but agree heart looks a bit enlarged. Pericarditis?

Any other symptoms eg exercise intolerance, change in respiratory rate/character?

Has some contrast been given in the last xray? Megoesophagus + inhalation?

Is the pyrexia definitely related to the chest eg rumbling IMHA?

Re: 'Challenging' Rads

sarah mason — Sun, 06 Sep 2009 19:38:28 GMT

The last similar history I saw turned out had a spenic abscess, similar aged dog with reoccuring pyrexia, I agree, BAL and also Baermans on the faeces (dont think angiostrongylus can be ruled out, even with worming, only specific regimes with advocate and milbemax have a license).

They look like inspiratory films? VHS combined with cardiac echo should give you an idea of cardiomegally

Re: 'Challenging' Rads

Clive Ansell — Sun, 06 Sep 2009 07:14:36 GMT

My rad reading skills are not the best, but the heart seems enlarged to me, particularly on the VD view. are there any signs of cardiac disease? how are crt, mm, pulses? any murmur or cough? any enlarged lymph nodes? any ocular or nasal discharge?

Are there any changes on routine blood work, neutrophilia? Given the pyrexia I would guess there has to be a focus of infection somewhere?

I think bronchial lavage and/or endoscopy would be my next move, and maybe blood culture too?

Re: 'Challenging' Rads

Glen McIntosh — Sat, 05 Sep 2009 22:13:48 GMT

Yeah, I am thinking cardiac issue as well, but doesnt easily explain pyrexia. Am I seeing significant cardiomegally? Are heart sounds auscultable? Heart rate/pulse etc? How is the dog apart from fever?

Interesting case. Please let us know the outcome.

Re: 'Challenging' Rads

ms1083 — Sat, 05 Sep 2009 21:59:54 GMT

Dear Martin,

Might be thinking up completely wrong angle (thinking cardiac issue or possible lung FB with secondory infection) I assume as wormed regurlly that angiostronglus can be ruled out? Got some questions:

could you consider doing a broncho-alveolar-lavage? Done a few, 20ml sterile saline down dog urinary catheter down ET tube, suck as much back up as possible, place it in EDTA tube and send off to lab (I used Langford).

Also, can you do ecocardiology? Would also be worth doing general abdominal US at same time.

Hope my typing whilst thinking is of some help.

Matthew