Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Andre Escudeiro-Vieites — Thu, 31 Mar 2011 21:40:02 GMT

She is a pet, not particularly active, as far as I know. No noticeable lymphadenopathy at palpation of superficial LNs. Had a bout of pyoderma, or something along those lines, if I remember well from reading the history, 6 years ago or so.

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Richard Fox — Thu, 31 Mar 2011 12:32:13 GMT

BTW is is an active or working ESSP? Have seen a number of working dogs with recurrent pyrexia and lymphadenitis and nodular granulomatous dermatitis?

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Andre Escudeiro-Vieites — Wed, 30 Mar 2011 22:36:32 GMT

Good response to corticosteroids!

Funds limited so more investigations are nor possible.

Coming tomorrow for a check up after a week on preds.

Nurse spoke to the owner today and she is doing really well!!

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Paul Higgs — Tue, 29 Mar 2011 12:06:56 GMT

ESS are prone to recurrent pyrexia and often we don't find out the exact underlying cause. The approach to these cases unfortunately can be long and expensive and need to follow a logical approach. Also, unfortunately there is strong evidence to suggest that you are unlikely to identify the underlying cause whilst the dog is not pyrexic but also if it has received any antibiotics, nsaids or steroids recently. I certainly would not advise exploratory laparotomy in a recurrent pyrexia unless you have identfied a clear abdominal problem such as an abcess or liver disease.

There are a large bank of diagnostics that are used in the investigation of PUO including basic bloods, full abdo ultrasound, chest rads, spinal rads (discospondylitis), echo (endocarditis), cystocentesis full urinalysis, faecal analysis, lymph node aspirates (if lymphadomegaly), tick borne disease profile, arthrocentesis sample (at least 4-6 joints), CSF (if suspicious), MRI if suspcious, etc, etc, etc.

Obviously not all of these tests are appropriate (e.g. I would not suggest performing a CSF tap without experience or sufficient suspicion) however, in dogs, particularly ESS, that present with PUO without overt obvious causes for the fever the diagnostic investigation can be long and frustrating, even in referral.

My suggestion would be to wait until the dog is pyrexic again and then consider referral immediately. If you opt for this the referral centre will probably be most grateful if you refrain from restarting antibiotics or NSAIDs but just give opiod analgesia and IVFT if necessary. This advice is based upon studies that show that any medication given prior to diagnostic investigation can result in no diagnosis or mis-diagnosis. Further info can be found in the following JSAP article: Normal 0 false false false EN-GB X-NONE X-NONE MicrosoftInternetExplorer4

I. A. Battersby et al (2006) Retrospective study of fever in dogs: laboratory testing, diagnoses and influence of prior treatment Journal of Small Animal Practice 47, 370-376

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Nicola Lawlor — Sat, 19 Mar 2011 21:03:10 GMT

Had a dog (spaniel) a couple of years back with similar recurrent pyrexic episodes but no obvious causes for the first few episodes. Dog responded well to antibiotics and NSAIDs but would relapse usually within weeks. Eventually with one episode the dog became painful over the lumbar spine area though x-rays were inconclusive. The dog was referred for an MRI scan and this finally located a grass awn right up by the lumbar vertebrae. It was surgically removed and the dog did very well for several months before one further episode of pyrexia that we have no idea if was related, but fine ever since after some antibiotics/NSAIDs again.

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Zita Okarina — Sat, 19 Mar 2011 14:47:02 GMT

Same goes to my patient here as well,

Mine is Lab 1 y.o , male, non-castrated. Few times came to our clinic with high fever, less appetite and soft stools. We tried NSAIDs before, scanned him, ex-lap, biochemistry, but all didn;t seems right until we gave him steroid! But in some certain time, the sickness keep bring him back to our place. We're not sure what was the causing prob of our patient, but steroid really works!

Zita

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Martin Jones — Sat, 19 Mar 2011 09:51:34 GMT

One random question: is this a dog who wallops her food down, and occasionally brings it back up again?

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Laurence Webb — Fri, 18 Mar 2011 20:03:54 GMT

Low albumin, high cholesterol - Possible glomerulonephropathy? Urinalysis including culture and UPC? I'm guessing the kidneys were looked at when the ultrasound was done.

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Andre Escudeiro-Vieites — Fri, 18 Mar 2011 19:41:58 GMT

Temperture today down to 39C.Eating and drinking . A lot brighter. Continueing with amoxi/clav, metronidazole, omeprazole, sucralfate. Looks on the mend once again resembling behaviour of previous episodes.

[quote user="Bob Russell"]locum left a swab [/quote] The episdes started before she had any abdominal surgery. NAD on abdominal rads.

[quote user="Gerry Henry"]consider idiopathic polyarthritis/myositis; are the muscles sore when gently squeezed (quads, triceps); [/quote]

No pain on manipulation o limbs,no swelling of joints

[quote user="Richard Fox"] I would do imaging and poss and exlap but it would depend on how long standing and sig the pyrexia is and continues to be?[/quote]

I thought about offering an ex-lap to the owner, but it is difficlult to justify now that she is clearly improving

[quote user="Richard Fox"]No eveidence of heart disease? [/quote]

No. As far as I can tell

[quote user="Richard Fox"]I would think if you have sig loss in pancreatic acinar cells you would get signs of EPI?[/quote]

That is again something not entirely fitting with my main DD (chronic pancreatitis). To have a low CanPLI shouldn't she also have symptoms of EPI? But there is no history of chronic D+.Her faeces are normally ok according to the owner.

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Bob Russell — Fri, 18 Mar 2011 17:12:37 GMT

Some sort of septic focus and flare up. Chest and abd radiographs would make sense IMHO. We had this picture when a locum left a swab in a spaniel many years ago!

I provisionally diagnose pancreatitis for everything else I cannot identify now as that seems to be the answer for most in the end!

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Gerry Henry — Fri, 18 Mar 2011 11:08:09 GMT

Intermittant grass seed migration? Any fistulae.

Would def consider idiopathic polyarthritis/myositis; are the muscles sore when gently squeezed (quads, triceps); resolves with cortisone - sorry!

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Richard Fox — Fri, 18 Mar 2011 10:44:57 GMT

I also doubt Cushings and you have no significant elevation in ALP!

High Cho maybe tranisnt esp if there is not sig elevation and ALP and ALT and if significant extra billiary?

Doesn't sound like you have sig clinical signs to find the answer - I would think if you have sig loss in pancreatic acinar cells you would get signs of EPI?

You do have a neutrophilia - what would link the pyrexia but not give you a source. I would do imaging and poss and exlap but it would depend on how long standing and sig the pyrexia is and continues to be?

No eveidence of heart disease? i.e. low grade endocarditis as these give flare ups?

I think imaging would be my next port of call.

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Utlendigur — Fri, 18 Mar 2011 00:05:45 GMT

Probably way off mark but I seem to remember reading somewhere recently that immune mediated polyarthritis was a not uncommon cause of PUO that was underdiagnosed. Any thickened or painful joints?

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Mark Holmes — Thu, 17 Mar 2011 23:33:58 GMT

Were chest xrays done? I generally get a couple of survey shots, in odd cases like this, mainly because its the only bit I cannot palpate and it is surprising how often something comes up. If that dipping albumin is persistent I would be a bit worried about that and not too quick to link the previous episodes to this one.

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Andre Escudeiro-Vieites — Thu, 17 Mar 2011 22:13:25 GMT

[quote user="Michael Woodhouse"]I would bet you it gets better when you cave in and give it some steroids. [/quote]

I have been tempted a couple of times, but she seemed better today.

But maybe I will have to do it. Maybe it is a false negative and Laura´s suggestion is right [quote user="Laura Henderson"]atrophy of functional acinar cells resulting EPI and therefore reduced PLI values can also ensue[/quote]

I remember form some CPD, actually at congress, but a couple of years ago, the specialists being braver lately with steroids in chronic cases.

In case there is no improvement and I feel brave enough...what dose of steroids? Antiinflammatory dose?

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Noweia — Thu, 17 Mar 2011 21:46:09 GMT

I'm not sure - I went to a lecture at BSAVA last eyar about CP being under-diagnosed in dogs. If the result was within ref ranges that would rule out an acute pancreatitis but maybe because there is a chronic condition the result could be lower?

[quote]It should be noted that atrophy of functional acinar cells resulting EPI and therefore reduced PLI values can also ensue.[/quote]

^ From a .pdf on pancreatic disease, http://www.tddslab.co.uk/tddsexeter/downloads/PLI_TLI_pancreatic%20disease.pdf

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Michael Woodhouse — Thu, 17 Mar 2011 21:43:07 GMT

I would bet you it gets better when you cave in and give it some steroids.

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Andre Escudeiro-Vieites — Thu, 17 Mar 2011 21:35:40 GMT

[quote user="Laura Henderson"]

Could it possibly be chronic pancreatitis? With flareups causing the episodes described?

[/quote]

That is what I thought. Ordered the CaninePLI and had a negative result. Shouln´t it be noticeably elevated, particularly during a "flare up" if the problem pancreatitis? Do you suggest it is a false negative?

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Noweia — Thu, 17 Mar 2011 21:29:59 GMT

Could it possibly be chronic pancreatitis? With flareups causing the episodes described?

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Andre Escudeiro-Vieites — Thu, 17 Mar 2011 21:21:42 GMT

Sorry, no endoscope.

And the budget of this non-insured-owner is getting a bit too stretched for a refettal.

No signs of Cushings at all.No PU/PD.Very lean and fit looking springer with tucked in abdomen and good coat condition and normal skin.

The ALP is elevated, but...?

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Stephen Courtney — Thu, 17 Mar 2011 21:16:07 GMT

It's not Cushings, an ACTH stim on an unwell animal is not helpful.

Remember PUO is hard to get to the bottom of at the best of times. this doesn't have to be the same condition as before but it is suspicious.

Repeat imaging is probably a good idea, and i always like a urine sample. Is there a budget for further investigations or possible referral?

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Busybee — Thu, 17 Mar 2011 21:11:21 GMT

Do you have an endoscope? Could be useful to actually see the stomach and assess the mucosa, especially around the pyloric region?

I'm also thinking liver/gallbladder/bile duct region but the bilirubin was normal....

Does the dog have any other clinical signs of Cushings?

Re: Recurrent-for years- pyrexia ina 10 y/o neutered female ESS

Andre Escudeiro-Vieites — Thu, 17 Mar 2011 20:21:44 GMT

Sorry it looks a mess, I think this system doesn't agree with my "copy and paste" !