mark maltman's Activities

Suspect Pure Red Cell Aplasia case not responding

Steve Leonard — Thu, 01 Sep 2022 07:26:59 GMT

Hi,

www.vetsurgeon.org/.../Bloods.pdf

A month ago we had a second opinion on an anaemic 7 yo neutered Whippet. She had been worked up for GI issues and had some imaging but her reticulocyte count had always been very low (PCV 20%, retic 5.5 on her first visit).

We discussed bone marrow biopsy but owners declined at this point. The presumptive dx being PRCA as no other cell lines affected and couldn't see any reason for EPO to be the issue at this point.

We started her on 2mg/kg Preds and B12, which helped resolve her GI issues and caused a mild increase in her reticulocyte count. We then added in MMF as her PCV was still falling as I'm assuming her RBC population at this point is at the aged end of the spectrum. Another mild increase in reticulocyte count but still not adequate to maintain her PCV.

Once her PCV hit 11% and she was starting to get very weak we gave her packed cells that brought her PCV up to 22% but it is starting to fall again and her reticulocyte count is still only in the bottom half of the reference range.

She has no travel hx outside the UK, she is BAR in herself with no other symptoms. Her other cells lines are appropriate (PMNs elevated since starting steroid) I am considering either swapping the MMF for chlorambucil or adding it in to the regime.

I have read they can take a while to respond to therapy but wanted to ask whether I should be checking EPO levels or considering other dx or tx regimes.

Your suggestions very gratefully received.

Cheers

Steve

post-prandial distress syndrome in a dog

Roger Wilkinson — Thu, 06 Feb 2020 18:29:40 GMT

Hi guys,

Would be v grateful for any help with this one....

My current no.1 nightmare case is Basil:

3 y.o. pointer x lab with a 6 month history of post-prandial 'distress'. Waxes and wanes a bit but happens most days.

signs closely related to feeding: typically within minutes of eating, whines, paces, looks at flanks, licks at his flanks and sometimes elsewhere, jumps up, sometimes refuses to lie down. Lasts anywhere from few minutes to an hour or two. I have an inbox full of Basil videos and I have to concede he looks very unhappy. it's not just owner perception.

sometimes has diarrhoea but that is an occasional issue only (and could easily be related to omeprazole, antibiotics etc)

similarly, occasionally vomits

belching is a common feature (owner says 1-2 x/hour). Also reportedly increased flatulence.

gradual weight loss (but may be related to succession of strict diets)

routine haem, biochem, lipase, TLI, B12 all unremarkable

abdo and thoracic sonography unremarkable

ex lap findings grossly unremarkable

Full thickness biopsies: Mild lymphoplasmacytic and eosinophilic enteritis (full histo below)

Upper GI endoscopy NAD

Thoracic rads unremarkable (oesophagus looks OK)

No response to rigorous diets: hydrolysed or 'hypoallergenic' single protein source.

No response to 1mg/Kg bid prednisolone for 2 months

No response to 1mg/Kg bid omeprazole for 6 weeks

No response to tylosin or metronidazole

No response to Saccharomyces

So, hunting around the internet in desperation I find that 'postprandial distress syndrome' is described in people. Possibly overlapping with a similar phenomenon of 'epigastric pain syndrome'.

www.ncbi.nlm.nih.gov/.../

..and these share some features with 'Basil syndrome'. The main differentiation being that he does have some evidence of GI inflammation on histopath.

Does anyone else recognise this kind of thing? and anyone got any bright ideas? (please!).

Based on what I can find from human medicine we have possible options of mirtazapine (my current plan), additional immunosuppression (don't feel enthusiasm for this somehow), amitryptyline (arrhythmia risk), buspirone (human stuff suggests not so effective in painful cases) or acotiamide -which appears unavailable in the UK.

Happy to offer a small prize for advice leading to resolution!

Roger

--------

Fundic stomach Two full thickness sections of fundic stomach. There are small to moderate numbers of spiral organisms present adjacent the surface epithelium and within gastric pits. The architecture and cytological features of the mucosa are otherwise within normal. The submucosa appears somewhat compressed (artefact) and submucosal ganglia are not definitively identified. The outer muscular layers are present in an unusual plane of section with areas of recent haemorrhage, but appear otherwise normal. Myenteric ganglia contain normal ganglion cells. .

2. Ileum Two sections of small intestine, which are multifocally affected by stretch/crush artefact, with areas of recent haemorrhage and separation of the surface epithelium (collection artefact). Villi are present in various planes of section and appear mildly thickened (for site). There is a mild increase in eosinophils, lymphocytes and plasma cells, including, within the deep lamina propria, a band-like infiltrate of lymphocytes, plasma cells and eosinophils, and there is frequent infiltration of the crypt epithelium by eosinophils. Submucosal ganglia contain normal ganglion cells. The outer muscular layers are markedly disrupted and are present in an unusual plane of section, but appear otherwise normal. Myenteric ganglia contain normal ganglion cells. .

3. Duodenum Two full thickness sections of small intestine are presented on one slide. Villi are present in various planes of section and appear mildly thickened. There is a mild increase in eosinophils, lymphocytes and plasma cells with, within the deep lamina propria, a band-like infiltrate of eosinophils with fewer lymphocytes and plasma cells, and frequent infiltration of crypt epithelium by eosinophils. Submucosal ganglia contain normal ganglion cells. The appearance of the outer muscular layers is within normal limits and myenteric ganglia include normal
ganglion cells. .

4. Pancreas One section of the pancreas, with areas of artifactual expansion of the interstitium and haemorrhage (collection artefacts). The architectural and cytological features of the exocrine and endocrine pancreas are otherwise within normal limits. . Diagnosis Mild lymphoplasmacytic and eosinophilic enteritis

severe and worsening hypercalcaemia in 11 week puppy

mark maltman — Fri, 15 Jul 2016 14:36:21 GMT

Dear All

I would appreciate any thoughts and help with a case we currently have:

11 week old Labrador retriever bitch pup
Apparently normal until rehoming
Had first DHP/L2/KC vac at 8 weeks, but not second
Advocated at 8 weeks
11^th July – off colour, mild vom and LI diarrhoea, improved unremarkably over 24 hours
12^th Jul – soft cough, tachypnea 48/min, nomothermic, seen overnight in 13^th July
13^th July – brighter,but more notable cough, radiographs suggest bronchopneumonia, no megaesophagus (on survey and barium swallow) nor dysphagia/swallowing difficulty when eating, started cefuroxime IV,angio detect test negative (baermans still pending as back up as did not believe it), RX fenbendazole regardless
Haematology on 13^th July, leucocytosis (25.4), mature neutrophilia ( 16.26), monocytosis (3.05), eosinophilia (1.78)
Chemistry on 13^th July – urea mildly elevated (19.4), normal creatinine, mild hyperlipidaemia (chol 6.72, TG 1.37), raised CRP 49.2, raised calcium (3.5mmol/l) – we felt the latter combined with the eosinophilia made ?angio ?EBP possible ddx for the chest but we felt that by the time we reviewed all this on 14^th July that she had become too unwell to tolerate any kind of lavage of her lungs
By 14/15^th July, she has now progressed to profound malaise and reduced mentation. She remains mostly normothermic, but occasionally mildly raised but only to 39.1 and her level of consciousness /activity now seems inconsistent with this level of pyrexia/hyperthermia
By 14^th July her total calcium was 4.37mmol/l and ionised 2.08 mmol/l; despite heavy diuresis with normal saline over the last 18 hours, her ionised calcium is up further today to 2.22mmol/l
Sodium was just below reference range yesterday (135) leading to consideration of congenital Addison’s but ACTH stim normal (169, 384)
Normal total thyroxine (low reference range 13.4)
ACR antibodies are pending – submitted when there was thought as to aspiration pneumonia without other apparent cause
No known access to vitamin D toxins
Been eating commercial dog food, but waiting to try to confirm what breeder was feeding
About to run PTH, PTHrP, vitamin D metabolites, though not certain of any credible rationale for the former two?

Questions?

Worth testing food for vitamin D or analogues?
What do people think of a pamidrontate infusion at this age?
Is there such a thing as calcitonin deficiency? Can this be tested anywhere?
Are we missing something?

Best wishes

Mark

Small Animal Vet

mark maltman — Mon, 21 Mar 2016 09:07:49 GMT

FULL-TIME AND PART-TIME VETERINARY SURGEON

Maltman Cosham is a RCVS accredited, independently owned and run, Small Animal Practice in Slinfold, West Sussex near Horsham, a vibrant market town with good access to London, South Coast and Gatwick.

Our primary focus is providing excellent patient and client care, with high clinical standards and a compassionate led approach.

Our enthusiastic team of 5 Veterinary Surgeons and 10 Nurses is expanding and therefore has created 2 positions for a motivated candidate with a caring and conscientious approach.

The practice was opened 5 years ago, with the aim of providing independent veterinary care, tailored to the client and patient with continuity of care from individual vets within the team. We are well equipped with modern facilities and diagnostics including: digital radiography, ultrasonography, ECG, BP, MPM anaesthesia monitoring and laboratory blood analysis.

Four day working week with OOH/weekend rota. Salary commensurate with experience. CPD is encouraged and funded.

Please email your CV and covering letter to josie.cosham@maltmancosham.co.uk or call Josie Cosham on 01403 791011

Kolanticon (active ingredient dicyclomine) in replacement of mebeverine (due to cost)

mark maltman — Mon, 18 Jan 2016 16:58:50 GMT

Dear All

Does any one have any experience with the use of Kolanticon (active ingredient dicyclomine) as an alternative to mebeverine (due to cost) as an antispasmodic and, if so, a dose. To cut an enormously long story short, the case is an uninsured diabetic Poodle with a plethora of problems, the investigation of which has been v limited and the treatment of which has been fairly empirical. He has bouts of severe abdominal pain which seem to respond only to opiates and more recently spasmolytics, but ongoing mebeverine is cost prohibitive.

Best wishes

Mark

amyloidosis in Siamese cats

mark maltman — Thu, 01 Oct 2015 14:04:21 GMT

Dear All

I would appreciate a quick survey of thoughts please. I have a 3yr FN Siamese cat with mild renal azotaemia and proteinuria. Urea 22, creatinine 181, urine pr:cr 0.5, inactive sediment, USG 1.012.

One differential being early amyloidosis, what are the thoughts on:

1. Is there benefit to confirming this with biopsy? Or will this open the usual problem with interpretation of renal histology and quantification/significance of any amyloid present?

2. My understanding is that colchicine may well not alter the progression of amyloidosis anyway and therefore is there any point in biopsy with a view to using it? Or is it better to simply manage as any other CKD case and avoid any adverse effects of colchicine?

Many thanks.

Mark

VetSurgeon.org

Tue, 11 Nov 2008 09:19:25 GMT