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Friday, December 19, 2008
Solution for case 7


Radiographs showed that stomach has ingesta in it with some radiopaque materials. Large amount of gas was found in small intestine. Colon was full of fecal material with some radiopaque material.



Tentative diagnosis: Ehrlichea (because of thrombocytopenia) and foreign body in stomach



Further diagnostic tests:


4Dx SNAP test: Heart Worm - negative, Ehrlichea canis + Positive, Anaplasma – negative, Lyme – negative


Coagulation panel: to rule out the rodenticide poisoning.



Ehrlichea: Active infection confirmed by SNAP test, fever and thrombocytopenia are likely responsible for the epistaxis. Epistaxis is the most frequent hemorrhage due to ehrlichea. Increased BUN suggests the possibility of a GI bleed. The Ehrlichea also accounts for the fever and lymphodonopathy. Trauma and rodenticide poisoning are differentials.


Abdominal pain: With a Hx of being fed chicken bones and the multiple opacities in the lower GIT a foreign body (FB) is suggested. The radiographs showed a substantial amount of feces in the large colon with a large amount of gas in the small intestine which may suggest ileus/obstruction from a FB or constipation.

Treatment:

Doxycyline 10mg/kg (88mg) IV SID to treat Ehrlichea.

20cc warm soapy water enema and repeated later in the day to empty the bowel and see if that helps to evacuate the feces from the bowel and resolve the gas and abdominal discomfort. No fluid treatment was done due to the severe anemia.

Day 2:

The patient is QAR and still seems painful in the abdomen. The epistaxis has stopped.

Good appetite with no vomiting.

40cc warm soapy water enema was given but no defecation.

DAY 3:

QAR. Painful around the abdomen, reluctant to move. Pain seems to have become generalized. No further epistaxis.

Good Appetite without vomiting

Urinated on her own but still without defecation. 60cc warm soapy water enema was given, which in 15-20 minutes produced a moderate amount of liquid/soft feces.

PCV = 8%

TP = 6 g/dL

The patient was radiographed again and showed multiple FB in the stomach and increased gas in the small and large intestine as shown in the figure below:


Evening of Day 3


Temperature decreased sharply to 97.9.


Blood transfusion was given very slowly at a rate of 4mL/hr (0.5mL/kg/hr) for 30 minutes while checking TPR, MM, CRT every 5min as to ensure the patient was not having a transfusion reaction of increased respiratory effort, injected MM, or tachycardia. The only change was the temperature increased by 1 degree from 97.9 to 98.9.


After the initial 30minute transfusion trial the rate was increased to 6mL/kg/hr at 50mL/hr.


Two hours later the patient developed profuse diarrhea and respiratory distress.


The blood transfusion was stopped immediately.


Dexamethasone and Diphenhydramine were given IV in case of a delayed transfusion reaction. However, at night the patient died.

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posted by Dr Banga's Websites @ 12:00 AM  
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