Solution for Case 13

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Radiographic findings: Complete fracture of caudal aspect of L6 and ventral displacement of caudal part of L6 and L7. Complete fracture of the left wing of the ilium. A lateral and VD radiographs of thoracic vertebrae were also taken and all appeared unremarkable. 

Diagnosis: Spinal cord trauma due to Fracture of L6/L7 (UMN damage to the spinal cord).

Differentials for the signs presented:

• Lumbar or sacral spinal trauma
• Trauma and fracture of any portion of pelvis

Treatment: Establish an IV catheter and place on twice the maintenance at 4ml/kg/hr fluid rate with lactated ringer solution. Administer buprenophine 0.2mg/kg IV for pain. Treatment options are spinal surgery and devices such as a doggie carts along with possible complications of urinary and fecal incontinence. After all diagnostics were evaluated, all the treatment options including euthanasia were discussed with the owner and the patient was euthanized with pentobarbital (390mg/kg). 

Case 13

Presentation:

A 9 to 10 month old intact female, mixbreed was presented to AcaseAweek Clinic around 2:30pm after being hit by a car approximately 6:40am that morning. Owner said that the patient started biting at her vulva and so blood was seen around the vulva and mouth. The patient was in lateral recumbency and manual manipulation was painful. 

Physical exam:

• Weight = 10kg, 
• TPR all WNL, 
• MM pink
• CRT<2 >
• EENT all normal 
• Thoracic auscultation was nonremarkable. 
• A mild lymphadenopathy was noted in all lymph nodes. 
• When palpating the caudal vertebrae an obvious defect of the vertebrae could be felt just cranial to the sacrum. 

Neurological exam: Hyperreflexia in both right and left hindlimbs. Withdrawl reflex was absent in both. Ischial groove reflex of the left hindlimb produces a reflex in the right limb that was hyperreflexive. Anus was flaccid and showed no tone. 

Radiographs of lumbosacral and pelvis region were taken as shown below (Click on image to enlarge):

What are the radiographic findings and diagnosis?

What are differentials for the signs presented?

How will you treat and manage this case?

Solution to this case

Solution for case 12

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Radiographic findings: Thoracic radiographs showed a valentine shaped heart with significant generalized cardiomegaly and enlarged pulmonary arteries and veins. Abdominal radiographs showed homogenous soft tissue opacities with little visceral details which strongly suggest the presence of a significant amount fluid in the abdomen.

Tentative diagnosis: Congestive heart failure (Hypertrophic cardiomyopathy).

Differentials:

• Heartworm
• Restrictive and Dilated cardiomyopathy
• Hyperthyroidism
• Feline infectious peritonitis (FIP)
• Feline asthma

Hypertrophic cardiomyopathy is common in the cat and is characterized by concentric ventricular hypertrophy in which the ventricular walls become thickened. The heart pumps well but cannot relax well during diastole. In addition, the thickening of the ventricles results in malorientation of the AV valves so the cat may develop mitral regurgitation. The cat may also develop dynamic aortic outflow obstruction secondary to the systolic anterior motion of the mitral valve.

Cat was positive for heartworm, and can be further confirmed by ultrasound which is more reliable in cats.

This patient is suffering from ascites and dyspnea secondary to hypertrophic cardiomyopathy complicated by heartworm disease. Thorax radiograph showed enlarged pulmonary arteries and veins which may be supportive of heartworm disease.

Two possible differentials are dilated cardiomyopathy caused by a taurine deficiency and restrictive cardiomyopathy caused by fibrosis of the endocardium, myocardium, or subendocardial tissues. These can be differentiated from HCM because dilated cardiomyopathy is rare since most cat foods are supplemented with taurine and restrictive cardiomyopathy usually shows enlargement of one or both atria and not a generalized hypertrophy.

A T4 test was done to rule out hyperthyroidism.

In FIP we will see presence of an exudate aspirated from the abdomen as well as an inflammatory CBC.

There was no eosinophilia present in the CBC to support a diagnosis of feline asthma; however, eosinophils in a transtracheal lavage would be more diagnostic.

Treatment:

Due to the dyspnea, the patient was immediately started on oxygen therapy with a pulse oximeter and oxygen levels increased from 80% to 98% oxygen saturation. A catheter was placed, IV fluids were started.

The patient was placed on furosamide (10mg IV twice a day) and diltiazem (10 mg/kg PO q24h) (Ca channel blocker) to treat the hypertrophic cardiomyopathy, pulmonary edema, and ascites. Fluid therapy was continued at twice the maintenance dose (2-3ml/kg/h) for 4 days.

Client education: The patient needs to be on daily heart medications for the rest of its life. Heartworm preventative needs to be given monthly to help prevent the heartworm disease from getting worse.

Case 12

Presentation:
A 20 yr old neutered male Siamese cat was presented to the AcaseAweek clinic for dyspnea, anorexia, and lethargy. The cat was brought in by people who were watching it while the owners have been away. Vaccination and heartworm prevention status’s are both unknown.


Physical exam:
Weight: 4.5kg
T: 101.2 F
P: 220
R:60
Mouth: severe odontoclastic resorptive lesions and gingivitis
Auscultation: Severe gallop rhythm with grade III systolic murmur with PMI greatest over the LAV valve, respiratory sounds: crackles.
Abdominal palpation: very distended with a fluid wave. No masses were palpated.
Musculoskeletal: Generalized Weakness
General appearance: depressed, dyspneic, weak


CBC and chemistry panel were unremarkable except a mildly elevated BUN and creatinine.

ELISA snap test was positive for heartworm.


Abdominocentesis cytology revealed an obstructive transudate that was mildly cellular, containing mostly round, mesothelial type cells with some neutrophils and few lymphocytes.


Once the cat was stabilized, thoracic and abdominal radiographs were taken and are shown below:

What are the radiographic findings?
What is your diagnosis?
Give differentials for your diagnosis.
How will you treat and manage this case?
Solution to this case

Solution for case 11

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Radiographic findings:

Skull radiographs showed massive loss of turbinate bones. Loss of alveolar bone on the maxillary side, showing clear tooth roots.

Tentative diagnosis: Tumor (Nasal adenocarcinoma)

Further tests: Nasal biopsy histopathology/cytology, rhinoscopy, bacterial cultures, fungal cultures, nasal swab/lavage, thoracic radiographs.

Differentials:

• Bacterial sinusitis
• Aspergillosis
• Trauma
• Tooth root abscess
• Foreign body
• Coagulopathy

Nasal tumors are rare but found primarily in long-nose breeds. Adenocarcinoma is most common nasal tumors in dogs. The average age for the onset of canine nasal tumors is seven years. The clinical signs typically associated with nasal tumors are sneezing, nasal discharge, epistaxis, exophthalmia, facial swelling, nasolacrimal duct obstruction and, sometimes, neurological disturbances. Deformation of the facial bone, hard palate, or maxillary dental arcade may be visible. These signs are non-specific since they mimic bacterial or mycotic rhinitis, sinusitis, dental diseases, nasal trauma or foreign bodies lodged in the upper respiratory tract. Definitive diagnosis of nasal tumors is achieved by cytology or histopathology. However, the final diagnosis is generally reached at a time when the tumor is already in an advanced stage, and has invaded adjacent nasal structures or more distant organs, such as the brain. The prognosis is generally poor as most nasal tumors are malignant. Radiotherapy and chemotherapy can prolong survival rates and improve the quality of life of dogs. Without treatment, the survival following diagnosis of nasal tumors is usually only a few months.

Aspergillosis, in dogs, is typically localized to the nasal cavity or paranasal sinuses and is usually caused by infection with A fumigatus. Nasal aspergillosis is seen mainly in dolichocephalic breeds. It begins in the posterior region of the ventral maxilloturbinate with signs of lethargy, nasal pain, ulceration of the nares, sneezing, unilateral or bilateral sanguinopurulent nasal discharge, frontal sinus osteomyelitis, and epistaxis. Gross lesions vary considerably with site of infection, but a layer of gray-black necrotic material and fungal growth may cover the mucosa of the nasal and paranasal sinuses. The mucosa and the underlying bone may be necrotic with loss of bone definition on radiographs.

Treatment: The patient was given Cefazolin 500mg (5ml) three times a day. A triple antibiotic ointment was also used when discharge was cleaned off. Tissue biopsy confirmed the adenocarcinoma. As it was a rescued animal, owned opted for euthanasia. If not euthanized we can go for surgery, radiation therapy and chemotherapy, but prognosis is poor.

Case 11

Presentation: A 3-6 year old intact male pothound canine, rescued with unknown history, was presented at AcaseAweek Clinic for castration. The only abnormality he had was unilateral mucous ocular and nasal discharge from the left side. While at the clinic, patient’s condition worsened over a weekend time. The ocular discharge became mucopurelent and the nasal discharge became bloody. His overall demeanor declined as his condition worsened.


Physical exam was performed, and besides the obvious nasal and ocular discharge he was physically sound. Nose was painful on palpation.

CRT: <2

Weight: 19.8 kg

Temp: 100.8°F

HR: 131bpm

RR: 22rpm

Auscultation revealed abnormal bilateral lung sounds.

The patient was tested for both ehrlichia and heartworm, testing positive for ehrlichia.

Blood chemistry and CBC values fell within normal limits except for Hct (30.5%), HGB (10.6g/dl), EOS (3.1 x 10), GLOB (6.3g/dL), and TP (9.0g/dL).

Under general anesthesia, radiographs were taken as shown below:

What are the radiographic findings?
What is your tentative diagnosis?
Give list of differentials for your tentative diagnosis.
How will you treat and manage this case?

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Solution for case 10

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Radiographs show radiopaque foreign body (FB) in pharyngeal region (indicated by green lined boxes/areas).

Differentials for the signs presented:

• Rabies
• FB
• Toxin ingestion
• Esophageal stricture
• Laryngitis
• Congential/Acquired esophageal weakness
• Cricopharyngeal Achalasia
• Pharyngeal Dysphagia
• Esophageal neoplasia

Rabies should always be suspected in all the cases of hypersalivation, dyaphagia and FB.

Esophageal stricture (cicatrix) can form from a prior esophagitis (e.g., subsequent to foreign bodies or severe gastroesophageal reflux) of any cause.

Laryngitis was ruled out due to lack of cough on palpation.

Congenital/Acquired esophageal weakness usually present with regurgitation with or without weight loss and were ruled out from the radiographic findings.

Cricopharyngeal achalasia is usually congenital and there is an incoordination between the cricopharyngeus muscle and the rest of the swallowing reflex which produces an obstruction at the cricopharngeal sphincter during swallowing.

Pharyngeal dysphagia is an acquired disorder related to myopathies, neuropathies and junctionopathies and the inability to form a normal food bolus. This would present most often in an older animal with regurgitation associated with swallowing.

Esophageal neoplasia such as primary sarcomas (due to Spirocerca lupi), primary carcinomas, leiomyomas/sarcomas were ruled out due to the age of the patient and toxin was ruled out due to the absence of more severe clinical signs.

Treatment and Management:

Surgical removal of the bone foreign body was decided to be the best treatment for this patient. The patient was sedated with 3mg/kg Propofol intravenously. Her oral cavity was evaluated with a laryngoscope and the FB was removed with alligator forceps. The FB was positively identified as fish bone vertebrae. The patient was given 2mg/kg ketoprofen subcutaneously for pain management and to reduce esophageal inflammation. After recovering from anesthesia puppy was offered some soft food which she ate immediately.

The patient was given Clavamox 15 mg/kg bid for 7 days and advised the owner to feed the puppy soft diet for 2 weeks. The patient has now made a full recovery.

Case 10

Presentation:

5 month old, intact female pit mix canine was presented to AcaseAweek Clinic with chief complaint of hypersalivation and retching for few hours. Puppy was up to date on vaccination and deworming. Puppy is indoor/outdoor.

Physical exam:

• QAR, slightly lethargic
• Weight: 6.1kg
• Choking and gagging induced by gentle palpation of the laryngeal region
• Hypersalivation
• MM pink
• Abdomen distended
• Fleas and ticks present
• Waxy debris in both ears

Radiographs of head and neck region were taken as shown below:

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Give radiographic interpretation.

What is your diagnosis? Give differentials for the signs presented.

How will you treat and manage this case?

Solution to this case

Solution for case 9

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Radiographic interpretation: Lateral radiograph shows the loss of cardiac silhouette and loss of continuity of the diaphragmatic line. Gas filled loops of intestine are seen in the thorax. There are also poor thoracic details on the ventral caudal thorax. On VD view we can see fissure lines on the left thorax suggestive of the pleural effusion. On the right side of thorax we can see loops of gas filled intestine.

Diagnosis: Traumatic diaphragmatic hernia / pleuroperitoneal hernia.

Treatment and management: Surgery to repair the ruptured diaphragm after patient has been stabilized is the treatment of choice. Oxygen should be supplied if animal is dyspenic. If pleural effusion is present, thoracentasis should be performed. If animal is in shock, should be treated first for shock. If stomach is herniated surgery should be done at earliest possible as gastric dilatation may further compromise the respiration. Mortality is higher when surgery is performed within 24 hours or after 1 year of the injury.

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