Case 21

A 4 year old intact male pit-bull mix canine  was presented to ACaseAweek Clinic for generalised weakness and a swollen left hindlimb since one week. He is both indoor and outdoor and he is fed home made food which is mainly rice and chicken. He is upto date on vaccination, heartworm and ectoparasites control.

Physical Exam:
Weight 25.1Kg
T: 100.9*F
PR/HR: 90bpm
RR: 36bpm
MM: Pale
CRT: >2sec
EENT: Normal
M/S – Swollen hind limb with pitting edema that is not painful.
Thorax: Muffled heart sounds on auscultation, but regular with no arrhythmias or murmurs noted.  Possible diminished lung sounds.
Abdominal palpation – Enlarged abdomen, with fluid wave on palpation.
LN: wnl
Neuro,  rectal – not examined.
BCS:  2/5

CBC and Chemistry:PCV 27% ( 37-55)
RBC morphology: mild anisocytosis and normochromic – non regenerative
No microfilaria seen,
All other values: wnl
ALB 1.9 g/dl (2.3 -4.0)
BUN 33 mg/dl (7-27)  
Creatinine: 1.7 mg/dl (0.5-1.6)
TP 4.8 g/dL (5.2 -8.2)
Urinalysis (free catch):Mild odor,
Color: yellow
SG: 1.020
Radiographs (Click to enlarge):

 

What are radiographic and ultrasound findings?What is your tentative and differential diagnosis?
What further diagnostic tests you will perform?
What will be your treatment plan?

Solution to this case

Solution to case 20

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Tentative diagnosis: FIV/FeLV

Differentials: FIV, FeLV, hemobartonella, cytoxazoon, Eosinophilic granuloma complex, superficial pyoderma, IMHA, hyperthyroidism, renal disease. 

Further diagnostic tests:IDEXX Combo FIV/FeLV snap test, blood smear for blood protozoa, impression smear of the oral lesions, skin scraping and bacterial culture and sensitivity for the skin lesions. T4 test. PCR test for hemobartonella is also available. 

In this case the IDEXX combo test was positive for FeLV. No blood protozoa was seen on the blood smear. No eosinophils were seen on the impression smear of the oral cavity. Skin scraping was negative. Culture for skin lesions was positive for Staph infection and sensitive to Potentiated Amoxicillin. T4 levels were normal.

Based on the clinical signs and results from CBC and IDEXX snap test, FeLV is at the top of the differential list.  Her general appearance, lethargy, skin condition and lymphadenopathy all are signs that the immune system is not functioning optimally. Increase in the BUN/Creatinine and total proteins is due to dehydration. 

FeLV is a retrovirus in the same family as HIV/AIDS in humans.  It is more common in outdoor cats and kittens.  It is transmitted primarily through saliva from sharing utensils or from bite wounds and licking.  It can also be transmitted via urine, tears, feces, milk and through placenta.   Its main effect is suppression of the immune system thus affected individuals have many other organ system issues. 30% of animals develop cancer (lymphosarcoma).  This virus also leads to bone marrow suppression thus this animal had non-regenerative anemia, leucopenia and thrombocytopenia. Animals can live for years with the disease but usually by the time the diagnosis is made, the cat is already viremic.  Expected lifespan is 1-2 years after diagnosis.
IDEXX combo snap test for FeLV needs to be repeated in six weeks or Immunoflourecent Antibody (IFA) test needs to be done to confirm the diagnosis.  

Treatment Plan:
Blood transfusion was done and supportive therapy was provided as follows:  
IV fluids - LRS
Antibiotics - Potentiated Amoxicillin
B-complex
a/d Hills diet (high nutrition diet for recovering sick animals)

Advised to keep the cat indoors and prevent being around others both so they are not possibly exposed to FeLV. Any secondary infections should be treated as soon as possible. FeLV in this case was repeated in six weeks and was still positive thus confirming the diagnosis.

Case 20

A 2.5 year old female spayed DSH outdoor was presented to the AcaseAweek Clinic with a five week history of lethargy, has not been eating for the past 2 days, and has many areas of alopecia accompanied by pruritis.  She is not up to date on vaccines nor is she on heartworm preventative.  She was given pyrantel 3 days ago.

Physical Exam:Weight = 2.2kg
Temp = 101.5
HR/Pulse = 204
RR = 36
General appearance: “scruffy” and unkempt
MM: pale but moist
Oral: Halitosis and stomatitis
CV: Tachycardia but strong pulse
Integument: Areas of alopecia on right lateral stifle, along dorsal spine, left abdomen, dorsal neck with associated areas of scabbing and pustules. Entire head had short fur and dry underlying skin.  
Musculoskeletal: Thin, BCS 2/5
Ears: Black/brown debris in both ears
Eyes: 3rd eyelids prolapsed
Lymph nodes: Superficial lymph nodes were reactive

CBC and Chemistry:
PCV = 9.8% (24-45)
Hb = 3.1 g/dl (8-15)
Granulocytes = 2.0x109/L (2.5-12.5)
Platelets = 21 x109/L (175-500)
BUN = 41 mg/dl (18-33)
Creatinine: 2.5 mg/dl (1.1-1.2)
Total protein = 9 g/dl (6.6-8.4)
Other values within normal limits

Urinalysis:
Appearance = normal
SG = 1.026
No other abnormality noticed in UA.



What is your tentative and differential diagnosis?
What further diagnostic tests you will perform?
What will be your treatment plan?

Solution to this case

Solution for case 19

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Radiographic findings:

Lateral view: New bone formation on ventral aspect of T13, L1, L2 and L3. Intervertebral disc (IVD) space between T13 - L1 and between L3 - L4 is reduced. Osteolytic lesions on the ventral aspect of L3.
VD View: Bone proliferation on the lateral aspect of T13-L1 and L1- L2 and L2 - L3. Reduced intervertebral space between L3-L4.

Tentative Diagnosis: Diskospondylitis.

Differentials: IVD protrusion, Vertebral fractures or luxation, Focal meningomyelitis, Vertebral neoplasia, Spondylosis deformans

Further diagnostic tests:
Myelogram, urinalysis, urine culture and sensitivity, brucellosis test (serology), blood culture for aerobes, anarobes and fungus, CSF analysis.
Urine and blood culture reports showed the Staphylococus spp sensitive to cephalexin. Brucellosis test was negative. CSF tap and myelogram was not performed in this case. 

Common infectious agent found in diskospondylitis lesions: 
Bacterial: Staphylococcus aureus and Staphylococcus intermedius are most commonly isolated. Other bacteria include Brucella canis, Streptococcus spp, Corynebacterium spp, Escherichia coli, Proteus spp, Pasteurella spp, and Bactericides spp.
Brucella is common in intact males. So unlikely in this case.
Fungal: Aspergillus spp and Coccidioides immitis
Focal meningomyelitis is still possible and a CSF analysis is needed to differentiate.

Intervertebral disk protrusion may cause similar clinical signs but can be differentiated on the basis of radiography and myelography. The lesion seen on radiographs was not consistent with intervertebral disk protrusion.
Vertebral fracture/luxation was not detected on radiographs.

Vertebral neoplasia usually does not affect adjacent vertebral end-plates. This is unlikely in this case due to adjacent vertebral end-plates being involved.

Spondylosis deformans rarely causes lysis of the vertebral endplates. 

Treatment plan

1. Cephalexin 1000mg BID PO for 6 weeks.
2. Tramadol 50mg 1 capsule BID PO for 5 days.Taper to 50mg SID for another 5 days to gauge the effectiveness of antibiotic therapy.
3. Recheck after 5days of therapy. If improvement is seen do clinical revaluation every 2 wks and radiographs every 2-4 wks.
4. If no improvement change the antibiotics and reassess.

Case 19

A 4.5 year old neutered male large breed mix canine was presented to AcaseAweek Clinic with sudden onset of acute hind limbs weakness for 2 days. The patient is both indoor and outdoor and is current on all the vaccinations, deworming and heart worm prevention.



Physical Exam:

T= 101.9 oF
HR/PR=114
R=panting
Weight= 37.8kg
MM=moist and pink
CRT=<2 sec



Neurological: Mild pain on palpation of spine in thoraco-lumber area.

No other abnormalities noted at this time on P/E.



CBC and Biochemistry: All values within normal limits.



4Dx snap test: Negative.



Radiographs: Pelvic radiograph on this patient was normal. Lateral and VD view of thoraco-lumber area were taken and are as shown below (Click on the images to enlarge):

What are your radiographic findings?
What is your tentative and differential diagnosis?
What further diagnostic tests you will perform?
What will be your treatment plan?




Solution to this case