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Friday, October 1, 2010
Solution to case 21
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Radiographic findings:
Globe like cardiac silhouette with distended pulmonary veins.

Ultrasound findings:
Fluid around the heart (pericardial effusion). US also showed the fluid in the abdomen around the spleen, between the diaphragm, the liver and around the bladder.

Tentative diagnosis: Right sided heart failure/pericardial effusion.

Differential diagnoses for pericardial effusion include, tumors (most common especially in dogs greater than 7 years) such as hemangiosarcomas, chemodectomas (most often in brachycephalic breeds), ectopic thyroid carcinoma, mesothelioma,  lymphosarcoma.  Idiopathic pericardial effusion is the second most common cause and is usually found in dogs 6-7 years old.  Others include anticoagulant poisoning such as rat poison and other coagulopathies, pericardial cysts, constrictive pericarditis, infectious disease, atrial tear in small breed dogs, bacteria, FB, fungus, sepsis, trauma, viruses. Top differentials in this case include hemangiosarcoma, Idiopathic, coagulopathy, infectious or constrictive pericarditis.

Anemia and hypoproteinemia due to hypoalbuminemia shown by a low PCV and low TP suggest recent hemorrhage.  The nonregenerative anemia is likely due to acute disease within the last 4 days. High BUN and Creatinine are due to dehydration (prerenal azotemia).

Large cardiac Silhouette on radiographs suggests cardiac effusion. Muffled heart sounds are characteristic for pericardial effusion. In cardiac enlargement is heart sounds are louder, pinging heart sounds if the heart was enlarged.

Characteristic findings for pericardial effusion include a large globular cardiac silhouette rounded in all views, enlarged vena cava, and occasionally distended pulmonary veins. With small effusions, these findings may not be evident. Chest x-rays should always be carefully evaluated for evidence of a heart base mass and for metastatic disease. In this case an ultrasound also showed a pericardial effusion and ascities.

Ascites is a common sequel of pericardial effusion.  Pericardial effusion can lead to pericardial tamponade and right cardiac heart failure signs such as tachycardia, ascities, swollen limbs and increased respiratory rate.

Ultrasound helps to determine and locate any tumors in the heart.  If a mass is found it is important to biopsy the mass or pieces of the pericardium.  If mass is determined to be hemangiosarcoma there is a very poor prognosis and only a 3 mo survival period for most dogs without surgery.  Chemodectomas carry a better prognosis for 3 years survival with subtotal pericardectomy.

Further diagnostic tests:

1. Coagulation panel
To rule out any coagulopathies and make sure it is safe to perform pericardiocentesis.  Also, hemangiosarcoma may lead to minor DIC and coagulopathies.

2. Pericardiocentesis and abdominocentesis
They are more therapeutic than diagnostic.  

Pericardial effusion can be differentiated from peripheral blood in that it rarely clots unless it is from very recent hemorrhage and the PCV is significantly lower than that of peripheral blood.

The most common causes of pericardial effusion cannot be diagnosed due to the fact that hemangiosarcomas and chemodectomas do not exfoliate leading to a false negative result.  Reactive mesothelial cells may be mistaken for neoplastic resulting in a false positive result.  

In this case the fluid in pericardium was blood tinged with PCV <27%.

Abdominocentesis needs to be done to determine the type of the fluid (exudate, transudate or hemorrhagic). In this case abdominocentesis was performed and the fluid was found to be transudate.

3. Blood culture and sensitivity test:
This is required to rule out any infectious etiology for the pericardial effusion. In this case no organism was isolated.

4. 4 DX snap test was negative in this case.

Therapeutic plan:
This case was treated as indiopathic pericardial effuision as no mass was seen on the ultrasound.
The patient was stabilized (iv fluids) and pericardiocentesis was performed and animal was put on predisolone. Recheck was advised in 2 weeks time.
One pericardiocentesis may be enough in idiopathic pericardial effusion in 50% of dogs.  However, if more than 2 pericardiocentesis are required a subtotal pericardiectomy is recommended. +/- prednisone for inflammation after pericardiocentesis is performed.
In this case prognosis was fair as there was no recurrence of the pericardial effusion.
posted by Dr Banga's Websites @ 12:00 AM  
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