A 13 year old, female spayed, mixed breed dog was presented to AcaseAweek Clinic with history of collapse, depression, lethargy and vomiting 3 times the night before presentation. The patient had been anorexic for the past 2 days and appeared healthy previously. The patient lives mostly inside and her owner reported no possibility of accidental ingestion of foreign body or chemicals. Her vaccination status is current and she is on heartworm preventative. She was treated for Ehrlichiosis with doxycycline two months back.
Physical Exam:
Remarkable weight loss and muscle atrophy.
T: 98
P: 88
R: 44
MM: pale pink
CRT> 2 sec
Cardiovascular: murmur, cardiac arrhythmia, pulse deficit.
Respiratory: lungs sound clear
Abdomen: distended, positive succession, moderately painful
CBC/Cytology:
PCV: 23% [37-55]
WBC: 28.9 x103/μL [6-16.9]
Mature Neutrophils: 26.3 x103/μL [3.3-12]
Band Neutrophils: 0.6 x103/μL
Lymphocytes: 0.3 x103/μL
NRBC: 0.9 x103/μL
Smear: Platelets: 1-4/hpf
RBC morph: marked polychromasia, moderate anisocytosis
Biochemistry:
ALKP: 267 U/L [23-212]
ALT: 164 U/L [10-100]
AMYL: 2490 U/L [500-1500]
BUN: 130 mg/dL [7-27]
CREA: 6.1 mg/dL [0.5-1.8]
PHOS: >16.1 mg/dL [2.5-6.8]
TBIL: 1.4 mg/dL [0-0.9]
Urinalysis:
Bilirubin: ++
SG: 1.013
Blood: +++
pH: 5.0
Protein: +
Abdominocentesis:10 mL fluid was withdrawn.
Abdominal Fluid Analysis/Cytology:
Color: red
Turbidity: 3+
Protein: 7.2 g/dL
PCV: 23%
Smear: many RBCs, neutrophils and macrophages, moderate lymphocytes, almost no platelets seen, few reactive mesothelial cells.
What will be your tentative and differential diagnosis?Physical Exam:
Remarkable weight loss and muscle atrophy.
T: 98
P: 88
R: 44
MM: pale pink
CRT> 2 sec
Cardiovascular: murmur, cardiac arrhythmia, pulse deficit.
Respiratory: lungs sound clear
Abdomen: distended, positive succession, moderately painful
CBC/Cytology:
PCV: 23% [37-55]
WBC: 28.9 x103/μL [6-16.9]
Mature Neutrophils: 26.3 x103/μL [3.3-12]
Band Neutrophils: 0.6 x103/μL
Lymphocytes: 0.3 x103/μL
NRBC: 0.9 x103/μL
Smear: Platelets: 1-4/hpf
RBC morph: marked polychromasia, moderate anisocytosis
Biochemistry:
ALKP: 267 U/L [23-212]
ALT: 164 U/L [10-100]
AMYL: 2490 U/L [500-1500]
BUN: 130 mg/dL [7-27]
CREA: 6.1 mg/dL [0.5-1.8]
PHOS: >16.1 mg/dL [2.5-6.8]
TBIL: 1.4 mg/dL [0-0.9]
Urinalysis:
Bilirubin: ++
SG: 1.013
Blood: +++
pH: 5.0
Protein: +
Abdominocentesis:10 mL fluid was withdrawn.
Abdominal Fluid Analysis/Cytology:
Color: red
Turbidity: 3+
Protein: 7.2 g/dL
PCV: 23%
Smear: many RBCs, neutrophils and macrophages, moderate lymphocytes, almost no platelets seen, few reactive mesothelial cells.
What further diagnostic test(s) you will perform to confirm your diagnosis?
What will be your treatment plan(s)?
Solution to this case
5 comments:
Tentative diagnosis:-
Anemia R/O blood loss, haemorrhagic,hemolytic , chronic disease ,
Murmur , cardiac arrythmia , pulse deficit R/O anemia , cardiac disease
distended abdomen R/O hemorrhage , ruptured spleenic mass, intestinal rupture , tumor.
Chemsitry and CBC R/O anemia , inflamation , renal compromise ,effect on liver ,
Abdominocentesis - fluid shows blood having high PCV and Protein .
Further Diagnostic plans
1. radiography
2. ultrasound
Tentative Diagnosis:
Unresolved Chronic Ehrlichiosis
Differential Diagnosis:
(1)Rocky Mountain Spotted Fever - do serologic testing
(2) SLE - perform ANA test
(3) Chronic Lymphocytic Leukemia - do cytology of bone marrow
Additional Diagnostic Tests to Confirm Chronic Ehrlichiosis:
PCR, IFA and Tests for Other Accompanying Pathogens: Babesiosis, Hemobartonellosis, Hepatozoon
TREATMENT:
(1)Initial medication for anemia and hemorrhagic tendencies, balanced electrolyte solution, platelet-rich plasma or blood transfusion
(2)Doxycycline 10mg/kg PO q 24 hours for 14 days, Give IV for 5 days because dog is vomitting
(3) Imidocarb - as an alternative to Doxycycline, 5mg/kg for 2 doses for 14 days apart
(3) Oxymetholone or Nandrolone Decanoate to stimulate bone marrow production
(4) Treat also against ticks
Patient Case Management
(1) Platelet Monitoring - every 3 days
(2)Serologic Testing - repeat after 9 months
Diagnosis:
Hemangiosarcoma
Tests: Thoracic and abdominal radiographs to look at the extent of spread and organs involved
RX: Surgical or Doxirubicin
Prognosis: grave
Radiography or ultrasound were not diagnostic in this case because of lots of fluid in abdomen.
hemangiosarcoma
Post a Comment