Case 7

Presentation:
A 7 month old, intact female mixed breed canine was presented to AcaseAweek Clinic as an emergency with epistaxis of one night duration and abdominal pain of about 5 days duration.
The owner has recently placed rat bait (Klerat = Bradisacoum) under the house. The owner does not believe the patient ingested any but is not certain.
The dog is fed people food and chicken bones.
The owner does not and is unable to monitor urination and defecation as the dog lives outside.
The owner does not believe there was any trauma to the patient.

Physical Exam:

• Weight = 8.8kg
• T = 104
• mm = pale
• P = 210
• R = 40
• EENT: Pale conjunctiva, epistaxis x1 day
• C/V: Tachycardia, no other abnormalities heard
• U/G: Brown/mucoid vaginal d/c.
• GI: Very painful on abdominal palpation, mostly caudal abdomen.
• LNN: Mildly enlarged pre-scapular and popliteal LN’s
• The patient had a “hunched” appearance. The dog was shivering and had bloody nasal discharge (epistaxis). The epistaxis was more pronounced from the Right nare. The dog was also groaning.

CBC:

• PCV = 9.0%
• TP 6.0
• WBC = 3.1
• Plt = 41
• CBC revealed a severe hemorrhagic regenerative anemia with severe thrombocytopenia, leucopenia and granulocytopenia. MCHC was borderline normal/elevated.

Blood Chemistry revealed hypoalbuminemia along with borderline normal/high BUN and borderline normal/low Creatinine and ALT. All other values were within normal limits.
Radiographs of abdomen were taken as shown in following pictures:Give interpretations of the radiographs.
What is your tentative diagnosis? Give your differentials.
What further tests you will do to confirm your diagnosis?
How will you treat and manage this case?
Solution to this case

Solution for case 6

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Tentative diagnosis: Leptospirosis; Clinical signs with history of exposure to contaminated urine suggest leptospirosis.

Differential diagnosis:

• Immune-mediated hemolytic anemia
• Infectious canine hepatitis virus
• Canine herpesvirus
• Hepatic neoplasia
• Trauma/bacteremia
• Rocky Mountain spotted fever
• Ehrlichiosis
• Toxoplasmosis
• Renal neoplasia/renal calculi

Leptospirosis is an infectious disease that can cause renal azotemia as the bacteria cause damage to the renal tubules decreasing the capacity of the kidneys to excrete urea. Also Creatinine levels could be high if the glomerular filtration rate of the kidney decreases in a renal failure. Usually dogs with subacute Leptospirosis will present azotemia, high liver enzymes (AP more high than ALT), icterus, dehydrated, mild anemic (Leptospirosis damaging RBC walls and endothelium) and 20% of dog with thrombocytopenia do to vasculitis. High liver enzymes are also observed in dogs with leptospirosis. All these signs make this patient a suspect of subacute leptospirosis. Also clinical signs and history of “rats around the environment” increase the suspicion of leptospirosis.

Urinary tract obstruction, a post renal condition (frequently in male dogs) can also increase BUN/Creatinine levels but usually clinical signs as hematuria and urinary incontinence will be seen in the dog. This was not in this case, as he was urinating with no signs of hematuria and no urinary incontinence.

Further diagnostic tests:

• Leptospira isolated from blood and urine after 7-10 days of infection 
• 2 weeks after infection use liquid culture to growth
• Dark field microscopic, FA, Silver impregnation technique for tissue (Kidney, liver, lung) with the organism
• Serology
• Microscopic agglutination test
• Not good if the dog was previously vaccinated, or infected or had passive immunity
• ELISA (anti-lepto-antibodies), DNA probes, PCR

Treatment:

• Supportive therapy (IV fluids) and antibiotics
• Ampicillin: Leptospiremia
• Dosage 5-10 mg/Kg IV, IM, SQ BID
• Ampicillin 300 mg à 0.3 ml SQ BID
• Doxycycline: eliminate renal carrier state
• Dosage 5-10 mg/kg PO, SID
• Doxycycline (100mg)tablets BID
• Should be given for 1 month

Prevention:

• Vaccination at yearly intervals and more often in enzootic areas
• Be aware of new vaccines for Leptospirosis that induce immunity for new serovars

Be concern that it is a Zoonotic disease!!

• Owner of the pet should be oriented about how to manage the dog and give the complete dose of antibiotics to eliminate the carrier stage
• Clean the cage with bleach or diluted iodine

If the dog does not recover after the treatment further diagnostic test should be performed as kidney and/or liver biopsy, ultrasound, and x-rays.