Case 8

Presentation: 

A six month old, intact, male, mix breed dog (pothound) was presented to AcaseAweek Clinic with a history of anorexia, weight loss and lethargy. The dog has an indoor/outdoor lifestyle, is fed puppy Science Diet, is up to date on its vaccinations and is treated for ectoparasites with Adam’s spray. The owner was away during the summer and upon return found ticks on the dog. There are four other dogs in the household, one of them is showing similar clinical signs and happens to be this patient’s brother. 

Physical examination revealed that the patient was mildly depressed, alert and responsive, had a temperature of 100.4ºF, heart rate was 100bpm, respiratory rate was 12bpm and weighted 18.2 kg.

Ears, eyes, nose, throat: mild black, thick, tarry exudate on both ears. No ocular or nasal discharge observed.

Mucus membranes: grey, pale and slightly yellow (icterus). CRT<2>

Lymph nodes: generalized lymphadenopathy.

Laboratory tests:

Snap test: Ehrlichia, Heartworm, Anaplasma and Lyme disease negative.

CBC: unremarkable, except for mild eosinophilia.

Chemistry profile:

• AP 1259 U/L (46-337)
• ALT 673 U/L (8-75)
• Glob: 4.1 g/dL (2.3-3.8)
• TBIL: 1.3 g/dL (0.0-0.8)

Urinalysis- unremarkable.

What is your tentative diagnosis? Give list of differentials.

What diagnostic test(s) will you perform to confirm your diagnosis?

How will you treat and manage this case?

Solution to this case

Solution for case 7

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Radiographs showed that stomach has ingesta in it with some radiopaque materials. Large amount of gas was found in small intestine. Colon was full of fecal material with some radiopaque material.

Tentative diagnosis: Ehrlichea (because of thrombocytopenia) and foreign body in stomach

Further diagnostic tests:

4Dx SNAP test: Heart Worm - negative, Ehrlichea canis + Positive, Anaplasma – negative, Lyme – negative

Coagulation panel: to rule out the rodenticide poisoning.

Ehrlichea: Active infection confirmed by SNAP test, fever and thrombocytopenia are likely responsible for the epistaxis. Epistaxis is the most frequent hemorrhage due to ehrlichea. Increased BUN suggests the possibility of a GI bleed. The Ehrlichea also accounts for the fever and lymphodonopathy. Trauma and rodenticide poisoning are differentials.

Abdominal pain: With a Hx of being fed chicken bones and the multiple opacities in the lower GIT a foreign body (FB) is suggested. The radiographs showed a substantial amount of feces in the large colon with a large amount of gas in the small intestine which may suggest ileus/obstruction from a FB or constipation.

Treatment:

Doxycyline 10mg/kg (88mg) IV SID to treat Ehrlichea.

20cc warm soapy water enema and repeated later in the day to empty the bowel and see if that helps to evacuate the feces from the bowel and resolve the gas and abdominal discomfort. No fluid treatment was done due to the severe anemia.

Day 2:

The patient is QAR and still seems painful in the abdomen. The epistaxis has stopped.

Good appetite with no vomiting.

40cc warm soapy water enema was given but no defecation.

DAY 3:

QAR. Painful around the abdomen, reluctant to move. Pain seems to have become generalized. No further epistaxis.

Good Appetite without vomiting

Urinated on her own but still without defecation. 60cc warm soapy water enema was given, which in 15-20 minutes produced a moderate amount of liquid/soft feces.

PCV = 8%

TP = 6 g/dL

The patient was radiographed again and showed multiple FB in the stomach and increased gas in the small and large intestine as shown in the figure below:

Evening of Day 3


Temperature decreased sharply to 97.9.


Blood transfusion was given very slowly at a rate of 4mL/hr (0.5mL/kg/hr) for 30 minutes while checking TPR, MM, CRT every 5min as to ensure the patient was not having a transfusion reaction of increased respiratory effort, injected MM, or tachycardia. The only change was the temperature increased by 1 degree from 97.9 to 98.9.


After the initial 30minute transfusion trial the rate was increased to 6mL/kg/hr at 50mL/hr.


Two hours later the patient developed profuse diarrhea and respiratory distress.


The blood transfusion was stopped immediately.


Dexamethasone and Diphenhydramine were given IV in case of a delayed transfusion reaction. However, at night the patient died.