Solution for case 15

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Radiographs: Nephrolith found in renal pelvis of the left kidney.

Diagnosis: Calculi in renal pelvis and secondary cystitis.

Further diagnostic tests:

• Ultrasound: Shadow effect from left kidney pelvis suggested of mineralized material present.
• Urine Culture and Sensitivity: Proteus and Klebsiella cultured, both sensitive to Clavamox.

Urolithiasis:

The etiology of urolith formation is multifactorial including concurrent urinary tract infection, diet, intestinal absorption, urine volume and frequency, drugs, and genetics. Nephroliths are often asymptomatic unless the patient has a concurrent pyelonephritis. Nephrotomy is indicated for removal of nephrolith.

Cystitis:

The urine had an alkaline pH which favours the formation of struvite crystals. Proteus species are urease producing bacteria which cause the pH of urine to increase thus favouring the conditions for struvite crystal formation. 

Treatment and management:

1. Antibiotic therapy (Clavamox) was initiated and after 3 weeks urinalysis showed that the numbers of bacteria had decreased to few and there was a marked decrease in the amount of blood in the urine showing a positive response to therapy. 
2. The patient’s diet was changed to Hill’s S/D to acidify urine to prevent recurrence and dissolve crystals in urine. 
3. After 3 weeks of antibiotic course, Nephrotomy was performed to remove the urolith from renal pelvis of left kidney.
4. The patient was continued on another 3 weeks on Clavamox.
5. Repeat CBC and urinalysis after one month.
6. Owner advised to monitor the patient at home for stranguria, hematuria, dysuria, appetite and attitude.

Case 15

Presentation:

A 9 year old spayed female poodle was presented to AcaseAweek Clinic with a one month history of bloody urine which has progressively gotten worse in the past 2 weeks. The owner claims to have seen blood clots passed in the urine recently. The patient has not been eating well for the past 2 days and has vomited 4 times in the past 24 hours. Animal is unvaccinated and has no history of flea or heartworm prevention. Dog is fed home-made food. 

Physical exam:

• Weight: 7.04 kg 
• Temperature: 105.2 F
• Pulse: 112 bpm
• RR: 54 
• MM: pale
• CRT: 2 sec

Complete Blood Count:

• Hct: 27% (37-55)
• RBC: 5.2 x109/L (5.5-8.5)
• Hb: 10.3 g/dL (12-18)
• WBC: 3.2 x 109/L (6-16.9)
• Grans: 1.7 x 109/L (3.3-12)
• PLT: 374 x 109/L (175-500)
• TP: 9 g/dL (5.2-8.2)
• nRBC : 1%

Biochemistry Profile:

• AP: 65 U/L (23-212)
• ALT: 35 U/L (10-100)
• Glob: 4.9 g/dL (2.5-4.5)
• Alb: 2.6g/dL (2.7-3.7)
• BUN 33 mg/dL (7-27)
• CREA 1.3 mg/dL (0.5-1.8)

Urinalysis:

• Colour: Red
• Odour: Strong
• Turbidity: 3+
• G: 1.019
• pH: 8.5
• Glucose: -ve
• Bilirubin: -ve
• Ketones: -ve
• Protein: 4+
• Blood: 3+
• RBC: 3+
• WBC: 3+
• Squamous: few
• Transitional epi: -ve
• Tubular epi: -ve
• Bacteria: 3+
• Casts: -ve
• Crystals: 2+ (struvite)

Abdominal radiographs were taken as shown below (click on the image to enlarge):

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Solution to this case