Case 16

Presentation:

A 2-year-old intact male, mix-breed dog was presented to AcaseAweek Clinic with history of loss of appetite for 2 weeks duration, rapid weight loss, labored breathing, and lethargy. The patient lives in an outdoor/enclosed area. Vaccines are overdue and the patient was de-wormed two months ago with fenbendazole. The patient is not on heartworm prevention. His diet consists of dried kibble mixed with rice fed once daily in the morning.

Physical exam:

• BAR
• Weight 14.3kg.
• Temp: 102.3oF
• HR/PR: 140
• RR: 40
• CRT <2>
• MM: pink and moist
• Body score: 2/5
• Patient showed respiratory distress with mild inspiratory effort, had shallow breathing but no open mouth breathing. The patients lung sounds were decreased ventrally. 
• Heart sounds were muffled. Abdominal and rectal palpation revealed no abnormalities. 

CBC and Chemistry: All values fell within normal limits. The snap test for heartworms, lyme, and ehrlichia was negative. Thoracic radiographs were taken as shown below (click on image to enlarge):

What are the radiographic findings?

What is tentative diagnosis?

What further diagnostic tests will you perform to confirm your diagnosis?

How will you treat and manage this case?

Solution to this case

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.