Case 20

A 2.5 year old female spayed DSH outdoor was presented to the AcaseAweek Clinic with a five week history of lethargy, has not been eating for the past 2 days, and has many areas of alopecia accompanied by pruritis.  She is not up to date on vaccines nor is she on heartworm preventative.  She was given pyrantel 3 days ago.

Physical Exam:Weight = 2.2kg
Temp = 101.5
HR/Pulse = 204
RR = 36
General appearance: “scruffy” and unkempt
MM: pale but moist
Oral: Halitosis and stomatitis
CV: Tachycardia but strong pulse
Integument: Areas of alopecia on right lateral stifle, along dorsal spine, left abdomen, dorsal neck with associated areas of scabbing and pustules. Entire head had short fur and dry underlying skin.  
Musculoskeletal: Thin, BCS 2/5
Ears: Black/brown debris in both ears
Eyes: 3rd eyelids prolapsed
Lymph nodes: Superficial lymph nodes were reactive

CBC and Chemistry:
PCV = 9.8% (24-45)
Hb = 3.1 g/dl (8-15)
Granulocytes = 2.0x109/L (2.5-12.5)
Platelets = 21 x109/L (175-500)
BUN = 41 mg/dl (18-33)
Creatinine: 2.5 mg/dl (1.1-1.2)
Total protein = 9 g/dl (6.6-8.4)
Other values within normal limits

Urinalysis:
Appearance = normal
SG = 1.026
No other abnormality noticed in UA.



What is your tentative and differential diagnosis?
What further diagnostic tests you will perform?
What will be your treatment plan?

Solution to this case

Solution for case 19

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Radiographic findings:

Lateral view: New bone formation on ventral aspect of T13, L1, L2 and L3. Intervertebral disc (IVD) space between T13 - L1 and between L3 - L4 is reduced. Osteolytic lesions on the ventral aspect of L3.
VD View: Bone proliferation on the lateral aspect of T13-L1 and L1- L2 and L2 - L3. Reduced intervertebral space between L3-L4.

Tentative Diagnosis: Diskospondylitis.

Differentials: IVD protrusion, Vertebral fractures or luxation, Focal meningomyelitis, Vertebral neoplasia, Spondylosis deformans

Further diagnostic tests:
Myelogram, urinalysis, urine culture and sensitivity, brucellosis test (serology), blood culture for aerobes, anarobes and fungus, CSF analysis.
Urine and blood culture reports showed the Staphylococus spp sensitive to cephalexin. Brucellosis test was negative. CSF tap and myelogram was not performed in this case. 

Common infectious agent found in diskospondylitis lesions: 
Bacterial: Staphylococcus aureus and Staphylococcus intermedius are most commonly isolated. Other bacteria include Brucella canis, Streptococcus spp, Corynebacterium spp, Escherichia coli, Proteus spp, Pasteurella spp, and Bactericides spp.
Brucella is common in intact males. So unlikely in this case.
Fungal: Aspergillus spp and Coccidioides immitis
Focal meningomyelitis is still possible and a CSF analysis is needed to differentiate.

Intervertebral disk protrusion may cause similar clinical signs but can be differentiated on the basis of radiography and myelography. The lesion seen on radiographs was not consistent with intervertebral disk protrusion.
Vertebral fracture/luxation was not detected on radiographs.

Vertebral neoplasia usually does not affect adjacent vertebral end-plates. This is unlikely in this case due to adjacent vertebral end-plates being involved.

Spondylosis deformans rarely causes lysis of the vertebral endplates. 

Treatment plan

1. Cephalexin 1000mg BID PO for 6 weeks.
2. Tramadol 50mg 1 capsule BID PO for 5 days.Taper to 50mg SID for another 5 days to gauge the effectiveness of antibiotic therapy.
3. Recheck after 5days of therapy. If improvement is seen do clinical revaluation every 2 wks and radiographs every 2-4 wks.
4. If no improvement change the antibiotics and reassess.