Solution for case 22

Click here to see this case


Tentative diagnosis: Protein-loosing nephropathy. 

Differential diagnosis: Glomerulonephritis, amylodosis, idiopathic glomerulopathy, liver disease, right sided heart failure, protein loosing enteropathy.  

Further diagnostic tests:
1. Abdominocentesis: Analysis of fluid revealed transudate nature.

2. Urine Protein:Creatinine ratio: more than 4 (less than 1 is normal)

3. 4DX snap test: Negative in this case. 

4. Renal Biopsy: To formulate prognosis by differentiating between glomerulonephritis and amylodosis. Renal biopsy was not done in this case. 

5. Fecal float for GI parasites: no parasite eggs were found. 


Although there are many causes for abdominal effusion or ascites, hypoalbuminemia, due to protein losing enteropathy or liver failure, can be ruled out at this time based on normal liver enzyme, negative fecal float and balanced diet for this patient. The abdominal fluid sample tested yielded a transudate, a potential cause could include a protein losing nephropathy/enteropathy or liver disease. In this case the hypoalbuminemia, hypercholestrolemia, proteinuria and urinary hyaline casts are hallmark of protein loosing nephropathy (nephrotic syndrome). Thromboembolism is a potential complication in such cases because of the reduced antithrombin III.

Most probable suspected cause here is the idiopathic.

This patient also had severe peridontal disease. 

Therapeutic Plan:  
Treatment is usually difficult and unrewarding. Prognosis is guarded in this case.
Abdominocentesis to make animal comfortable.
Sodium restricted diet. High quality low quantity protein diet (Hill’s k/d)
Enalapril: Vasodilator, Reduced sodium retention and reduce proteinuria and hypertesion.
Restricted activity and anticoagulants (aspirin) to reduce chances of thromboembolism.

Case 22

A 12 year old, intact female Pompek canine presented to AcaseAweek clinic for abdominal distention.  The owner reported abdominal distention worsening for last one and half week.  As the patient was eating, drinking, eliminating and otherwise showing no remarkable behavioral changes at home, the owner was unsure of the exact duration of her condition.  The dog is upto date on vaccines and deworming but not on any ectoparasite or heartworm control. Animal is fed Hill’s Science diet for senior dogs. 
Physical Exam:
Weight= 5.5 kg
T=100.9 °F
HR/PR=160 bpm  
RR=panting/open mouth breathing
EENT:  Normal, except right prolapsed third eyelid
Oral:  MM pink/moist, CRT<2s, Halitosis, Excessive tartar, gum recession, missing teeth: 101/102, 201/202, 301-303, 401/402
LLN:  Normal
Thorax:  Heart/Lung auscultate normally, with normal peripheral pulse, no jugular vein            distention
Abdomen: Distended, Firm, Unable to palpate internal organs, No pain on manipulation, +ve reaction on Ballotment
U/G: Normal, intact
Skin: Normal
MSk: BCS 2/5
Neuro: Normal
CBC/Chemistry:
PCV= 31.7% (37-55%)
Albumin= 1.2g/dl (2.6-4.0 g/dl)
Total Protein=3.8g/dl  (5.5-7.5 g/dl)
Cholesterol= 347 mg/dl (116-254 mg/dl)
All other values WNL
Urinalysis:
Protein= Dipstick protein ++++
Hyaline casts and few RBCs observed in urine sediment.
What is your tentative and differential diagnosis?
What further diagnostic tests you will perform?
What will be your treatment plan?