Case 23

A 13 year old, female spayed, mixed breed dog was presented to AcaseAweek Clinic with history of collapse, depression, lethargy and vomiting 3 times the night before presentation. The patient had been anorexic for the past 2 days and appeared healthy previously. The patient lives mostly inside and her owner reported no possibility of accidental ingestion of foreign body or chemicals. Her vaccination status is current and she is on heartworm preventative. She was treated for Ehrlichiosis with doxycycline two months back.

Physical Exam:
Remarkable weight loss and muscle atrophy.
T: 98
P: 88
R: 44
MM: pale pink
CRT> 2 sec

Cardiovascular: murmur, cardiac arrhythmia, pulse deficit.
Respiratory: lungs sound clear
Abdomen: distended, positive succession, moderately painful

CBC/Cytology:
PCV: 23% [37-55]
WBC: 28.9 x103/μL [6-16.9]
Mature Neutrophils: 26.3 x103/μL [3.3-12]
Band Neutrophils: 0.6 x103/μL
Lymphocytes: 0.3 x103/μL
NRBC: 0.9 x103/μL
Smear: Platelets: 1-4/hpf
RBC morph: marked polychromasia, moderate anisocytosis

Biochemistry:
ALKP: 267 U/L [23-212]
ALT: 164 U/L [10-100]
AMYL: 2490 U/L [500-1500]
BUN: 130 mg/dL [7-27]
CREA: 6.1 mg/dL [0.5-1.8]
PHOS: >16.1 mg/dL [2.5-6.8]
TBIL: 1.4 mg/dL [0-0.9]

Urinalysis:
Bilirubin: ++
SG: 1.013
Blood: +++
pH: 5.0
Protein: +

Abdominocentesis:10 mL fluid was withdrawn.
Abdominal Fluid Analysis/Cytology:
Color: red
Turbidity: 3+
Protein: 7.2 g/dL
PCV: 23%
Smear: many RBCs, neutrophils and macrophages, moderate lymphocytes, almost no platelets seen, few reactive mesothelial cells.

What will be your tentative and differential diagnosis?
What further diagnostic test(s) you will perform to confirm your diagnosis?
What will be your treatment plan(s)?

Solution to this case

Solution for case 22

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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.