Your Pet's Best Friend

Diagnostic Workup Success - that almost wasn't.

This is Molly.  A few days ago she was presented for an examination.  She had been limping a little the night before and just didn't feel well.

There was no lameness when she came in, but she didn't have much mojo.  She didn't seem in any distress really, just no energy.  She also had not wanted to eat much.  There was no fever, nothing seemed swollen or out of place, and I couldn't find a sore spot anywhere.

She lives in a fenced yard, so trauma didn't seem likely, even though she shares it with another pretty big dog.   There just wasn't really anything to put your finger on, but you could tell she was unhappy.

I was about to send her home with some anti-inflammatory medicine, thinking she might have slipped and made a bad landing in the mud the night before.  Then her owner said, "You know she usually chews on everything, but she doesn't want anything today."  I asked, "Everything, as in a lot of things that aren't food?"  She replied in the affirmative.

With that piece of information, I thought of all the dogs with foreign body intestinal blockages I have seen who had no specific outward signs -- they just didn't feel good. "Let's take an X-ray of that belly. We probably won't see anything, but I'd hate to miss a ridiculously obvious foreign object."  Okay, let's do it.

The abdominal X-ray looked normal, but there was a little bit of the chest on the film, too.  When I looked at the whole film, the chest part looked "funny" (funny-strange, not funny-haha).  We took pictures of the chest.

There was what appeared to be a significant amount of fluid in the chest.  That will make you feel bad.  We tapped her chest - it was blood.  Internal bleeding will also make you feel bad.  In your chest, it will squish your lungs and eventually keep you from breathing, even if you don't go into shock first.

Even though there was no history of exposure to rat-poison, we filled her full of vitamin-K (the antidote).  That stuff makes the dog a free bleeder, and bleeding into the chest (hemothorax) is not uncommon.  Since my associate is pretty knowledgeable in Chinese medicine, we also started the herbal preparation called Yunnan Baiyao, as it helps to get the body's own clotting mechanisms into high gear.

The alternatives to rat-poison were not happy ones: a bleeding tumor, some other abnormal structure that had begun to bleed, or some other heretofore unnoticed bleeding disorder in the dog.  All of those have a terrible prognosis, not to mention that referral to a surgical specialist was not in the cards.

Thankfully, Molly has responded well to treatment and seems about normal now.   Who takes a full set of X-rays every time a patient just "doesn't feel good"?  Nobody.  A chance remark, a look at the wrong place, and we got an accidental look at the right place.  And I almost sent her home with some pain-killers.  Serendipity, it's called.

Testimony to Good Nursing Care

A stray cat had kittens out in a fellow's shed.  She took off and abandoned two  of them.  One of them had already died, and the second was just dragging himself around a little.  This tender-hearted gentleman brought in the surviving kitten.  He had been working at feeding it formula.  

He was pretty sure about the date of birth, and the kitten was right at two weeks old when we first saw it on June 25.  The little guy should have weighed 8 ounces, but he only weighed five.  He was very thin, and potbellied, like your average starving refugee.  There was plenty of flea-dirt on him, and we didn't think he could afford the extra blood loss.

So, we treated him for parasites, deworming and got rid of the fleas.  We showed the owner how to stimulate the little guy to eliminate after each feeding, and recommended bumping up the frequency of the feeding.  At this age, they can't really maintain body temperature without some help from mama.  Thus, a heating pad needs to be provided, with the option to get on or off, as needed.

He seemed a little better over the next couple of days, but on June 30, he seemed to be shutting down.  He had gained only about 8 grams (less than 1/3 of an ounce).  His eyes were mattered shut and he was at least 10% dehydrated.  We gave him fluid therapy, and some glucose for energy.

The next day, he was reported 100% better.  The day after that, he was crashing again with  diarrhea, and his legs were weak again.  He was up to six ounces now, gaining one ounce in 7 days.  Four ounces would be a more normal rate.

More fluids, started on Albon suspension for possible coccidia (a microscopic one-celled parasite that causes malabsorption of nutrients, and eventually diarrhea).  We also sent home some Nutri-cal to use between bottle-feedings.

Day 17, and he's up to ten ounces (should be 17 or 18).  He had been doing better, but his eyes are all cruddy with discharge.  We re-dewormed him, and started an antibiotic eye ointment.  He was still taking the Albon.  Still taking a bottle, too. 

Day 19, now he's coughing a little, but the good news is that he will eat solid food, at least he'll eat really soft solid food (Hill's A/D is about the consistency of soft-serve ice cream).  We changed his antibiotic, too.

Day 21 - He is feeling better, up to almost eleven ounces, and owner is feeding a teaspoon of A/D every three hours.

Day 23 - Up to 11.5 ounces, and feeling much better, hardly coughing at all now.

Day 39 - Up to 22 ounces, starting to look like a winner, eating better and time for re-deworming.

Day 61 - He weighs nearly three pounds and he's just a little over three months old, so he is just about caught up.

The point of this heart-warming story is that here at Kennett Veterinary Clinic, we didn't do much.  Sure, we gave fluid therapy, prescribed medicines that helped, and so forth.  All the real work was done at home:  all that hand-feeding every three hours... for weeks, noticing every time that something started south, rushing him right in whenever things changed, constant tender loving care.  You can't dispense that in a bottle, and you can't give it in a "shot". 

The good nursing care is what saved this little guy, and the owner is the nurse who deserves the credit.

 

Osteomyelitis in a Toe

This is Storm today.  She looks pretty happy.  That's because her toe is not hurting nearly so badly as it was 10 days ago.  Now she can walk on her right hind paw, though it still gets sore toward the end of the day.

 Here she is 10 days ago, not putting that paw on the ground at all.  It hurts too much to bear any weight on toe #5.  

Here's a close-up of toe #5 before beginning treatment.  It does NOT look good. The X-rays look bad, too.

 

 

 

Here are normal toes on the left, and the affected toe on the right.  The third phalanx (last bone at the tip, also abbreviated P3) is the bone the nail grows from. Notice that the P3 on that bad toe just looks like it exploded. (Sorry my pictures are not as well in focus as I'd like.) 

That could be anything from a bone infection (osteomyelitis) to bone cancer.  There could have been a wound, a nail pulled loose and infected, a penetrating foreign object.  A biopsy could be your next step (taking a small piece of abnormal tissue).  Sometimes that doesn't give you all the information you'd like to have.  In this case, the clients opted for a trial therapy of antibiotics first.

If you don't have bone cancer (or some other kind of cancer that happens to be eating into the bone nearby) and if you picked the right antibiotics (and they get into the bone), it might get better.  If it does, great, and keep taking your medicine for the next four to six weeks.  If not, it's biopsy time, or maybe even amputation time (the toe, not the leg).

And it is better, at least 50% better.  The swelling is down by half, and (as noted above) she can walk most of the day on it before it starts getting sore.  So, we're optimistic.  It may still "go south" on us, but we're optimistic (and continuing treatment).

 

Mega-Esophagus and "The Third Opinion"

This is Bear.  He's nibbling at the grass here.  For over one year he has had frequent episodes of vomiting.  Sometimes it's just a little fluid, sometimes undigested food, sometimes a little grass, or a combination of the above.

He came to see us after having numerous unsatisfactory attempts at treatment.  "I'm here for a second opinion." Third, actually.  My associate spent a long time getting the past medical history, everything that has been tried and the results (or lack of them) of those efforts.  That's par for the course when you are giving a "second opinion".

The "second opinion" case is not something I really look forward to, at least not when something has been going on for a year.  This suggests that the problem is not simple nor straightforward, and it probably isn't going to "fix itself".  If any of those were the case, I wouldn't be seeing it. 

So, more often than not, you spend a long time extracting the history, and documenting it, and concluding that the other doctor has been very thorough and done everything you can think of and it did not work.  Oh, I can hardly wait to see one of these cases.  They really ought to be seeing a specialist, but they are seeing me instead.  Hard to be a hero on these.

Of course, sometimes you just have a different point of view than the other guy (gal).  After working with a case for a long time, you can get tunnel-vision.  You have made that initial assessment and it biases everything you do after that.  So, a fresh pair of eyes (and ears) sometimes has an easier time finding a fresh perspective on the case.

My associate started over with basic lab tests.  Some had been done before, some hadn't.  At any rate, we needed to see where Bear was at present.  We might get a clue. [In a referral situation, they recommend a "minimum database", which includes  a complete blood count, biochemistry profile of 12 to 20 tests, a stool exam and a urinalysis.]  In this case, there was nothing in the data to suggest a specific diagnosis.

Bear's owner said, "Just keep him a couple of days until you find out what it is. I'm tired of going round and round with this."  So now it's my turn. Hey, no pressure.

Ah, but here was that rare case.  There is a logical progression of diagnostic tests.  I can see what has already been done, I can see what hasn't worked.  I don't have to do any of that over again myself, and there is a clear next step.

Vomiting food that isn't digested.  Maybe it isn't even getting to the stomach.  "Have you tried feeding him with his dish elevated?  Does it make a difference?"  Well, yes they have, and maybe it does.

So, I take an X-ray of his chest.  You can't tell much about his esophagus, but his trachea (windpipe) looks pushed down out of place a little.  Then I mixed a little barium with some dog food and Bear scarfed it right down.

Now, your esophagus is firm, small, muscular tube (when it's normal).  It squeezes the food right on down to your stomach without the aid of gravity.  If you stand on your head, it squeezes the food right on up to your stomach when you swallow. [I tried that in seventh grade.  I used a pillow under my head, and leaned against a wall so I wouldn't fall, and I used a straw to drink the water.  It worked.]  The food goes right on down (or up) in a hurry.  Unless you have mega-esophagus.[Follow the link to a discussion on Veterinary Partner.]

Bear has mega-esophagus.  He's had it all along.  I found it with the first test I ran.  All that food should be in his stomach, not in his chest.  I look like a genius, but it's just the luck of the draw.  It's one of those rare occasions when being the "third opinion" doesn't turn out to be a major frustration.

Since Bear's esophagus is a big flabby sack (instead of a firm, muscular tube), and further testing shows no thyroid problems and no myasthenia gravis (possible causes), he will have to rely on gravity.  From now on, he gets to eat while standing on his hind legs.  Some fun, huh?  Too bad the "genius" can't cure what I diagnosed.

Spay your dog while she's young and healthy - new episode.

I have posted before on this very subject before.  Today's case is just too much for words (unless, like myself, you've got a way with words).  Little miss Backtrack here is in a pretty precarious situation today due to several serious medical problems.  I didn't get to ride my motorcycle on this beautiful day, as I've had to spend most of my so-called "afternoon off" riding herd on her condition.

She came in this morning with a history of being sick for two days, and a bloody, nasty vaginal discharge for two days.  Nine years old and never been spayed.  My receptionist suspected pyometra just from that description over the telephone, and she was not wrong. [Here are your review articles on Pyometra and Pyometra with gross pictures.]  Backtrack also won't eat, and has been vomiting, as well.

Physical exam shows her to be between 5% and 10% dehydrated... and a little thin.  "Wow!  She's really lost weight if she just weighs 12 pounds.  She weighed 16&1/2 pounds two months ago when she got her shots." [Somewhere else - the same somewhere else that told her not to worry about the breast tumor one  year ago, which has doubled in size since then.]

Ultrasound shows an empty bladder (bad, but not too surprising since she is approaching the hydration status of a raisin), and more importantly, the uterus is not enlarged with a ton of pus.  This is good, because the pus has mostly been draining out her cervix.  So, even though it's making her sick, it's not about to explode inside her.  That's good.

All the experts say, "Don't let the sun set on a pyometra."  In other words, do surgery to take it out, as soon as possible.  In this case, though, we need to get her hydrated.  Also, it wouldn't be bad to check out a chest X-ray and some blood-work before we anesthetize her.  She doesn't look too great, and she might have some other problems.  This was the biggest understatement since Noah said, "It looks like rain."

Her kidney waste levels were three times normal, and her blood sugar was 620 (110 is about tops for a normal dog).  So, she has sugar diabetes (Diabetes mellitus) and her kidneys aren't working worth a flip.  The kidneys could be ruined, but maybe they are just sick (and have a chance to get better). 

Having a terrible uterine infection will make your kidneys sick.  So will a totally out-of-control case of diabetes that's been going on long enough for you to lose one fourth of your body weight.  One fourth of your body weight -- alarm bells ought be going off.  This is not the Fat-Fairy coming in the night to make you into a super-model.  Something is wrong.

So now we have three serious medical problems -- pyometra, kidney failure, advanced diabetes -- any one of which could kill you in the next little bit, because they are all way over the edge.  This dog has three feet in the grave and one on a banana peel.  The amazing thing is that she has only been obviously ill to her owner for the last two days.  It's not like her owner doesn't care about her -- they sleep together, and she's beside herself with guilt for not realizing things sooner. We are treating her intensively to try to get her stabilized.

After the first ten hours, she is better hydrated, levels of kidney wastes in her blood have dropped by 30%, and her sugar is about half what it was.  If we can keep progressing like that for the next twelve hours, she may be stable enough to have surgery tomorrow.  At least her chest X-rays looked good.

The heck of it is, if she had been spayed when she was young, she wouldn't have the pyometra, and she wouldn't have the breast tumor, and she probably wouldn't be in kidney failure.  We'd still be dealing with the diabetes, but it would be SO much less complicated.

SO, spay your dog while she's young and healthy.  I needed that motorcyle ride I didn't get today.

Diabetic Cat Surprise

Here's Mimo. He and his house-mate Perry are boarding at the clinic for a few days.  "While they're here I want to get their vaccines up to date, and Mimo needs his teeth cleaned.  He has really bad breath."  The admitting staff asked if he had any other problems.  "Well, he vomits a lot, but he seems to feel good. He eats really well." The owner okayed pre-anesthetic blood-work before the dental, signed the release forms, and headed off on vacation.

When I did Mimo's physical exam, he did look pretty good, except for the periodontal disease.  Several teeth have been lost and the gums are really inflamed around those that remain.  Here's a funny thing: the last time we saw him (two years ago), he weighed over 15 pounds.  Today, 11.9 pounds.  That's a 20% weight loss... and he vomits a lot...(but "he feels good"). Maybe we ought to do that lab-work right now.

I've had a surprise diabetic patient before, and here's another one.  His blood glucose was 460mg/dl.  It shouldn't be over 150.  Let's check a little urine, and it's not only full of sugar, it's full of ketones, as well.  That's those two really dark pads at the bottom of the dipstick.  They ought to be the same color as the pads on the left, rather than dark brown.  Full of ketones is bad. 

When you can't utilize sugar for energy, you lose it in the urine.  You also have to have something else to use for energy.   So you break down body fat and use fatty acids for energy.  That works, but if you do too much, too fast, the waste products from that process (the ketones)can make you really sick.  Fortunately, Mimo still "feels good", still eating well, so we're not in the crisis that we could be in.

We've started Mimo on insulin injections and his prognosis for a normal quality of life is great.  I've got to talk to his owner about something, though. 

My notes in the record say that Mimo never goes outside.  I've got to wonder about who's changing the litter box.  This cat put out four ounces of urine during the night.  He has to have been soaking the litter-box.  I would think somebody would have been concerned over the fact that the cat is peeing like a race-horse. The owner must have a maid.

That excessive water-drinking and urination completes the classical picture of the diabetic patient: big appetite, weight loss, excessive water-drinking and urination (usually the first thing you see).

Oddly, in obese cats who develop diabetes, sometimes the first thing we see is vomiting when the ketones go crazy.  The cat hasn't lost weight, no change in the water intake/output.

Mimo is a little more on the classic lines.  Me, too.  I look like Michaelangelo's "David" (only not so muscular and good-looking).

Right-side Heart Failure and Ascites

Fluid accumulation in the abdominal cavity (around the organs) is called "ascites".  The old-timey name for it was "dropsy".  Right-sided heart failure can certainly cause it.  There are other things that can cause it, as well. 

Cancerous growths in the abdomen can secrete fluid.   The first sign of my mother's ovarian cancer was the fluid build-up.  Starvation can cause it.  The plasma protein albumin is a big molecule that helps hold fluid inside the blood vessels.  They seep fluid without it, which is why those starving refugee kids (that you quickly skip past when channel-surfing) have such big bellies.  Without protein, they can't make albumin; that big belly doesn't mean they just got their CARE package.  If your liver is failing, it can't use the protein you have to make albumin, so that's another possible cause of ascites.

Hemorrhage from a ruptured spleen or urine from a ruptured bladder may fill the abdomen with fluid, but you'd have a lot of other things going wrong as well.

Since heartworms reside mostly in the pulmonary arteries (taking blood through the lungs to get oxygen), they are the most common cause of right-side heart failure in dogs.  The arteries filled with worms create too much work for the heart to pump against, and it wears out from constant overwork.  It becomes enlarged because the weakened muscle gets "flabby" and stretches out of shape.  Now it can no longer contract forcefully, and blood that should be getting pumped forward gets backed up in the great veins returning blood to the heart from the rest of the body.

This back-pressure causes the veins to seep water like a canvas hose, and fluid accumulates in the abdominal cavity.  Ginny, here, does not have heartworms, but has (for unknown reasons) developed right-sided heart failure at a very young age.  She doesn't look too bad from the side view above, but she is carrying about three gallons of unwanted fluid on her abdomen.  From the top view you can get a better appreciation for the amount of abdominal enlargement she has. 

Medications can help the failing heart by decreasing its workload, such as diuretics (i.e. Lasix or furosemeide, spironolactone) to reduce fluid loading, and vasodilators (such as enalapril) to decrease the resistance in the blood vessels, and pushing the heart muscle a little harder (pimobendan, and the old standby digoxin).  Ginny is taking all of these, but it doesn't prevent the fluid build-up.  It's not too bad for a couple of weeks, but then she hits a "tipping point" and it balloons out of control.   We try to catch it before this point, but the big ice storm and two-week power-outage messed up our schedule. 

Here's Ginny with the bucket (literally) full of fluid that we just drained out of her. 

And here's a close-up.  The fluid looks clear when it is draining, but there are enough abdominal lining cells and blood cells present to make it look red when you have three gallons of it like this.

And here's Ginny, 24 pounds lighter, feeling good and looking a lot different.  Once that fluid is out, she feels pretty good.  She can't tolerate any strenuous exercise, but she has a good quality of life.  Pretty great for someone the cardiologist predicted would succumb by last October.  Her owner's devotion to getting all her meds on time, twice a day, every day has made the difference.  That and a few trips to the draining station.

Pericardial Effusion

This is Big Jake.  "When he lays around the house, he really lays around the house." [rim-shot!]  His 147 pounds are covering my exam table and slopping off the edge.  Five days ago he came in because he had been panting in the early morning.  He seemed to feel better by the time they came in, but he did seem to be favoring his left hind leg, and you could see where he had been licking it.  I couldn't find much, but we radiographed the foot (no mean feat, as he covers the X-ray table, too -- how to get him on the table, with his foot in the middle of the table, without the rest of Jake in the way?  Not to mention lifting him!)

So we sent him home with some anti-inflammatory/pain reliever and a little "wait and see".  He progressed to be more and more uncomfortable.  He panted more, couldn't get comfortable and quit eating.  It wasn't the medicine, because he refused to take that.  His owner noted that he was more uncomfortable lying down, and often resumed a sitting position to relieve his discomfort.  That "sitting up to get comfortable" is a hallmark of patients who are having breathing problems.  So, we asked her to bring him back in. [If you're wondering about the delay, the owner lives 60 miles away.  She doesn't just rush in on a moment's notice.]

His exam wasn't much different from the other day, and his lungs sounded okay.  The clinical signs and history still say something's wrong in his chest, and this is it.  His heart looks like a basketball.  I've talked about big hearts in a previous post.   Is it a stretched out of shape, weak, flabby heart?  A big, thickened, overly muscular heart?  A heart trapped in a pericardial sac full of fluid?  [A pericardial effusion is exactly that.] The ultrasound exam (echocardiogram) will tell us.  Of course, getting Big Jake in position was a logistical challenge[, but we finally got it done.  It's a big sac full of fluid, putting constant pressure on his heart, interfering with its function, making him hurt.

As with anything else on a dog this big, tapping and draining that sac was a pretty big project.  It was certainly more challenging than the case I had last fall.  We drained 600 cc (20 ounces) of fluid, giving him dramatic relief.  Unfortunately, he's going to need a chest surgery to remove that sac (and the heart-base tumor that we think is in it).  He feels better for now, though.

Kidney failure

Here’s a portrait of a nice, healthy kidney, but that’s not the kind we’re talking about. We are talking about pets with kidney failure. Does that mean "it’s over"? Maybe yes, maybe no. Kidney failure (or renal failure, as we scientific types like to say) can be acute or chronic. "Renal failure" means that the kidneys are not working well enough to clear waste from the bloodstream. We measure BUN, creatinine, and phosphorus levels (among other things). The patient may be producing lots of urine (or not), but when these wastes rise above normal levels, we know the kidneys aren’t working well.

BUN is Blood Urea Nitrogen, a waste-product that can fluctuate rapidly in the course of a day, being influenced even by how much you eat and drink. It still shouldn’t get much above 30. It can rise to double or triple that value, or even more. Creatinine levels change slowly, over a period of days, and phosphorus levels don’t start creeping up until the kidneys have really gone south.

This could be chronic -- the culmination of a long-standing, slow deterioration, and there is just not much functional kidney tissue left. Or it could be acute – the kidneys just suddenly got sick; they aren’t functioning, but they are not destroyed, either, and they could get well. Sometimes the only way to find out is to treat the patient and see if they respond.

You start out with about four times as much kidney capacity as you need. You could get by with half of one healthy kidney, and you have two whole ones. Thus, you could have a slow, gradual long-term destruction of the organs. Until you get down below 25% of kidney tissue, you still feel okay. Even when you get below 25%, your body can stand the increased levels of waste and become accustomed to them. When these guys finally get sick enough to quit eating, when they get nauseated and start throwing up, they are beyond saving. BUN is 100, other values up, and things don’t look good.

On the other hand, the kid whose kidneys shut down because of an infection will be just as sick, and his numbers may be just as bad. Yet, with appropriate treatment he could get well.

How do we know whether your pet’s kidney disease is acute or chronic? Can you tell by looking at the dog? This dog looks pretty good, beautiful hair coat, but she has lousy numbers – very high levels of waste in her blood. She looks awfully good, but her kidneys don’t look so good.

When we ultrasounded her kidneys, they looked shrunken and misshapen, as in this diagram. Her owners wanted to treat her, even though her prognosis didn’t look good. Intensive fluid and diuretic therapy were instituted, but she just did not respond. She couldn’t respond, as she just didn’t have the functional kidney tissue. Things won’t always be that clear-cut, though. Sometimes the kidneys really won’t look bad on the ultrasound, even though the damage may be severe and irreversible, whether chronic or acute.

This little dog doesn’t look nearly as healthy as the last one, and she is several years older, and she had lousy numbers when she came in.

Her ultrasound looked okay, but that was no guarantee. This is a sick kidney, but it hasn'treally changed shape.  This dog is a classic illustration of the principle that sometimes the only way to tell if a patient is treatable is to treat them. In this case, we also saw evidence of kidney infection in her urine specimen, so we hoped that intensive therapy with I.V. fluids and antibiotics might turn her around.

And so it did. Here she is the next day, feeling great, and eating, and she is still trucking along months later. If we had tried to "tell by looking", I’d have given her up. I’m glad we gave her our best.

Pyometra revisited

Warning: gross pictures at the bottom

I've posted on pyometra before, and also on why you should spay your dog while she's young and healthy.   Today we had a really spectacular case, though.  This  beautiful German Shepherd is only 2 years old, and had what appeared to be a normal heat cycle three weeks ago.  Yesterday she started having a bloody discharge.

Her clotting time was normal and she had plenty of platelets, so it didn't look like a "bleeding problem", despite the blood on the floor.  White blood cell count was really high (30,000/mm3, vs 7,000 to 16,000 normal range), and red blood cells were a little low.   An ultrasound of her uterus showed it to be huge.  How huge was it?

The normal uterus, even in a big dog like this, is about the size and weight of a couple of pencils.  This baby weighed over 4&1/2 pounds.

When we opened it, yes, it was full of pus. More than two liters of pus.  Man, do I ever wish this dog had been spayed a long time ago.  Did I mention I had to do the surgery on my afternoon off? Yeah.  The upside is, she's doing great now. Prognosis is good.