Saturday, January 22, 2011

Phew

Busy first day back at work, but everything moved along fairly smoothly. I was stuck there until 7:30pm, 2 hours past the end of my shift, as often happens. A late, complicated case came in and I stayed long after my shift trying to work it all out. It was an interesting day with several very interesting/complicated cases.

Earlier in the day, a cat with acute onset of neurological signs and Horner's syndrome presented. Horner's syndrome describes a condition in which one side of the face looks paralyzed. The 3rd eyelid becomes elevated and covers the eye, the pupil becomes tiny (miotic) on the one side, and the eyelid starts to droop (ptosis). This condition is usually caused by interruption of the innervation to the side of the face where it is observed. Differentials for this are numerous and somewhat surprising as they include a mass in the chest. Why a mass in the chest? Part of the nerve runs through the chest, so compression with a mass can lead to Horner's syndrome. Other causes are severe middle to inner ear infections, tumors in the inner ear, trauma to the shoulder/shoulder area, tumor in the shoulder area, idiopathic (no underlying cause), trauma to the cervicothoracic area, sinus infections, etc. Unfortunately, given the cat's age (15), and the severity of the other signs (including staggering and ataxia), he did not want to pursue either diagnostics or treatment. I ended up euthanizing kitty. I didn't feel good about it, as the cat was oriented and talkative otherwise, but I understood the decision.




Following that came a 9 year old, severely lethargic, unable to stand Golden Retriever mix. She'd been treated at her rDVM for a severe whipworm infestation. They had sent her home that morning, but the owners were concerned, as her condition seemed to be worsening. No bloodwork or xrays had been done. The patient had been diagnosed with severe whipworm infestation and discharged home. When I saw her, I was immediately suspicious of a condition called 'pseudo-Addison's disease' secondary to her whipworms. Addison's disease is a condition in which the body cannot or does not produce natural steroids (needed for every small function of the body, practically). As this worsens, this lack leads to weakness, lethargy, vomiting, diarrhea, a drop in blood glucose, electrolyte imbalances (potentially life-threatening), and eventual collapse. For some reason that I cannot remember pathophysiologically, dogs will develop a pseudo-Addisonian crisis when infested with whipworms.

When I ran my bloodwork, my suspicions were confirmed - high potassium, very low sodium and chloride - indicative of an Addisonian crisis. She has improved markedly already with fluids and is able to stand and walk outside.

And then there was the puzzler at the end of the day. An 11 year old, intact male dog that became acutely lethargic and feverish (104.9). When he came in, he walked with a very hunched posture. His temperature was elevated, and he was very dehydrated. He was also very lethargic, although he managed a slow tail wag when I talked to him. Bloodwork showed possible infection/inflammation. His urine was a horrifying muddy brown color with tons of white blood cells but few bacteria. At this point, I am thinking he is suffering prostatitis - inflammation and/or infection of the prostate gland. This is much more common in intact dogs (virtually unheard of in neutered dogs). Prostatic neoplasia is possible, as is prostatic abscessation. Treatment of prostatitis requires long-term antibiotics and eventual neutering. I hope that I am right about his diagnosis and that I'm not missing something else. That's the scary thing about medicine. You just never know. I've spent some time on VIN tonight cruising articles to determine if I'm missing something...

Sprinkled liberally throughout were the usual frustrations: a woman with a Rottweiler (3 years old) that had never been vaccinated and now had parvovirus. This was her 5th dog with parvovirus, and yet she still refuses to vaccinate. Oh, and said dog has puppies at home. Splendid, eh? Then the Boxer puppy in severe, severe respiratory distress (I suspect electrocution or choking injury) with bloody fluid coming out of its nose. The "breeder" (I use the term loosely) had no finances at all, not even enough to pay for the exam fee. Given the severity of the puppy's condition, I offered free euthanasia. It sucked, as well.

Despite that, I was happy to be back at work, refreshed and interested and in a much better mood. I'm not sure where the mental resolution and cheerfulness came from - perhaps just time in Florida near my grandparents, but it was there!

10 comments:

Holly said...

question not the gift of refreshing your spirit.

Welcome back!

Elizabeth said...

Belonging to the Addison Dogs yahoo list I have seen the 'pseudo-Addison's disease'a few times. Unfortunately it was in dogs that were diagnosed with Addison's by their Vet. They had not been given the ACTH test (which would have ruled out Addison's) nor tested for Whips. Most dogs were given percorten, some florinef but were still not doing as well as they should have if it had been Addison's. After convincing these people they needed a second opinion, or needed to test at least for whips (that is tough sometimes as they do not want to insult their vet) these dogs are all fine now..
I just do not understand why some vets do not run the ACTH test before starting treatment for Addison's.. it's not that tough. It saves a whole lot of heart ache knowing one way or another.

The Homeless Parrot said...

Elizabeth, many vets are unaware of pseudo-Addisonian cases. I don't even remember being taught it in vet school...although I'm sure we were, at some point. I re-learned it during my internship.

Another thing to consider is that a fecal exam is very frequently negative - so even if a vet tested for whips, they might not be present. This might lead some vets down the garden path.

On the other hand, in any suspected Addisonian patient, an ACTH stimulation test should absolutely be done.

The Homeless Parrot said...

To clarify - a pet can test negative for whipworm eggs but still have whipworms. They do not shed eggs all the time.

Elizabeth said...

Considering that this is an expensive life long disease, when a vet is at the point of treating for it then the ACTH test should be run first. Since the test if done correctly (meaning no steroids prior to the ACTH test other and than dexamethasone)is definitive.
I am more and more thankful for ER's like yours that are seeing these dogs in crisis and picking the disease up sooner and sooner. Experience certainly counts with this disease and the more you see the more it is on your radar..

Learning said...

Wow, what a full day -good for you to maintain a positive attitude after all that. I am embarrassed to admit I haven't heard of pseudo-Addisons (that I can remember). Love to learn new things! :) Work has been really slow, so I like hearing about the exciting things you see. Btw did you palpate the prostate? (Or maybe that's not appropriate to post?)

The Homeless Parrot said...

Learning: I was unable to palpate the dog's prostate. He was old, and he was very tall and long, so my stubby little fingers wouldn't reach. I also suspect (from the xrays) that it was over the pelvic brim. It was about the same width as the pelvic inlet, so fairly enlarged. The only time he EVER showed pain was when we ultrasounded that area. He was incredibly stoic, but light pressure over the prostatic area caused him to flinch repeatedly.

BSDVM12 said...

Just wanted to say that your information about the pseudo-Addisonian condition associated with whipworm infestation helped me answer today's ZukuReview question correctly (and was something I've heard nothing about so far in my 2.5 years of vet school). Thanks for all of the interesting cases you post, and please know that there are some of us vet students out here who will be better vets from reading your blog!

The Homeless Parrot said...

BSDVM11: Thank you so much for the kind words! It's heartening to hear that my blog is helpful to vets/vet students.

What was the question on Zuku?

BSDVM12 said...

The Zuku question was: Which parasite has been associated with a hypoadrenocorticism-like syndrome and has been suggested as a cause for cecocolic intussusception in dogs? (Physaloptera spp, Spirocerca lupi, Trichuris vulpis, Ancylostoma caninum, or Toxocara canis)