Practical Clinical Pathology Cases - Outside Lab Tests Wendy Blount, DVM Nacogdoches TX

Greta 10 yr old SF Chesapeake Bay Retriever CC: weight loss, lethargy She stinks really bad History – repeated pyoderma Exam – T 98.3Fo, P 66, R 24 Papules, scaling – generalized Seborrhea and hair loss around the eyes and on the ventral neck She falls asleep on the exam table

Greta Skin Scraping – negative Skin Cytologies Thyroid Panel Crusts – many cocci bacteria Seborrheic areas – many yeast Thyroid Panel TT4 - >7 mcg/dl (normal 1.51-3.11) fT4 – 20 pmol/L (normal 12-33) TSH – 0.6 ng/ml (normal 0.03-0.4)

Greta fT4ED, TAb Diagnosis: Hypothyroidism fT4ED 3 pmol/L (normal 12-33) T4Ab 29 (normal <20) T3Ab 9 (normal <10) TGAb 1912% (normal <200) Diagnosis: Hypothyroidism <1% of hypothyroid dogs have normal to elevated TT4 (RIA) due to Auto Ab

Maddie 2 yr old F Doberman Wants thyroid screen for breeding Exam – T 101.3Fo, P 96, R 24 No significant abnormal findings Michigan State Premium Thyroid Panel

Maddie 2 yr old F Doberman Wants thyroid screen for breeding Exam – T 101.3Fo, P 96, R 24 No significant abnormal findings Michigan State Premium Thyroid Panel normal normal high high high

Maddie Diagnosis: Treatment: Follow-up: Stage 2 – Subclinical Hypothyroidism Treatment: None at this time Follow-up: Recheck TSH, TT4, fT4 once to twice yearly, or sooner if symptoms of hypothyroidism develop

Maddie Breeding Recommendation: Delay breeding until 3-4 years old, if no signs of hypothyroidism have developed Screen for other genetic predispositions DCM – echocardiogram for FS Neurologic exam for Cervical Vertebral Instability and Degenerative Myelopathy CERF eye certification OFA or Penn Hip certification VWDz Testing (Cornell) DNA for VWDz, DCM, DM + Narcolepsy (http://vetgen.com)

Eli 2 year old neutered male Great Pyrenees – Chow mix CC – “Sometimes he looks at me like he doesn’t know me.” Also, he laid down in Lowe’s the other day and would not get up.

Eli Exam Cardiovascular exam Neurologic exam overweight Cardiovascular exam NSAF – HR 80-90 Neurologic exam Cranial nerves, spinal nerves, postural reflexes normal CBC, panel (HW Test current) Cholesterol 385 (not fasted)

Eli In House TT4, send out Thyroid panel TT4 < 0.5 mcg/dl (undetectable) TSH normal, TT4 0.3 mcg/dl, fT4 0.2 ng/dl Eventually settled on 1.0 mg PO BID Behavior returned to normal Died at 8 years of age of adrenal neoplasia The Story of Eli

Trauma to the right inguinal area Benji Boy 3 year old neutered male papillon Hx – never been sick before, except got stepped on by a cow 6 weeks ago, and he hasn’t been right since Wheezes in the lungs Trauma to the right inguinal area Healed with time CC – anorexia and lethargy, vomits 1-2x a week Exam – NSAF

Benji Boy CBC – WBC 22,450/ul Neutrophil 16,390/ul Monocytes 2,360/ul Basophils 140/ul Electrolytes – normal Panel – SAP 262 U/L Fecal flotation – negative Abdominal x-rays & US – NSAF Tx Denosyl 90 mg PO SID Clavamox 62.5 mg PO BID x 7d

Benji Boy 5 days later – not eating or drinking, still does not feel good, in pain Exam – mild to moderate discomfort on abdominal palpation, grunts Temp 104.7oF cPL - >400 Abdominal US

Benji Boy 5 days later – not eating or drinking, still does not feel good, in pain Exam – mild to moderate discomfort on abdominal palpation, grunts Temp 104.7oF cPL - >400 Abdominal US

Benji Boy 5 days later – not eating or drinking, still does not feel good, in pain Exam – mild to moderate discomfort on abdominal palpation, grunts Temp 104.7oF cPL - >400 Abdominal US

Benji Boy 5 days later – not eating or drinking, still does not feel good, in pain Exam – mild to moderate discomfort on abdominal palpation, grunts Temp 104.7oF cPL - >400 Abdominal US

Benji Boy 5 days later – not eating or drinking, still does not feel good, in pain Exam – mild to moderate discomfort on abdominal palpation, grunts Temp 104.7oF cPL - >400 Abdominal US Pancreas enlarged and mottled in echotexture, ascites in the cranial abdomen 2-3mm lines, Corrugation of the duodenum

Benji Boy Dx - Pancreatitis Hospitalized to treat for pancreatitis IV fluids Continue Denosyl Cerenia® Buprenex for pain Ampicillin and enrofloxacin Eating in a few days, fever down, sent home on antibiotics, Cerenia, and Denosyl®

Benji Boy 2 weeks later CC - Did well for awhile, now there is straining to defecate and fresh blood and mucus on the stool, eating well. Wt - 6 months ago 14 pounds, 1 month ago 12 pounds, now 11.5 pounds Exam – no pain on abdominal palpation, rectal exam and rest NSAF Fecal – negative Rx – metronidazole 62.5 mg PO BID x 7 days

Benji Boy 3 weeks later CC – got better for awhile, but now worse - anorexia, vomiting, diarrhea Wt – 9 lbs Exam – NSAF Fecal – negative rectal scraping – no fungal organisms seen Tx – Cerenia and Tylan while awaiting GI lab results

Benji Boy 5 days later – appetite better GI panel – B12, PLI, TLI normal Folate low Proximal small intestinal disease Recommend intestinal biopsies Declines referral for flexible endoscope Diagnostic surgery for multiple biopsies liver, stomach, duodenum, jejunum, ileum Rigid scope colon biopsies

Benji Boy Histopath Moderate suppurative hepatitis Inflammatory bowel disease (EP inflammation in the duodenum and jejunum, villous blunting, crypt lesions) Tx – prednisone 5 mg PO BID x 2 weeks, then 5 mg PO SID 3 weeks later – Benji doing great 10.2 lbs Owner - “Dr. Blount is the smartest vet in the universe”

Benji Boy 1 week after that (8 weeks after 1st visit) CC - not feeling well GI signs have stopped, but Benji cries out when you pick him up Owner – “Dr. Blount, are you sure you know what you are doing?”

Benji Boy Exam Wt 11.5 lbs (way up) Mucopurulent discharge from the eyes Cranial drawer sign both stifles Pain on palpation of the muscles and long bones T – 104.7oF What’s the catch?

Benji Boy CBC – WBC 52K – segs, monos Panel – SAP 1132 U/L Lytes - normal Radiographs Pelvis Front limbs Rear limbs

Benji Boy

Benji Boy

Benji Boy DDx Periosteal proliferation Pulmonary hypertrophic osteopathy Hepatozoon spp. Thoracic radiographs – normal Abdominal ultrasound – normal MiraVista Histoplasma Ag – negative (tests) Hepatozoon PCR – positive (order kit) Clindamycin 25 mg/kg PO BID x 2 weeks Albon 25 mg/kg PO BID x 2 weeks decoquinate 50 mg/kg once daily

Benji Boy Benji did well as long as he took decoquinate He needed an occasional round of Albon and clindamycin – 2-3x a year Did well for several years, until he had a severe episode Referred to TAMU for re-evaluation, and they made no new diagnosis Benji was euthanized at 8 years of age

Lessons from Benji Boy IBD is not a disease, it is a lesion description IBD can be secondary, even when evidence of chronicity is on histopath IBD almost never causes fever Pancreatitis is often not primary Immunosuppressive therapy for one disease can unmask infectious disease that is present Pay attention to symptoms unexplained by Dx Just because someone says you are the smartest vet in the universe, doesn’t mean you are

Acknowledgements Richard Nelson. Small Animal Clinical Diagnosis by Laboratory Methods, 5th Edition. Ch 12 – Endocrine, Metabolic and Lipid Disorders. Eds. Michael Willard, Harold Tvedten. Mark C Johnson. Small Animal Clinical Diagnosis by Laboratory Methods, 5th Edition. Ch 12 – Immunologic and Plasma Protein Disorders. Eds. Michael Willard, Harold Tvedten.