|
   
| | Case 22
Primary Clinicians: Janet
Aldrich, DVM & Aaron Wey, DVM
Supervising Clinician: Mark D. Kittleson,
DVM, PhD,
DipACVIM (Cardiology)
Signalment
13-year-old FS Australian Shepherd Cross weighing 20 kg
("Chimere")
First Visit
Presenting Complaints
Non-weight bearing lameness & vomiting
Pertinent History
 | Non-weight bearing lame on right front leg began Saturday 10/30/99.
|
| Chimere began to vomit
Sunday evening and was febrile (temp=104.0). The initial vomitus contained chicken, later becoming only bile stained fluid. Owner administered famotidine and 75
mg Baytril. Vomiting has since stopped. |
| Remaining medical history includes: Shifting leg lameness of long standing duration. Owner reports
that Chimere has slowed down over the last year and appears weak in the hind quarters. She
stumbles when running and does not seem to be able carry toys in her mouth. Within the last two
weeks owner has noticed seizure like activity as evidenced by facial twitching and tooth chattering. |
| A neurology consult was completed this morning revealing underlying neuropathy which may
explain recent changes in Chimere's activity and coordination, however, Chimere's poorly defined
neurologic condition is thought to have little to do with her presentation today.
|
| Other treatment
history includes Rimadyl and glucosamine/ chondroitin over the last year for chronic arthritis. |
Physical Examination
| Obtunded and lethargic. No change in skin turgor noted. T=104.2; P=120; R=30. |
| Coat is clean and dry. Skin is clean, no lacerations, erythema noted. Abdomen shaven for
ultrasound. |
| CRT=1.5 sec. Facial expression symmetrical. Marked nuclear sclerosis OU, normal PLR,
otherwise clean and clear. Ears with mild discharge bilaterally. Tonsils in crypts. Canines |
| fractured, incisors worn, severe calculus with moderate gingivitis. Serous discharge noted from
both nares. |
| Non-weight bearing lame on right front. Unwilling to stand without support. Right Lateral
metacarpus swollen and painful on palpation. Right elbow also painful on manipulation, no |
| swelling or effusion is noted. Musculature over R & L hip atrophied, with no apparent
lameness. |
| Adequate pulses with occasional dysrhythmia noted. No murmurs ausculted. |
| Exaggerated respiratory pattern. Breaths sounds on inspiration dorsally and ventral on the LEFT,
markedly diminished breath sounds on the right dorsally. |
| Liver not palpable, caudal pole of left kidney not palpable. Gut loops are smooth. |
| Bladder palpates small. Vulva clean, no discharge noted. Rectal revealed symmetrical ventral coccygeal muscles, small urethra, moderately full anal sacs R & L, and soft formed brown stool. |
| Neurologic consult revealed ill-defined neuropathy. Cranial nerves intact. |
| Submandibular 1/4 cm, prescapular = 1 cm, popliteal = 1 cm. |
Problems
| Fever (rename = sepsis) |
| Vomiting (rename = sepsis) |
| Liver disease (rename = sepsis) |
| Right front limb lameness
|
Visit Summary
| Problem 1 (Fever) O: T= 104.4 (spiked at 105.2), WBC=21,100
(neutrophils = 20,256; lymphocytes=211), platelets=148,000, plasma fibrinogen=600,
protein : fibrinogen=13, anion gap=31, potassium=3.7, creatine kinase=499. Urinalysis revealed
4+ protein, 5-10 WBC per hpf, 2-5 RBC per hpf, rare transitional epithelial cells, gram positive
cocci. Arterial blood gas revealed PCO2 of 20.8, PO2 of 90.5,
HCO3=13 and base deficit of -10. Thoracic radiographs were within normal
limits; abdominal ultrasound revealed a course textured liver but was otherwise unremarkable. Initial antibiotic therapy with
oxacillin resulted in vomiting (treatment discontinued).
|
A: Presence of gram-positive cocci in urine sediment highlights infection as a likely
source of fever. Given the degree of lethargy and fever, if infection is indeed the underlying etiology, sepsis is
suspected. Leukocytosis with neutrophilia (w/slight toxicity) and a left shift as well as an elevated fibrinogen
also highlight the likelihood of infection. Blood cultures are pending to rule in/out a septic process.
Inflammatory causes of fever including liver disease and joint disease have not been ruled out at
this time. Further diagnostics including liver biopsy and joint taps would be required to identify
underlying liver and joint pathology and are not being pursued at this time.
P: Diagnostic- Blood culture results pending to rule-out sepsis. Therapeutic: Timentin
(ticarcillin) 50 mg/kg IV q 6 hours (given slowly over ten minutes). Monitor temperature q 1 hour. Offer 100 ml water q 2 hours. LRS qs to 20 mEq
KCl at 100 ml/hr (2 times maintenance). As the owner is a veterinary technician
she has opted to care for Chimere at home during the evening. Owner has been
instructed to continue antibiotic and fluid therapy throughout the evening.
Chimere need to be turned every few hours to alleviate any chronic pressure from
being recumbent.
| Problem 2 (Vomiting): Vomiting had ceased since approximately 3
AM this morning following the administration of famotidine. Chimere vomited only once today after the
administration of Oxacillin IV. Treatment was discontinued and replaced with Timentin
without further incidence. |
| Problem 3(Liver disease):
S/O: U/S revealed course textured liver. ALT=537, Alk Phos=621, Bilirubin total=.5, cholesterol=597, GGT=18.
A: The increased ALT and GGT is possibly due to long-standing Carprofen treatment for noted arthritis. Causes
for an increased Alk Phos include intrahepatic (swelling of hepatocytes) and extrahepatic (obstruction).
Hyperbilirubinemia may be indicative of intrahepatic disease as well, but may also increase with
cholestasis or hemoglobin catabolism as seen with hemolysis.
P: Defining the exact nature of Chimere's hepatic disease would require biopsies and will not be pursued at this time.
|
| Problem 4 (Lameness)-
S/O: Non-weight bearing lame on right front leg. Orthopedic
consult agreed that the right elbow was painful on palpation, although no swelling or effusion was
appreciated. The right carpus is painful and warm to the touch. Radiographs of right carpus
revealed a soft tissue swelling of the lateral metacarpus, with irregular bony changes at the 4th
metacarpal bone. Radiographs of the right elbow were remarkably normal.
|
A: There appears to be no radiographic evidence to explain the degree of lameness exhibited by Chimere. There are no
obvious outward signs of trauma or penetrating wounds. Rule-outs for lameness include infection,
inflammation, trauma and neoplasia. Although infection may be a likely source when considering an
underlying septic process, joint taps would again be required to define the underlying etiology and
will not be done at this time.
P: Antibiotic therapy as described earlier. Note any swelling, erythema in the area.
Clinical Diagnoses
| Sepsis |
| Right forelimb lameness (metacarpus and elbow) |
Second Visit (Next Day)
Visit Summary
| Problem 1 (Septicemia) S/O: Chimere appears to be feeling better today. She is
in sternal recumbency some of the time, drinking on her own, no longer obtunded but remains very lethargic. Rectal
temperature at days end was 103.2. CBC revealed a leukocytosis with neutrophilia and a left shift,
plasma fibrinogen of 600 and a protein : fibrinogen of 13. Urinalysis revealed 4+
proteinuria, moderate numbers of WBC and RBC. Culture of urine sediment as well as blood grew pure
Staph. intermedius. Blood gas analysis was indicative of metabolic acidosis and attempted compensatory
respiratory alkalosis (base deficit -10, pCO2 =20.8, PO2 = 90). Chimere was placed on IV fluids
(LRS qs to 20 mEq KCl), administered 20 mEq sodium bicarbonate and started on IV antibiotics.
Current antibiotic therapy includes Timentin @ 50mg/kg IV QID (initial therapy with
oxacillin was discontinued given that first administration resulted in vomiting). Urine and Blood culture
sensitivities are pending. Recheck blood gases....pH=7.34, pCO2 25.5, pO2 51.9, HCO3=12.9,
base deficit=-10, K=3.4, Na=146, Ca=1.02, O2 sat=79%.
|
A: Antibiotic therapy appears to be addressing Chimere's septic process. Her degree of pyrexia has steadily decreased throughout the
day and continues to improve as does her general attitude. Hypokalemia may be associated with
obvious decrease in intake/anorexia, or an increased output via fluid diuresis.
P: therapeutic - Continue antibiotic therapy (Timentin 50 mg/kg QID IV), 20
MEq NaHC03 IV over 1 hour, recheck blood gases and electrolytes in the morning. owner education - owner has again elected to care
for Chimere at home this evening. Owner had been instructed to continue therapy and turn Chimere
every four hours to alleviate any chronic pressure on her down side.
| Problem 2 (Right forelimb lameness) S/O: Although still not bearing any weight on her
right front leg, the metacarpal area is not as painful on palpation, but is still mildly swollen and
warm to the touch.
|
A: As there was no definitive explanation from previous radiographs and the
problem does not appear to worsening, no further diagnostics will be pursued at this time.
P: Recheck BID for increased swelling or pain.
Discharge Instructions
| Please continue fluid therapy for Chimere at home this evening at 100
ml/hr. |
| Timentin IV every 6 hours IV slowly over 10 minutes. |
| Monitor temperature every 4 hours. |
| Rotate every four hours to prevent pressure sores. |
Third Visit (Third Day)
Pertinent History
| Chimere presents today for continued therapy and monitoring. |
| Owner reports that Chimere seems to be improving. |
| She was force fed 2 tbsp of cat food last evening and did not vomit.
|
| Her fever has decreased throughout the evening and by early this
morning was down to 102.6. |
Physical Examination
| General: Sitting sternal, very quiet. Is looking brighter than yesterday. Chimere now makes an effort
to stand when you pick her up, but she can not remain standing for even a short length of time.
Appears painful when attempting to stand although focal pain response is limited to metacarpus. |
| Integ: Coat clean and dry. Skin over right metatarsus is red and bruised (site used for venipuncture)
as is the medial right metatarsus. |
| E/E/N/T: Eyes clean, no conjunctival hyperemia noted, marked nuclear sclerosis OU. Ears with
mild exudate, no odor or erythema noted. Nose is dry, no discharge present, planum nasale is
hyperkeratotic, dry and crusty. Tonsils in crypts. |
| M/S: Will bear some weight on R forelimb. BCS 4/9. Unable to stand for any length of time
unassisted. |
| C/V: Heart murmur ausculted over mitral (3/6). Increased breath sounds on inspiration. |
| GI/U: Liver, left kidney not palpable. Gut loops smooth, bladder empty. |
| LN: submandibular, 1/4 cm, prescapular 1/2 cm , popliteal = 1 cm. |
Problems
| Staph septicemia |
| Right forelimb lameness ( lateral metacarpus, and elbow) |
| 2-3/6 systolic heart murmur |
Discharge Summary
| Problem 1 (Septicemia) S/O: Chimere appears to be feeling better today. She is sitting
upright, drinking water on her own and ate 2 tbsp of A/D twice today without vomiting.
Bacteriological isolate report is sensitive to Timentin. 3/6 Heart murmur recognized on PE this
AM.
A: Antibiotic therapy appears to be addressing Chimere's septic process. The appearance of a heart
murmur at this time is likely due to vegetative endocarditis as a sequel to sepsis. Other rule outs
for a sudden murmur include anemia, and ruptured chordae tendineae. Cardiac ultrasound necessary
to define the underlying etiology of the heart murmur will not be pursued at this time given owner's
desire to keep costs down and that answers to this question will not change our given course of
therapy.
|
P: Continue antibiotic therapy (Timentin 50 mg/kg QID). IV Fluids at 10 ml/ht qs to 10
mEq KCl. Owner has again elected to care for Chimere at home this evening.
| Problem 2 (R forelimb lameness) S/O: Although still swollen
and red over the metacarpus, Chimere is placing some weight on this limb when
standing. Elbow is not painful to palpation. Toes are warm, no edema except at
the focal area described above.
A: At this time the problem appears to be static as no further diagnostics
will be pursued at this time the underlying etiology (trauma, infection,
inflammation, neoplasia) remain unclear.
P: Continue checking foot for increased swelling, pain and redness.
|
Author's Note
Because of the owner's reluctance to pursue further diagnostics, a cardiac
consultation was not performed until 5 days later. The diagnostic test results
are on the following pages.
 |
