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Case 27
 | 11/12/99 2230 Problem 1: Historical bleeding. S/O: CBC is unremarkable.
Chemistry panel is unremarkable. PT and PTT are normal. A: There is no
evidence of a bleeding abnormality, no evidence of blood loss, and no
evidence of organ dysfunction. Blood found in the mouth may be from the oral
cavity, the lungs or the GI tract. The melena may be from swallowing blood
or may be from GI bleeding. P: Monitor for vomiting, bleeding, or diarrhea. |
| 11/12/99 2230 Problem 2: Interstitial pulmonary pattern. S/O: Thoracic
radiographs show a moderate interstitial pattern in the caudal lung lobes.
Blood gases show a PaCo2 of 29.8 mmHg and a PaO2 of 91.5 mmHg. A: His blood
gases show that he is hyperventilating. This may be due to an attempt to
thermoregulate since he has a fever. It is not due to hypoxemia since his
PaO2 is greater than 60 mmHg. P: Monitor respiratory rate and for dyspnea. |
| 11/13/99 1430 Problem 3: Heartworm disease. S/O: Overnight, found
coagulated blood in the dog's run once. It was unclear if it had been
vomited or coughed up. QAR, urinating, drinking, not interested in food,
T=102.2 F, P=118 beats/min, R=64 breaths/min, PaO2=89.2 mmHg, PaCO2=31.4
mmHg, K=3.2 mEq/L. A Snap heartworm antigen test was strongly positive. A
Difil microfilarial test was positive. An echocardiogram showed a worm in
the right pulmonary artery. A: Marso has heartworm disease and has both
adults and microfilariae. He has been coughing up blood due to a ruptured
pulmonary artery, which is what the owner saw yesterday, and he has been
swallowing blood, which is why he has melena. Since he appears to have
a high worm burden and because of his already compromised lungs (i.e., the
hemoptysis), we will treat Marso with one injection now to primarily kill
the smaller male worms and two injections in a month to kill the remaining
worms. P: Melarsomine (100mg IM) was given at 1100 in the right paralumbar
muscles near the 4th lumbar vertebrae. We will keep Marso overnight and
watch for reactions to the medication. Send home on strict cage rest for one
month. Recheck with Cardiology in one month to have two more melarsomine
injections. |
| Marso presented to the VMTH because of blood coming from his mouth. |
| On physical exam, he had a fever of 104.0, his mucus membranes were
injected, his CRT was less than 1, he had severe tartar and gingivitis, and
harsh lung sounds could be heard in all fields. |
| Radiographs showed a moderate interstitial pattern in the caudal lung
lobes and a large main pulmonary artery. His CBC, chemistry panel, PT and
PTT were unremarkable. Blood gases showed a PaCo2 of 29.8 mmHg and a PaO2 of
91.5 mmHg. A Snap heartworm antigen test was positive and a Difil
microfilarial test was positive. An echocardiogram showed a worm in one of
the pulmonary arteries. |
| Marso was treated with melarsomine 100mg in the right paralumbar
muscles near L4. He was sent home on strict cage rest and will need to
return in one month for his remaining two injections of melarsomine. |
| Thank you for bringing Marso to the VMTH. He has been a very good
patient. |
| Marso has been diagnosed with heartworm disease. This is a serious
disease which involves worms that live in the blood vessels of the lungs.
The worms have caused irritation to these vessels. As a result, one of the
vessels must have burst into the lung, causing him to cough up blood, which
is what you saw yesterday. This is a treatable disease. However, it is very
important that you carefully follow directions regarding his care for the
next month to improve Marso's chances of recovering fully. |
| Treatment for this disease requires two steps. The first step is to
kill the adult worms that are living in the lungs. In Marso, since he has so
many worms in his system, we don't want to kill them all at once, or this
could cause worse problems for Marso. Consequently, he received one
injection which will kill about half the worms and two injections will be
given in one month to kill the remaining hardier worms. |
| We gave the first injection on Saturday in the muscles near his lower
back. He may be sore in these muscles for up to a week. If he is very sore,
if you see marked swelling, or if the area is hot and painful, please call
us. |
| It is extremely important that over the next month you keep Marso as
quiet as possible. Any excitement or exercise may cause blood flow through
his lungs to increase, which may cause large pieces of dead worms to break
loose and lodge in his lungs. This can cause a severe reaction and can also
cause sudden death. If he is kept quiet, the dead worms will slowly
decompose and are less likely to cause a problem. |
| Marso needs his last two injections in one month. Please make an
appointment with the Cardiology Service. At that time, we will keep him
overnight, so that we may give two injections 24 hours apart. |
| The last step of Marso's treatment will be to kill any microfilariae
(heartworm larvae) that are in his system. This will be done after we have
treated the adults. We may decide to start this treatment the next time we
see him or a month after his next treatment depending on how he is doing.
Dr. Macdonald will help you with that decision in one month. |
| You should have your other dog tested for heartworm infection and keep
him on preventative while Marso is being treated. |
Quiz
Correct Quiz
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