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Case 33
Six weeks after first visit
 | Heartworm |
| Fisher was presented to the Cardiology Service
for his second round of melarsomine injections.
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| Fisher was diagnosed with stage III heartworm disease
6 weeks ago. Eight heartworms were removed (2 from
the left pulmonary artery and 6 from the right pulmonary artery)
using a flexible alligator forceps. He recovered
well from that procedure and received his first injection of melarsomine
4 weeks ago. |
| The owner reports that Fisher has been doing well at home. He has a
variable appetite but has a good attitude. He is still under
exercise-restriction; he is only allowed to go on leash walks to urinate and
defecate. Fisher occasionally still coughs, but the frequency has decreased.
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| The owners report no adverse side effects from the last injection. They
gave Fisher prednisone for about 2 days afterward to decrease any
inflammation. Fisher is not taking any medications currently. He is due for
his heartworm preventative (Heartgard) in 2 days.
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| Gen: BARH, BW=34 kg. |
| Integ: Full coat, shaved area over left epaxial muscles |
| EENT: Eyes-clear corneas, no ocular discharge OU; ears-clean; nose-no
discharge; throat-mild dental calculi, no oral masses. |
| MS: BCS=5/9, symmetrical muscling, no gait abnormalities. |
| CVS: No murmur or arrhythmia, split S2; strong, synchronous femoral
pulses bilaterally; MM=pink, CRT=1sec. |
| Resp: Quiet breath sounds bilaterally, eupneic, no cough on tracheal
palpation. |
| GI: No masses palpated. |
| GU: No preputial discharge. |
| LNs: Mandibulars, prescapular and popliteal LNs are
symmetrical and <1cm. |
| Stage III heartworm disease |
| Moderate pulmonary hypertension |
| Proteinuria |
| First day: 86mg Immiticide (3.4ml) deep IM
right epaxial muscles |
| Second day: 86mg Immiticide (3.4ml) deep IM
left epaxial muscles |
| Heartworm Ag: weak positive |
| Urine protein to creatinine ratio: 1.64
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| Urinalysis (free-catch sample): SpGr 1.050,
4+ protein, 1+ bilirubin, 2+ hemoprotein, 10-20 RBC, rare hyaline and 0-3
granular casts |
| Echocardiogram: IVSd 9
mm, LVIDd 39 mm, LVIDs
25 mm, LVFWd 10 mm, LVFWs
13 mm, IVSs 12 mm, Ao 22
mm, LA 33mm, LA:Ao 1.5, FS 35%;
overall decreased right heart size from last recheck;
no septal flattening in systole
or diastole; large main PA;
trivial pulmonic insufficiency (max velocity 2.96m/s, pressure gradient
35mmHg); no tricuspid regurgitation;
no heartworms were visualized
Conclusions: The echocardiographic findings
today showed that the pulmonary hypertension has decreased significantly.
There is no longer any tricuspid regurgitation. Heartworm treatment appears to
be effective at this time. |
| Heartworm Disease |
| First day: Problem 1 and 2
- Heartworm disease and pulmonary
hypertension. S/O: There is a split second heart sound
on auscultation. A repeat echocardiogram showed a decreased right heart size
overall. In addition the septal flattening in systole and
diastole noted at the first admission is no longer present and his tricuspid
regurgitation is gone, Pressure in the pulmonary artery during
diastole was estimated at 35mmHg
from a small pulmonic insufficiency jet velocity. A heartworm antigen
test was still weakly positive. Fisher received 86mg
(2.5mg/kg) of melarsomine deep IM in the right epaxial muscles. A: Fisher
currently has mild to moderate pulmonary
hypertension, but it represents a significant improvement since the last
recheck. The split S2 is likely due to the pulmonary hypertension. P: Monitor
Fisher overnight for increased respiratory effort and rate. Feed, water and
walk. Administer second dose of melarsomine tomorrow. |
| First day: Problem 3
- Proteinuria. S/O: A urinalysis showed 4+ protein, and UPC was
measured at 1.64. A: The proteinuria is likely due to the glomerulonephritis
secondary to heartworm disease but is only mild. P:
No action at this time. Recheck U/A and UPC in 3 months. |
| Second day: Problem 1 and 2-
Heartworm disease and pulmonary hypertension. S/O:
At 8am, T=101F, P=100bpm, R=36bpm. His lung sounds are quiet bilaterally, and
he is eupneic. At 8pm, T=101F, P=92bpm, R=60bpm, he is eupneic. Fisher
received his second melarsomine dose (86mg) deep IM in the left epaxial
muscles. Fisher appeared painful after the second injection. Therefore 70mg
ketoprofen was administered SC. A: Fisher received his last dose of
melarsomine. P: Monitor Fisher overnight for increased respiratory effort and
rate. Feed, water and walk. |
| Third day: Problem 1 and 2-
Heartworm disease and pulmonary hypertension. S/O:
At 8am, T=101F, P=140bpm, R=40bpm, eupneic, pink MM, CRT=1sec, quiet breath
sounds bilaterally. He appears less painful than yesterday. Ate well. A: No
immediate adverse reactions from the melarsomine injections other than pain.
P: Discharge today. Advise owners to exercise-restrict Fisher for another 4
weeks. Recheck radiographs, echo, heartworm antigen, u/a and UPC in 3 months. |
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