Partners In Care Winter 2020 | Volume 14:1 | angell.org | facebook.com/AngellReferringVeterinarians
VETERINARY REFERRAL NEWS FROM ANGELL ANIMAL MEDICAL CENTER
INTERNAL MEDICINE INTERNAL MEDICINE
PAGE 1 Therapies for Therapies for Refractory Refractory Urethral Sphincter Mechanism Urethral Sphincter Incompetence Mechanism Incompetence Zachary Crouse, DVM, DACVIM (SAIM) | [email protected] INTERNAL MEDICINE angell.org/internalmedicine | 617 541-5186
PAGE 1 rethral sphincter mechanism incompetence (USMI) to USMI in male dogs, hormones still appear to play a role in Approach to the is the most common cause of acquired urinary development of USMI in males, as USMI occurs more Coughing Cat incontinence in adult dogs.1,2 USMI can affect up frequently in neutered male dogs than intact male dogs.3 to 20% of neutered female dogs3 and is more Ucommon in large breed dogs.1 The urethral sphincter is Dogs with USMI typically leak urine when asleep or in lateral recumbency, but they may also have urine leakage during EMERGENCY composed of urethral smooth muscle, surrounding connective tissues, and vasculature.3 The pathophysiology of USMI is excitement or activity.2 A thorough history, physical exam with PAGE 5 complex and involves loss of estrogen receptors on the smooth attention to conformation of the urogenital tract, urinalysis, and Feline muscle, as well as changes to collagen content and culture are essential to exclude other causes of incontinence. A Hyperaldosteronism conformation of the patient (pelvic bladder, short urethra, complete blood count and serum chemistry may be indicated, recessed vulva).1,3 While loss of estrogen does not contribute (CONTINUED ON PAGE 2)
OPHTHALMOLOGY
PAGE 7 INTERNAL MEDICINE Navigating Corneal Ulcerative Disasters in Dogs Approach to the Coughing Cat INTERNAL MEDICINE Jean Duddy, DVM | angell.org/internalmedicine [email protected] | 617 541-5186 PAGE 10 Leptospirosis
he first challenge when treating a coughing cat is A cough is a defensive mechanism or reflex of the respiratory PATHOLOGY determining if the cat is actually coughing. Gagging system. It is used to dispatch foreign material from the airways. (such as with a hairball) or choking will need to be A cough occurs due to stimulation of mechanoreceptors or PAGE 15 ruled out. Since owners often cannot tell the chemoreceptors within the respiratory tract itself. These cough Canine and Feline Tdifference, it is very helpful to have your pet’s owner use a cell receptors are located throughout the entire respiratory tract from Cutaneous Round phone to video this at home. It is not very often that we have a the pharynx to the bronchioles. So a cough is very nonspecific cat come into our exam room and cough for us. and does not tell us if the cause is upper or lower airway issues. Cell Tumors (CONTINUED ON PAGE 3)
INSIDE: REFERRAL CONTACT INFO AND UPCOMING CES ON A REMOVABLE POSTCARD INTERNAL MEDICINE Therapies for Refractory Urethral Sphincter Mechanism Incompetence
CONTINUED FROM PAGE 1 INTERNAL MEDICINE INTERNAL during this time to maintain continence.4 UBAs are delivered FIGURE 1 cystoscopically by injecting the agent submucosally within the urethra. 4 Hydraulic occluder device, Norfolk Vet Products Currently, collagen is available in the United States for submucosal injection (Regain-Avalon Medical). Risks with injection of a UBA include infection, bleeding, urethral obstruction, failure of continence, and intolerance of the injected material.4 Prior to injection of a UBA, clients should be educated that expected continence rates are 50-70% with UBA and that medications and repeat procedures may be necessary as the UBA will have a limited duration of efficacy.4
Numerous surgical options to correct USMI have been described but typically have poor long-term efficacy. More recently, placement of a urethral hydraulic occluder (HO) has shown promise. A urethral HO is composed of an incomplete silicone ring that is sutured around the pelvic urethra. The silicone ring is inflatable and is connected to a small injection port that is sutured subcutaneously, to allow future access.5 After placement of the hydraulic occluder, many patients will require inflations to maximize continence. The protocol for inflation of the HO device is clinician dependent, but the goal is to incrementally increase the amount of saline in the occluder cuff until an acceptable level of urinary continence has been achieved. In one study of 18 female dogs with refractory urinary incontinence, all dogs had an improved continence score.5 In this same study, in dogs with owners who were compliant with follow-up, 92% were functionally continent and 77% were completely continent.5 In addition to female dogs, placement of urethral HO devices has been described in male dogs6 and female cats.7 and further urogenital imaging (abdominal ultrasound, cystoscopy, or CT) 2,3 may be necessary to exclude anatomic causes of incontinence. Dogs with The vast majority of patients diagnosed with USMI will respond to either USMI should have a compatible history and unremarkable lab work. Physical estriol, DES, or PPA. In cases of female dogs that are refractory to single exam and imaging studies may show anatomic abnormalities contributing agent medical therapy, use of both PPA and an estrogen drug should be to USMI, such as a pelvic bladder or recessed vulva, but should exclude attempted. If incontinence persists in these cases, then use of a UBA or separate causes of incontinence, such as ectopic ureters. surgical implantation of a urethral HO device can improve continence and quality of life. After a diagnosis of USMI has been made, medical therapy is considered the first line of treatment. Estriol (Incurin, see package insert for dosing instructions) and diethylstilbestrol (DES, 0.1-1.0 mg/dog po q24 for 5-7 d REFERENCES then weekly or as needed) are estrogen compounds that can be used to 1 Byron JK, Taylor KH, Phillips GS, and Stahl MS. Urethral increase the number and sensitivity of the estrogen receptors in the female sphincter mechanism incompetence in 163 neutered female dogs: dog’s urethral sphincter. Estriol is effective in 89% of cases of USMI, and diagnosis treatment, and relationship of weight and age at neuter DES is effective in 65% of cases. When using an estrogen compound, a to development of disease. J Vet Intern Med 2017; 31:442-448. CBC should be checked prior to starting treatment and after one month on the chosen drug, although bone marrow suppression is not listed as an 2 Owen LJ. Ureteral ectopia and urethral sphincter mechanism expected adverse event of estriol’s daily administration.3 Currently, estriol incompetence: an update on diagnosis and management options. is the only FDA-approved estrogen compound for treatment of USMI in J Small Anim Pract. 2018. Epub ahead of print. dogs and should be the first choice in female dogs suspected of having 3 Byron JK. Micturition disorders. Vet Clin Small Anim. 2015; 45: USMI. Phenylpropanolamine (PPA, 1.0-1.5 mg/kg po q8-12) is an alpha 769-782. adrenergic agonist which increases the tone of the smooth muscle comprising the urethral sphincter2 and ranges in efficacy from 75-90%3. A 4 Byron J. Injectable bulking agents for treatment of urinary combination of estrogen therapy with PPA is commonly used in dogs who incontinence. In: Veterinary image-guided interventions. 1st edn, do not respond to medical therapy with a single agent. While there is a lack Weisse C and Berent A eds, Wiley Blackwell, Ames, IA. 2015:398-409. of evidence to support a synergistic effect between PPA and estrogens, 5 Curao RL, Berent AC, Weisse C, and Fox P. Use of a 4 there are anecdotal reports of success when the therapies are combined. percutaneously controlled urethral hydraulic occluder for treatment Estrogen compounds should not be used in male dogs and should be used of refractory urinary incontinence in 18 female dogs. Vet Surg. 2 with caution in cats. When USMI remains refractory to medical therapy 2013 May; 42(4):440-7. with PPA (male dogs, cats) or a combination of PPA and an estrogen compound (female dogs), then use of a urethral bulking agent (UBA) or 6 Reeves L, Adin C, McLoughlin M, et al. Outcome after placement surgical intervention should be considered. of an artificial urethral sphincter in 27 dogs. Vet Surg. 2013; 42(1):12-8. UBAs should be used in patients where additional lower urinary tract 7 Wilson KE, Berent AC, and Weisse CW. Use of a percutaneously disease has been excluded and medical management has failed. These controlled hydraulic occluder for treatment of refractory urinary patients should have a negative culture within 2 weeks of injection of the incontinence in three female cats. J Am Vet Med Assoc. 2016 Mar; UBA. With the use of a UBA, many dogs have improvement in incontinence 248(5):544-51. for a period of 10-18 months, but they may also require medical management
2. Partners In Care Winter 2020 Volume 14:1 INTERNAL MEDICINE Approach to the Coughing Cat
CONTINUED FROM PAGE 1 INTERNAL MEDICINE INTERNAL Once we have determined there is coughing going – Expiratory noises are usually from on, we need to get a good history, as this will help the lower respiratory tract (lower guide us for our determination of the etiology of airways and pulmonary parenchyma). the cough. Is the cough acute or chronic? Any Wheezing may mean the airway is cough for more than 2 weeks is considered narrowing, while crackles or moist chronic. A young cat with acute coughing and sounds may indicate fluid within the nasal discharge is more likely to have an infectious lumen of the airway. or foreign body reaction, while an older cat with • Remember that with some diseases such as worsening coughing and weight loss may be more feline asthma, cats may auscult normally. likely to have neoplasia or asthma. • Palpation of the larynx and trachea can be Timing of the cough may give us some hint as done to check for masses, or try to elicit a well. Coughing after eating/drinking may indicate cough in the exam room. laryngeal dysfunction. Knowing if this is the first episode (or occurs only seasonally) as well as a • Complete your entire physical exam – response to any previous therapy will also help things such as abdominal masses can focus the search for the etiology of the cough. impinge on the diaphragm and cause increased respiratory rates and increased Cats that are in respiratory distress should be effort. Unlike dogs, cats do not cough that provided with oxygen immediately, while stable often from congestive heart failure, but cats should be observed prior to the actual heart murmurs and arrhythmias should physical exam. The exam is an important part of be noted for further evaluation. localization of the cough even though it is rare you will actually observe a cough. Observation Once we have determined the cat is coughing, of the cat’s respiratory rate and pattern as well the next step is to localize it to one area of the as any respiratory noises may give insight to the respiratory tract. Then a list of differential source of the cough. Stertorous respiration or diagnoses will help determine the next round inspiratory dyspnea may indicate laryngeal or Diagnostics would include radiographs to of diagnostic tests to be done. A minimum evaluate the trachea for narrowing or any mass upper airway disease, while wheezing may data base is indicated for all of these cats, indicate lower airway disease. lesions. A sedated (or anesthetized) airway exam including a CBC and biochemical profile. Other can evaluate laryngeal structures and function testing may include retrovirus testing for Be methodical in your physical exam. A “look, (movement of the larynx). Endoscopic evaluation FeLV and FIV, and PCR testing for respiratory listen, and feel” approach is often best. Look may be needed to fully assess the trachea. viruses (feline herpesvirus FHV-1 and feline from a distance to see the breathing patterns. calicivirus (FCV)). Listen for breathing noises both with and without Caution should be taken here to control the airway, especially if dealing with laryngeal or a stethoscope, and then feel or conduct your Oropharyngeal disease may be characterized physical exam. tracheal masses. Even minimal handling of these by a gurgle or rattling cough often followed by masses (such as a biopsy) can cause enough retching. Other respiratory signs such as stertor • Check oral mucus membranes for inflammation that emergency measures such as or inspiratory dyspnea are also often observed. color (cyanosis, pale). Check for any a tracheostomy may be needed. These cats There also can be excessive salivation or nasal abnormalities in the mouth, such as should be closely monitored while they are and/or ocular discharge present. foreign material, masses, ulcerations, waking up for any airway obstructions. trauma, etc. Common causes of oropharyngeal diseases would Lower Airway (Bronchial tree) disease is • Check the nasal passages for airflow, be pharyngitis (infectious or foreign body), characterized by a dry, harsh cough with discharge, or masses. Are there any nasopharyngeal polyp, neoplasia, or even trauma. wheezing and possibly crackles on auscultation. malformations? There is more of an abdominal effort by the cat Diagnostics would include a sedated (or when breathing. • Palpate over the trachea and larynx to anesthetized) oral exam. To evaluate for a detect masses or sensitivity. Can a cough nasopharyngeal polyp, use a spay hook to retract Common causes would be asthma and chronic be induced? the soft palate and a dental mirror to see if there bronchitis (+/- concurrent infections), foreign is a mass/polyp. Lateral skull radiographs or CT • Palpate the rib cage for masses and body, or neoplasia. should be obtained to check the tympanic bullae gauge the ability to compress the chest for an increased soft tissue density which may (excessive resistance can indicate fluid or Diagnostics would include thoracic radiographs, be associated with the polyp. mediastinal mass). fecal flotation, and the Baermann technique to rule out Aelurostrongylus abstrusus and • Now conduct auscultation over all parts Upper Airway (Larynx/Trachea) disease is Eucoleus aerophilus (feline lung worm). of the respiratory tract, including the characterized by a dry harsh cough and stridor. A Bronchoscopy and bronchoalveolar lavage larynx, trachea, and the lung fields. noisy breathing pattern may present on inspiration. (BAL) should be performed to obtain samples for cytology and bacterial cultures, and PCR – Inspiratory noises are usually from the Common causes would include laryngitis, testing should be performed for Mycoplasma upper respiratory tract (nose, pharynx, tracheitis (infectious, foreign body, neoplasia), spp. and Bordetella bronchiseptica. larynx, or trachea). or laryngeal paralysis. (CONTINUED ON PAGE 4)
Partners In Care Winter 2020 Volume 14:1 3. INTERNAL MEDICINE Approach to the Coughing Cat
CONTINUED FROM PAGE 3 INTERNAL MEDICINE INTERNAL Pulmonary parenchyma diseases often cause a and distress. Dull heart sounds and loss of airway diagnoses can be made and appropriate diagnostics moist cough and crackles on auscultation. sounds on auscultation may be noted. Also, the can be done. This will help you come up with a chest may be less compressible on palpation. definitive diagnosis and begin specific treatment. Common causes would be bronchopneumonia Neoplasia (mediastinal masses such as lymphoma (infectious, or secondary to aspiration), neoplasia, or thymoma) or pleural effusion from cardiac For more information, contact Angell’s Internal Medicine edema (cardiogenic or noncardiogenic), heartworm disease or neoplasia are some of the common service at 617 541-5186 or [email protected]. disease, hemorrhage, or pulmonary fibrosis. diseases. Diagnostics would include radiographs or, if those are too stressful, a thoracic ultrasound Diagnostics would include radiographs, will help confirm fluid or a mediastinal mass. An echocardiogram/EKG +/- BP and T4 if a murmur echocardiogram and thoracocentesis for pleural or arrhythmia is detected, and a coagulation panel effusion sampling would then be indicated. if a hemorrhage is suspected. Toxoplasmosis IgM and IgG titers should be considered if appropriate. In summary, a good history is important as most Otherwise, a BAL should be performed to obtain cats do not show symptoms of minor respiratory samples for cytology, cultures, and PCR testing. disease in the exam room. Be methodical in your physical exam, especially when dealing with the Pleural space diseases do not often cause respiratory tract. Localize the cough to a specific coughing but do cause respiratory compromise area of the respiratory tract so a list of differential
4 Angell’s Comfort Care Program Provides Extra TLC to Patients
The Angell Comfort Care Program provides extra comfort and reassurance for hospitalized patients in our Critical Care Unit (CCU). Trained volunteers provide extra cage-side affection to patients identified by veterinarians and technicians as animals that would benefit from additional TLC due to their particular circumstance (prolonged hospital stay, their level of anxiety, etc.).
Research indicates that comfort care makes a big difference for human babies – with faster weight gain, shorter hospital stays and improved social, emotional, and physical development resulting from a well-executed program. We believe that the Comfort Care program results in similar benefits for animals, including the reduction of patient anxiety and pain sensation.
Volunteers spend anywhere from 10 to 15 minutes with each animal before moving on to other patients.
Visit us on the web at: angell.org/comfortcare.
4. Partners In Care Winter 2020 Volume 14:1 F 0 o cases. of 90% about in seen level is aldosterone elevated an and cases), of (95% elevation kinase of creatine (50% cases), azotemia mild include irregularities clinpath Other sodium. excess the with resorbed being water by balanced usually itis problem. since seen this with not is cats hypernatremia of Interestingly, 90% in seen is potassium Low of hyperaldosteronism. suspicion a triggers that identified abnormality first the often is (<3.0mEq/L) hypokalemia Profound illness. of cause the as hyperaldosteronism suggest strongly can together, viewed when that, abnormalities clinicopathological and of clinical collection predictable afairly in result It does illnesses. of feline radar our on high not it is because identify to a bit tricky be can Hyperaldosteronism nephron. distal of the ducts collecting the in urine the into excreted being potassium and of Henle, loop of the tubule convoluted distal the in resorbed being sodium with levels, potassium and sodium balances that a hormone is Aldosterone secretion. aldosterone excessive in result can hyperplasia cortical adrenal or humans in 1955. in humans in issue the identified first who Conn, Jerome after hyperaldosteronism primary to applied eponym The species. that in existence its to testifying reports Partners In Care Care In Partners aldosterone secretion is made more easily. more made is secretion aldosterone of excessive asuspicion to leap –the detachment retinal or hemorrhage intraocular in result can which 1), hypertension (image or potassium low to due flexion neck ventral shows also apatient if PU/PD. But historical and loss, weight lethargy, with present generally patients These non-specific. fairly are hyperaldosteronism of signs historical or clinical The experience.) our in hyperaldosteronism, or disease kidney chronic from wasting potassium either to due always almost is furosemide taking not is that patient a in work lab initial on <3.0mEq/L EMERGENCY dogs, with only a few sporadic case case sporadic afew only with dogs, in identified rarely is It cats. affecting disease adrenocortical common most the likely is hyperaldosteronism eline Conn’s syndrome 2,3,4 1 Tumors of the adrenal cortex cortex adrenal of Tumors the (A serum potassium of potassium (A serum Winter 2020 Winter 2020 angell.org/emergency | [email protected] |617 522-7282 |[email protected] angell.org/emergency DACVECC DVM, Bracker, Kiko By Hyperaldosteronism Feline is sometimes is sometimes commonly commonly Volume 14:1 Volume
aldosterone hypersecretion. Either a spun and and spun a Either hypersecretion. aldosterone of suggestive and high, too considered be ahypokalemic in range normal the level within Even aldosterone an patient. normal the in off shut maximally be should secretion low, aldosterone level is then potassium blood the If potassium. reduce/excrete to is action primary Aldosterone’s level. potassium blood the to related directly is secretion Aldosterone possible. all at if potassium with supplementation to prior submitted be level should aldosterone An BID. 2-6mEq/cat at gluconate potassium oral with supplemented be can patients stable More supplementation. potassium IV aggressive and therapy fluid IV for hospitalized be should cats hypokalemic azotemic or weak Profoundly gets near to 2.0mEq/L, respiratory muscle muscle result. can hypoventilation and respiratory weakness 2.0mEq/L, to near gets level potassium the If accomplished. be can tests two those before often intervention some warrant does <3.0mEq/L of level potassium serum a But level. aldosterone an and ultrasound abdominal an be likely will steps diagnostic next The 4 1 FIGURE
Cervical ventroflexion due to due hypokalemia. ventroflexion Cervical patient would would patient 3,4 5,6 5,6 abdominal CT scan. abdominal an with evaluated critically more is involvement Caval 10% of cases. about only in evident occurrence, uncommon an is cava vena of the suspected, medical treatment should be started. confidently started. be should treatment is medical or suspected, made is diagnosis a Once identified. been have adenomas adrenal enlargement.Evenbilateralbilateraladrenal as itself manifest may hyperplasia cortical Adrenal gland. adrenal contralateral normal to a small with often finding, common most the are tumors suspected aldosterone secretion. Single adrenal of source the identify to modality imaging used commonly most the is ultrasound Abdominal requirements. shipping and sample specific lab about your Consult is helpful. sample of this submission prompt so aweek, to up be can time turnaround The serum. or plasma of 0.5-1.0ml of requirement sample a minimal level with aldosterone an evaluate to used be can tube clot a or sample plasma EDTA separated 2 (CONTINUED ON PAGE ON 6) (CONTINUED 3 Invasion Invasion 5.
EMERGENCY 6. at amlodipine with treated (>160mmHg) best is Hypertension of hypokalemia. complications any avoid to enough usually is which 3.0-4.0mEq/L, level at potassium serum the keep to Try goal. –toachieve but difficult usually is together gluconate potassium and spironolactone using when level even potassium normal A complication. to potential home avoid this at added be easily However, can fluid home. at subcutaneous worsen to cat azotemic mildly the cause to enough potent not itis effect, diuretic mild some has spironolactone Although basis. outpatient an on alone supplementation potassium level with potassium adequate an achieve to hard very be It can surgery. before weeks several for medically stabilized be should contemplated being is adrenalectomy surgical which for disease unilateral with cats and medically, managed be must disease adrenal Bilateral in conjunction with potassium supplementation. potassium with conjunction in used be should BID 1-2mg/kg at diuretic, mild and 4 2 FIGURE PAGE FROM 5 CONTINUED EMERGENCY
A unilateral adrenal adenoma in acat. adenoma adrenal A unilateral 2,3 Spironolactone, an aldosterone agonist agonist aldosterone an Spironolactone, normal should not be the the be not should 8 3,4
years. in measured be can times survival and good, very is alone management medical with prognosis The the reattachment. of retinal possibility maximize and quickly hypertension control to considered be should dosing BID then present, is the affected adrenal gland is removed, the prior prior the removed, is gland adrenal affected the Once challenging. access making liver, of the fossa renal the in up tucked are gland adrenal and kidney right the since masses right-sided than access to easier are tumors adrenal Left of choice. treatment the often is management surgical then identified, is enlargement or mass adrenal a unilateral If kidneys. the damages further which ofaldosterone effects profibrotic the and of hypertension control imperfect to to due years months over worsen gradually to azotemia for common It is assessment. panel renal BP and occasional have and lifelong medication on remain 0.625-1.25mg/cat SID-BID. 3 Cats on medical management will need to to need will management medical on Cats 7 If retinal detachment detachment retinal If Partners In Care Care In Partners ,9 days. 1,297 of time survival median a combined with different significantly not were carcinoma adrenal an or adenoma cortical adrenal an for adrenalectomy following times Survival avoided. be can secretion aldosterone of excess effects renal detrimental gradually the and stopped be can medications that benefit of surgery forunilateral adrenaldisease is The needed. is medication further no and quickly, quite resolve hypokalemia and hypertension identified with about the same frequency. same the about with identified REFERENCES 8 7 6 5 4 3 2 1 diagnosis 2012. Vet Med;107(3):118-125.diagnosis and recognition hyperaldosteronism: Feline Bruyette. DS J Bisignano, 2012. Vet Med;107(3):118-125.prognosis and treatment hyperaldosteronism: Feline Bruyette. DS J Bisignano, 2007;17(2):202-207.Care JVet Crit Emerg Hyperaldosteronism. with aCat in Failure Respiratory Causing Hypokalemia Profound al. et S Haldane, 2008;18(5):517-525. Care JVet Crit Emerg hyperaldosteronism. with acat in hypokalemia profound to secondary failure respiratory manage to ventilation mechanical of short-term use Successful Holm. JL Hammond, TN Surg JFel Med net. diagnostic the expanding hyperaldosteronism– Primary Kooistra. H SGalac, S Djajadiningrat-Laanen, 2005;7:173-182. Surg JFel Med 13 cases. of aseries cat: the in hyperaldosteronism STasker. Primary AHarvey, Ash, RA 2014;28:137-143. Med JVet Intern 1012). (2002- 10 cases adrenalectomy: unilateral by cats in tumors adrenocortical secreting of aldosterone- Treatment al. et Lo, AJ Med Clin JLab Aldosteronism. Primary Conn. JW 2011;13:641-650. 2 Carcinomas and adenomas are are adenomas and Carcinomas 1955;45:661-664. Winter 2020 Winter 2020 Volume 14:1 Volume 2,3
EMERGENCY Partners In Care Care In Partners focus: we will which on goals achievement six are there ulcers, corneal complicated of managing experience the through Walking examples. three name to herpes, ocular canine from suffering those and eye, dry to-treat difficult- with those brachycephalics, including vulnerable, most the in especially concern, a is relapse conditions certain Under situations. severe most the in referral by stabilization and repair surgical by augmented be can treatment medical and cases, some in months to weeks take can day. to Recovery day often is necessary monitoring the and intense, is keratitis ulcerative severe for plan treatment acute the Often, patient. every in addressed be must priorities four These repair. wound and management, inflammation and pain control, infection ulcer, of the cause primary the addressing are: cornea ulcerated every in of care points broad The healing. ulcer during use judicious with cosmesis and acuity visual preserve and scarring reduce to used be can NSAIDs topical and steroids topical humans, in though even activity; collagenolytic their to due afterward even and period repair wound the during avoided be to are form topical in NSAIDs or steroid general, In loss. vision partial and scarring for allow to room” “wiggle some is there so needs, vision human to contrast by demands of vision rigors same the with faced not we are fortunately, medicine, veterinary In loss. vision avoid functional to order in integrity structural and scarring minimal be there that demands cornea of the Wound repair vision. and eye the preserve to just surgeries multiple or single possibly and of treatment weeks requires disease complicated while treatment, symptomatic and time with heal can injuries Small we see. disease ulcerative of corneal types different the all as much as vary plans treatment and prognosis the such, As rupture. corneal or 1) (Figure descemetocele acomplete to leading stroma, of corneal loss total the to abrasion surface smallest the from of disease spectrum a wide represents condition ulcer corneal The INTRODUCTION OPHTHALMOLOGY Winter 2020 Winter 2020 angell.org/eyes | [email protected] |617 541-5095 |[email protected] angell.org/eyes DACVO DVM, Biros, Daniel Dogs in Disasters Navigating Ulcerative Corneal Volume 14:1 Volume blood or fibrin is suspected which could indicate indicate could which suspected is fibrin or blood if taken be must Care surface. ocular the reveal to saline with area surface the irrigating gently consider you may mucus, to due visible fully not is cornea the and 30minutes) lasting effect full for (up 5minutes to effect taken has anesthetic topical After rupture. near is or ithas case in cornea the to disturbance significant cause not to as so carefully away wiped be should mucus thick or crusting Any results. culture the affect may drops topical the since anesthetic topical to prior taken be should surface ocular of the cultures any possible, If blepharospasm. marked is there when (e.g., proparacaine) implemented always almost is anesthesia topical and patient, the of anxiety the of some neutralize will (methadone, buprenorphine) needed as medication pain of a systemic aid the with restraint manual secure and Comfortable eye. affected of the status vision the checking and adnexa, the evaluating chamber, anterior the and surface ocular the at look long and agood getting in lies examination corneal of asuccessful part essential The I. VI. V. IV. III. II. I. and productive examination productive and Create asafe for environment the productive examination. productive and asafe for environment the Create including size and stability. and size including area wound the of parameters Establish be ready to adjust treatment on the go. the on treatment to adjust ready be but adjustment, therapy and monitoring for place in plan adefinitive Put create a severe ulcer. asevere create can that problems common for Look comfort. Set realistic expectations. realistic Set comfort. ondiscussions outlook for vision and including disease corneal significant of realities to the client the Educate condition and direct therapy. direct and condition the of characterization the speed to diagnostics advanced Consider and supportive care. supportive and time with own its on sufficiently stabilized has wound the until or setting surgical a safe in until minimized be should tissue the touching then manipulation, any with leak will eye the suspect you if or suspected leakage humor aqueous is there we do. If done examination eye are every with and lesion the characterizing for helpful very also are Illustrations record. medical the in data objective some have to practice agood is of wounds dimensions estimating experience, with and, time, over wound the document to helpful often is Photography plugs. fibrin from mucus possible differentiate and bodies, foreign superficial dislodge lacerations, of corneal extent or depth the briefly explore surface, corneal the of stability the test to brand) use (Microbrush brushes often cytology We deeper. or stromal superficial is ulceration if especially melting, stromal as such it, for indications are there if aside set and taken gently be should swabs culture possible, is cornea ofthe visualization the Once surface? corneal the abutting synechiae or hypopyon, fibrin, blood, any there is and chamber anterior the visualize you Can leaks? of evidence any there Is blurred? or discreet edges wound the Are area? surface of the dimensions other or diameter the is What itdeep? Is prognosis. guide and progress monitor to important be will wound of the documentation Careful II. thickness perforation or puncture. puncture. or perforation thickness afull to due leak recent or cornea a leaking disease such as lagophthalmos, distichiae, ectopic ectopic distichiae, lagophthalmos, as such disease ocular associated other for look to inclined be you may history, agood With seen. changes the may have led to that conditions the characterizing better at essential is injury the around alook checked, initially been has area wound the and evaluation for comfortable is patient the Once III. and stability and size including area wound the of parameters Establish that can create ulcer that can asevere forLook common problems (CONTINUED ON PAGE ON 8) (CONTINUED
7.
OPHTHALMOLOGY 8. and CBC likely is there and in turned are cytology and now, By eye. the save cultures and process melting rapid the reverse to approach standard one is days several for hourly meds three ofto up recommendations ulcers, melting of case the in and intensive labor quite often are ulcers corneal severe for plans Treatment V. test. of the view best to awaythe get rinsed surface ocular theon fluid or mucus excess any and properly interpreted be to test the for still very be to has patient The of dilution. type same the cause also will wash eye even or tears from fluid as results test good have to open kept be to have eyelids The surface. ocular the along humor aqueous of the course the track will cornea aleaking in result that streaks green the often and green to change quickly will orange the aleak, is there If orange. bright is which surface corneal the on of fluorescein area a concentrated –leaving incision a surgical or atear, ulcer, an –whether of leakage suspected cornea of area an to briefly contact in applied actually is strip test the where test fluorescein the on a variation is testing Seidel cytologist. a to off sent or clinic in done and stain, gram or Diff-Quik be can Cytology South). (e.g. the warranted be would testing fungal areas but geographic some in New in England, submit to cultures of types at looking when sufficient be should culture Aerobic helpful. most be may cytology then on) and later submission for option (with first culture therapy, despite depth and size ulcer the of progression rapid or treatment antibacterial chronic been has there where ulcers corneal complicated in but indicated, or possible be not may tests all situation, emergency an In herpes. for testing PCR and cornea, the through humor aqueous of the leakage for testing Seidel cytology, culture, fungal culture, corneal bacterial aerobic involve also can testing additional disease, corneal severe In (retina). fundus and lens, chamber, anterior cornea, conjunctiva, of eyelids, the visualization and stain, fluorescein tonometry, test, tear Schirmer reflexes, palpebral reflexes, light pupillary response, a menace for a testing include exams eye most for tests ophthalmic core The IV. stable. more is eye the until skipped be may test this so proparacaine, topical received have who patients in lower be will test tear a Schirmer Remember, care. long-term need may others while spot the on addressed be can conditions these of Some pathology. the with involved directly be could that bodies foreign or eye, dry cilia, CONTINUED FROM PAGE FROM 7 CONTINUED OPHTHALMOLOGY adjusting treatment on the go the on treatment adjusting butadjustment, ready be for for monitoring and therapy place plan in Put adefinitive the condition and direct therapy direct and condition the of characterization the to speed diagnostics advanced Consider repair of a deep ulcer (Courtesy Willows Vet). Willows (Courtesy ulcer adeep of repair 4 2 FIGURE healing. accelerate and vision to preserve in order dryness and blinking poor the for causes the addressing as well as situation in this considered be should grafting repair). Conjunctival wound (endogenous supply vessel blood corneal the from distance alengthy is that location apoor and response, blink apoor from exposure corneal eyelids), at the mucus dried (note the tear production to low due developed has ulcer, to wound the this superior vascularization robust Despite exposed. stroma still is there where edges wound the at retention fluorescein but bed, ulcer in the uptake 4 1 FIGURE
The appearance of a conjunctival graft weeks post surgery for wound stabilization and and stabilization wound for surgery post weeks graft aconjunctival of appearance The stain non-fluorescein adarkened with to descemetocele eight-mm diameter Five- Partners In Care Care In Partners Winter 2020 Winter 2020 Volume 14:1 Volume
OPHTHALMOLOGY OPHTHALMOLOGY
CONTINUED FROM PAGE 8 OPHTHALMOLOGY chemistry panel results that will help focus the feel confident the wound is not going to ADDITIONAL READING options for systemic care. In specialty care destabilize, and try to get the treatments down clinics with 24-hour services, round-the-clock to at most every 4-6 hours. Dan G. O’Neill, Monica M. Lee, Dave C. care can be offered to lessen the burden of care Brodbelt, David B. Church, and Rick F. and allow the clients to get some sleep. Making VI. Educate the client to the Sanchez. Corneal ulcerative disease in dogs sure the patient’s anxiety is as low as possible realities of significant under primary veterinary care in England: will also help them take the medication without corneal disease including epidemiology and clinical management. the added problems of nausea, inappetence, high discussions on outlook for Canine Genet Epidemiol. 2017; 4: 5. vision and comfort. blood pressure, or aggression. Unless there is Set realistic expectations. Pot SA1, Gallhöfer NS, Matheis FL, Voelter- high risk from anesthesia, surgical stabilization Despite the best intentions of intensive medical Ratson K, Hafezi F, Spiess BM. Corneal by referral with conjunctival grafting is often therapy, some patients are poor responders, and collagen cross-linking as treatment for offered when the ulceration is large, deep, or if we don’t see improvement in 3-4 days at the infectious and noninfectious corneal melting actively leaking and the leak is no larger than 5-7 latest, we will discuss options in replacement of in cats and dogs: results of a prospective, mm (Figure 2). Risks for graft failure go up with or in addition to the medical therapy already nonrandomized, controlled trial. Vet larger injury (larger graft), but recent implemented. Obvious cases that would have us Ophthalmol. 2014 Jul;17(4):250-60. advancements in grafting options including consider surgical referral immediately would be amniotic membrane, synthetic or biological Ledbetter EC1, Franklin-Guild RJ2, those where the cornea is already perforated or collagen implants over the wound area; collagen Edelmann ML1. Capnocytophaga keratitis perforation is imminent. Descemetoceles and cross linking; and even corneal transplants in in dogs: clinical, histopathologic, and deep ulcers also are considered for the fast track certain situations are used to save an eye that microbiologic features of seven cases. Vet to surgical referral (Figure 1) if the patient is would otherwise be lost to medical therapy alone Ophthalmol. 2018 Nov;21(6):638-645. stable and the goal of care will enable the or that would greatly accelerate the wound preservation of some vision – or just keeping the Ledbetter EC1, Riis RC, Kern TJ, Haley healing process. There is also benefit, if possible, eye, knowing it will be blind if the client is NJ, Schatzberg SJ. Corneal ulceration to stabilize the cornea with medication for up to averse to enucleation. If the cornea is beyond associated with naturally occurring canine 24-48 hours prior to moving to surgical repair, having considered both surgery and herpesvirus-1 infection in two adult dogs. correction of the corneal ulcer. Grafts fail when medication options, then we can offer enucleation J Am Vet Med Assoc. 2006 Aug the inflammation is profound and the grafts as the humane course of therapy for the severest 1;229(3):376-84. succumb to neutrophilic digestion. However, cases to alleviate pain and speed the recovery Wilkie, David A. et al. Surgery of the with a few days of anti-inflammatory and quickly. For some the financial costs are too Cornea. In Veterinary Clinics: Small Animal antibiotic care, the surgical field can become strenuous for intensive medical care, and the Practice, Volume 27, Issue 5, 1067-1107. more stable and accepting of grafts. clients are not equipped to treat at home to meet Ledbetter EC, Gilger BC. Diseases and the needs of the patient. There is nothing lost if We will often use during hospitalization surgery of the canine cornea and sclera. In: the client wants to treat intensively at home to ofloxacin, cefazolin (compounded to 55 mg/ml Gelatt KN, Gilger BC, Kern TJ, editors. the best of their ability with reasonable rechecks in bacteriostatic water – refrigerated – good for Veterinary Ophthalmology, vol. 2. 5th ed. every day or so. Initial testing and evaluation for at least two weeks), and whole serum diluted up Oxford: Wiley-Blackwell; 2013. p. 976-1049. to 25-50% with artificial tears up to every hour a melting ulcer on emergency, including Vanore M, Chahory S, Payen G, Clerc B. for up to 3-4 days to start intensive treatment for evaluation, tests, cultures, and medication, can Surgical repair of deep melting ulcers with a melting ulcer and then taper down to a be upward of $800. If the patient stays for porcine small intestinal submucosa (SIS) frequency that the clients can handle at home intensive eye care in hospital, the cost can be up graft in dogs and cats. Vet Ophthalmol. once the wound is showing signs of repair. to $500 per day. Urgent surgery to repair a 2007;10(2):93-9. Atropine use can be very helpful, especially if severely damaged cornea can cost in the range of $2,500 to $3,500 for the surgery and post-op the uveitis is profound, and can be used up to 4-6 Lacerda RP, Peña Gimenez MT, Laguna F, care alone. times daily initially to dilate the pupil at the Costa D, Ríos J, Leiva M. Corneal grafting onset of treatment, but then tapered to the lower for the treatment of full-thickness corneal effective frequency to sustain dilation, often 1-2 SUMMARY defects in dogs: a review of 50 cases. Vet times daily. If profound uveitis with hyphema or Ophthalmol. 2016;1-10. hypopyon, systemic antibiotics are suitable to Basic training in managing corneal ulceration reach therapeutic intraocular concentrations. does not always prepare one for dealing with Systemic pain medication includes carprofen advanced cases of corneal melting or large, and gabapentin. We also will use methadone, deep ulcerative conditions. By considering meloxicam, and other options depending on the additional steps in the path of diagnosing and patient’s weight and history with these treating ulcerative keratitis, some advanced drugs. Trazadone can also be helpful if there cases may continue to have vision with ramped- is high anxiety, and cerenia or similar up medical and or surgical treatment by referral. is often used during hospitalization if there is The vision survival rate for serious corneal any perceived risk for nausea. When to send a ulcers in dogs is going to be lower by contrast patient with a healing ulcer for home care will to patients with less serious ulcers, but with depend on what the pet owner can do and how some adjustments to conventional therapy, stable the pet is. In general, we like to string many of these cases can stand a better chance together 2-3 successive days of improvement, to heal with functional vision.
Partners In Care Winter 2020 Volume 14:1 9. 10. alter may which flooding or rainfall recent account into take always not do studies Prevalence rainfall. (July-November)fall or heavy flooding after and to summer late in increases of infection Incidence water. slow-moving or stagnant in found be to likely more are They environments. alkaline moist, warm, prefer organisms Leptospiral examined. regions on based variable is seroprevalence and cat in reported been have leptospirosis of clinical cases few dogs, to contrast In region. geographic by varies of groups Prevalence testing. titer on evaluated typically groups the are kirshchneri L. and interrogans L. are States United the in dogs affecting species main genus of the (bacteria) spirochete motile gram-negative, filamentous, aerobic, an with infection by caused adisease is Leptospirosis Epidemiology DESCRIPTION DISEASE pig, horse), and Autumnalis (mouse). Autumnalis horse), pig, and (cow,Pomona (cow), (rat, pig), Hardjo Bratislava marsupials), (raccoon,Grippotyphosa skunk, (rat), (dog), Icterohaemorrhagiae Canicola include hosts reservoir their and serogroups common most The dogs. in pathogenic considered approximately 10 identified, serogroups are 20 the Of methods). detection antibody on cross-react may that serovars related (antigenically serogroups into divided are that species) same the in organisms distinct (antigenically of 250 up over serovars made are species and South Central areas of the United States. United of the areas Central South and Midwest Northeast, the in prevalence increased Great LakesGreat region. the around and West Coast, the West Virginia, Virginia, including areas certain in prevalence of increased pockets with States United the throughout documented been has Leptospirosis illness. clinical without often state, a carrier maintain who hosts reservoir of infection through environment the in remain body. Leptospira host the outside replicate cannot they though even conditions optimal under environments moist in months for viable remain Leptospira water. surface in of organisms survival prolong and urine, animal contaminating of evaporation prevent organisms, with soil the INTERNAL MEDICINE 2,5,6 2,5,6 Environmental flooding can saturate saturate can flooding Environmental 7 Other studies have shown an an shown have studies Other 617 541-5186 |617 |[email protected] angell.org/internalmedicine DACVIM DVM, Kearns, Shawn Leptospirosis Leptospira 2,3 2,4 . 1 These seven seven These
Leptospira spp. can can spp. . The . The spp. 8
>10 years. >10 dogs in reported been has seroprevalence lowest breeds. intermediate or of small be to of dogs 40-50% hepatic involvement compared to adult dogs. adult to compared involvement hepatic severe and signs clinical severe have to likely more macerated skin, and broken skin, after which they they which after skin, broken and skin, macerated or wet membranes, mucous penetrate Leptospires Pathophysiology common. less much is of tissues ingestion or wounds, bite transfer, placental or venereal via Transmission tissue. or urine infected with contaminated is that bedding or food, soil, sources, water to exposure via transmission indirect through or urine infected with contact through is animals in of transmission mode primary The Transmission exposure. environmental increased to due risk greatest at are dogs breed mixed and dogs, working hounds, dogs, herding affected, be can breed any Although Signalment infection. and/or exposure for factors risk as noted been have temperature and precipitation, increased land, forest deciduous lots, large on houses environments, urban in exposure to Exposure rodent kennels, crowded wildlife, and livestock season. to season prevalence 11,12,13 6,10 14 Younger dogs (<6 months of age) are of age) (<6 Younger are dogs months Dogs of any age are at risk, but the the but risk, at are age of any Dogs However, other studies have shown shown have studies other However, 5,7,9 15 Partners In Care Care In Partners cytokines. of pro-inflammatory release the stimulates and activation, platelet causes adherence, neutrophil stimulates macrophages, activates of leptospires envelope outer of the component (LPS) lipopolysaccharide The kidney. the within injury to ischemic leads also damage filtration. Endothelial glomerular decrease and perfusion renal impair can swelling Kidney treatment. without months to weeks for urine the in shed be and kidneys the in persist can Leptospires urine. the in shed being organisms to leading lumen, tubular and cells tubular renal proximal within found are Leptospires interstitium. the organisms penetrate the renal capillaries and enter kidneys, the Within organs. many in replicate up to 10 to up days. for last can phase bacteremic The inflammation. leakage, and hemorrhage, vascular vasculitis, cause and cells endothelial to attach Organisms multiply. quickly and stream blood the enter neutrophilic in type. One study of 10 dogs with of 10 with dogs study One type. in neutrophilic lymphoplasmacytic/ or granulomatous fibrosis, and chronic hepatitis. andchronic fibrosis, occlusion, duct bile necrosis, centrilobular subsequent with toxin leptospiral by damage from occur can dysfunction Hepatic leptospires. by affected organ main second the is liver The dysfunction. renal with associated commonly more are Grippotyphosa and Bratislava, 2 Infection with serogroups Canicola, Canicola, serogroups with Infection 16 Winter 2020 Winter 2020 Organisms then spread and 2,3 Hepatitis may be be may Hepatitis Volume 14:1 Volume
AVIANINTERNAL AND MEDICINE EXOTIC high mortality rates (up 70%). to rates mortality high with associated is LPHS documented. been has infiltrate cell inflammatory of marked absence the associated with hepatic involvement. hepatic with associated more are Pomona and Icterohaemorrhagiae Partners In Care Care In Partners or with leukocytosis, by followed be may and phase leptospiremic the during a leukopenia include may Changes non-specific. are changes CBC findings, exam and historical with As Count Blood Complete complaint. presenting initial the as myalgia fever, PU/PD, or just have may patients some but hypovelemia, and/or dehydration to due often are findings Exam common. less are signs systems nervous central and ocular, Pulmonary, history. the in noted commonly most are polydipsia and diarrhea), appetite, lethargy,decreased polyuria, (vomiting, signs organs Gastrointestinal damaged. target primary the to relate or specific non- often are signs Clinical patients. older to compared signs clinical severe more have to tend Young patients disease. chronic or subacute, acute, peracute, as manifest can Leptospirosis Findings Examination History/Physical (below). of testing pitfalls understand help can principles These infection. after weeks 2 approximately levels detectable to increase antibodies IgG early Anti-leptospiral rapidly infection. in increasing infection, of week first the in detected are antibodies IgM Anti-leptospiral hypocoagulable. were that those versus hypercoagulable were that patients however, in was lower, rate Themortality prognosis. influence not did this DIC have but to considered were dogs of 23% study, same this In profile. normal a had 40% and (20%) hypocoagulable were 7 14 dogs, (40%) hypercoagulable, were affected of 35 study one In of factors. a combination or syndrome, hemophagocytic causes, immune to due platelet consumption increased endothelium, vascular stimulated to due aggregation and adhesion, consumption, platelet from result may Thrombocytopenia diatheses. bleeding in a role play may all coagulation intravascular disseminated and thrombocytopenia, Vasculitis, occur. also can hemostasis secondary or primary abnormal from abnormalities Bleeding leptospirosis. acute with dogs in recognized increasingly is (LPHS) syndrome hemorrhagic pulmonary Leptospiral vasculitis. to secondary exudation fluid from and tissue, lung on toxin leptospiral of the effects the to secondary occur can abnormalities Pulmonary involvement. renal of prominent evidence clinical without hepatitis chronic leptospirosis demonstrated involvement may also occur. also may involvement CONTINUED FROM PAGE FROM 10 CONTINUED INTERNAL MEDICINE 17 Acute liver failure without renal renal without failure liver Acute 20 Intra-alveolar hemorrhage in in hemorrhage Intra-alveolar Winter 2020 Winter 2020 21,22 18 Serogroups 2,19 Volume 14:1 Volume 23 2
with Serogroup Pomona. Serogroup with Elevated creatine kinase has been reported in ~43% myositis. with ~43% in associated of leptospirosis of cases reported been has kinase creatine Elevated patients. many in difficult be also be noted in the absence of renal disease. of renal absence the in noted be also more likely to be thrombocytopenic. thrombocytopenic. be to likely more be may Pomona serogroup with infected Those clinical signs of respiratory distress, of respiratory signs clinical without seen be may changes radiographic As 70% of cases. to up in noted abnormalities radiograph thoracic with leptospirosis with dogs in reported been has involvement Pulmonary Radiography DIAGNOSTIC IMAGING casts. granular and cells, blood white cells, blood red reveal can examination Sediment ratio. protein:creatinine a by urine determined 0.15 from 7.34 to as ranged report one in but variable is Proteinuria hyperbilirubinuria. and proteinuria, glucosuria, hyposthenuria, include may Changes damage. tubular with consistent and non-specific are usually urinalysis from Results Urinalysis reported been also has involvement renal prominent without (granulomatous) hepatitis Chronic hyperbilirubinemic. were 69% and enzyme activities, liver increased had leptospirosis with the than of dogs 80% study, one In ALT activity. in greater increase usually is ALP of Elevation of onset azotemia the after a week to up occurring often ALP, AST, bilirubin) (ALT, enzymes hepatic increased with disease, renal than severe less usually is disease Hepatic in one study. finding common a also was Hypoalbuminemia Na+-K+-ATPase. tubular of the functions and glycolipoprotein expression also inhibits directly leptospiral however loss, gastrointestinal and renal both to due be may Hypokalemia present. commonly are acidosis metabolic as well as hyperphosphatemia), and/or hypophosphatemia, hyperkalemia, hypokalemia, hypochloremia, (hyponatremia, abnormalities Electrolyte severity. in bit a quite vary can azotemia the but azotemic are (87-100%)Most leptospirosis with dogs Panel Biochemistry course. disease the during develop or present (upbe 58%) to also may thrombocytopenia (up 63%) to and Anemia shift. a left without consolidation may be seen on thoracic thoracic on seen be may consolidation alveolar or densities alveolar nodular to Interstitial initially. apparently not if even progression disease of the course the over develop may disease of respiratory signs Clinical leptospirosis. have to suspect patients for plan diagnostic initial of the part as recommended are radiographs 17 , however, proving a prior infection may may infection aprior , however, proving 19 19 More severe azotemia has been noted noted been has azotemia severe More 24 25 . Hepatic disease may may disease . Hepatic 11,19 thoracic thoracic 11,19,22 1,11,24 26 19 19 11 11 11
cortical echogenicity. cortical increased 100% had leptospirosis, with dogs lymphadenomegaly. and sludge, biliary thickening, wall biliary mucocele, gallbladder hypoechogenicity, hepatic echotexture, splenic amottled with splenomegaly walls, intestinal and gastric of the thickening enlargement, pancreatic pancreas, the of hypoechogenicity include organs abdominal the caudal-dorsal lung fields. lung caudal-dorsal the in bilaterally appear initially that abnormalities (medullary rim sign). rim (medullary echogenicity of increased band amedullary and definition, corticomedullary reduced effusion, perinephric echogenicity, cortical increased pyelectasia, renomegaly, include kidneys the in detected Changes nature. in non-specific are but 85-100% of in dogs noted are changes Ultrasound Ultrasonography numbers are highest in blood at that time. After ~10 After time. at blood in that highest are numbers organism since infection of week first the during of choice sample the is Blood urine. and blood in highest are numbers bacterial when disease the of course the in early and administration antibiotic to prior useful most is testing Direct testing. direct used commonly most the is (PCR) reaction chain polymerase DNA using of bacterial Detection Assay (PCR) Chain Reaction Polymerase time. incubation along cultures, for and low sensitivity to due practice clinical in used rarely are microscopy field dark via visualization spp Leptospira against directed antibodies detect that those and directly bacteria detect that tests available: are testing of diagnostic Two categories main TESTING SPECIFIC LEPTOSPIROSIS of dogs. 6-50% in reported been have aPTT and of PT Prolongation variable. be can results testing coagulation so hypercoagulable, or hypo- be may leptospirosis with Patients Tests Clotting syndrome is more commonly seen in Europe. in seen commonly more is syndrome This mortality. ahigh with associated is and people in basis immune-mediated an have be to direct vascular damage from the spirochetes. spirochetes. the from damage vascular direct and/or coagulation, intravascular disseminated failure, hepatic to due be to suspected is but understood well not is humans and dogs in of bleeding mechanisms pathophysiologic are considered specific for leptospirosis, however. for leptospirosis, specific considered are antithrombin III activity. III antithrombin decreased as well as reported been has products degradation fibrinogen and d-dimer fibrinogen, radiographs. 11 Patients with LPHS typically have have typically LPHS with Patients . Direct testing via culture or or culture via testing . Direct (CONTINUED ON PAGE ON 12) (CONTINUED 1,21,28 2,21,25,27 28 Changes seen in other other in seen Changes None of these changes changes of these None In one study of 35 study one In 21 LPHS is thought thought is LPHS 23 The exact 1,29
Elevated Elevated 22 11.
INTERNAL MEDICINE infection but this drops to 34% at day 7. 34% day at to drops this but infection days 6of of first 86%the in a sensitivity had assay PCR blood-based One assays. of these performance the evaluating studies limited are there Unfortunately, regions. by varies prevalence but state carrier achronic indicate could PCR positive a dogs, asymptomatic In development. vaccine for important is and of epidemiology understanding our improves serovars infecting on information generally does not impact management, however This serovar. infecting the determine not do assays detection of leptospires. detection PCR real-time with interfere can vaccination predict the infecting serovar. infecting the predict not does response antibody serovars, among cross-reactions serologic to of Due 70-100%. a specificity with titers paired to 100% using when increases of testing MAT sensitivity The present. still often is increase titer 4-fold the response, antibody the blunt may therapy antibiotic While infection. of active suggestive also are increase a 4-fold show that apart weeks 2-4 taken titers Paired 69-100%. of specificity a and laboratory, diagnostic the on depending of 22-67% sensitivity a ≥1:800had of titer MAT single a that showed study One signs. clinical compatible with adog in suggestive is vaccination by covered of ≥1:800 titer positive A single not to a serogroup laboratories. different among results in variability considerable be may there and serovar infecting the with correlate always not does 12. 4months. over decline generally and low be to tend titers post-vaccinal however titers, of interpretation with interfere can Vaccination IgG production. in alag with along of disease course the in earlier results negative post explain help may This 8 infection. ~day until appear usually not do these but MAT in of leptospires agglutination the in role amajor plays lipopolysaccharide to leptospiral specific IgM circulating of magnitude The antibodies. IgG and IgM both by triggered being agglutination with reported, titer the is organisms of 50% leptospiral agglutinates that of serum dilution highest The animals. in leptospirosis for test used commonly most the been has MAT The Test (MAT) AgglutinationMicroscopic polydypsia. and polyuria azotemic non- as such signs mild only with present may that patients in considered be should and carriers subclinical in organisms detect may assays PCR false-negative results. of chance the reduce to submitted be should urine and blood both common, most is which unknown, is of infection time the If urine. in numbers greater in found are organisms of infection, days chance of a false negative after starting antibiotics. starting after negative of a false chance a high to due therapy antibiotic starting to prior CONTINUED FROM PAGE FROM 11 CONTINUED INTERNAL MEDICINE 32 In addition, the highest titer titer highest the addition, In 1 Samples should be obtained obtained be should Samples 21 Current commercial PCR PCR commercial Current 2,33 of infection infection of
33 Ongoing Ongoing 2 Recent Recent 30
sera. MAT. Differences in the sensitivity for these tests tests these for sensitivity the in MAT. Differences WITNESS for 93.5% course ofcourse the disease. the into of weeks acouple until seen not often are magnitude of this >1:3200 titers was MAT but used more frequently now. frequently more used are and antibodies these on based are tests care infection. The SNAP The infection. 14 day by 30/32 dogs post in seroconversion identified MAT 10 day by while dogs all in seroconversion identified (Zoetis) Lepto WITNESS the infected, 32 of experimentally dogs study another In diagnosis. final the for used was MAT in rise A4-fold 75%and respectively. was 97.6%, 10%, specificity while Lepto Witness 78.9% and Lepto, SNAP 86.5% (MAT), 70.3% were tests three the for sensitivities the dogs, of Lepto). a In 89 SNAP and study Lepto Witness MAT, (single available currently tests antibody main three the comparing reports two are There WITNESS The detect that developed been have tests Point-of-care Tests Point-of-Care MAT. to compared infection early at detecting is sensitive more ELISA IgM test the differences, these to Due infection. after weeks 1-3 quantities large in produced is IgG 2 weeks. around value a maximum with first of infection week the during rise generally antibodies IgM ELISA 1 year post-vaccine. 1 year to up seen been have vaccination from positives and Lepto SNAP the with detected are antibodies vaccinal strains. non- to especially titers, higher to contribute may of leptospires strains field to exposure cross-reactive antibodies at 12 at weeks. antibodies cross-reactive had vaccination post tested of dogs percent four Twenty- PCR. positive or titer MAT in arise by diagnosed later were that dogs 24% in MAT for only to of 75% compared asensitivity found cases clinical of acute diagnosis study MAT. via Another obtained with and compared 98% 93.5% was specificity sensitivity the study, one In Bratislava. sv interrogans L. and Grippotyphosa sv kirschneri L. from extracts cell whole using detected seroconversion in 3 dogs during the first first the 14 days. during dogs 3 in seroconversion detected cases. 83.2% of in Lepto SNAP and MAT between found agreement was there 1:800, ≥ were titers of Leptospira protein membrane abundant an LipL32, the against antibodies 20/131 (15%) positive. a false as identified but also tohave leptospirosis confirmed were 15/22 that in dogs positive was Lepto SNAP 29 33 The SNAP Lepto (IDEXX) detects Leptospira The highest agreement was found when when found was agreement highest The 32 Sensitivity was 98% and specificity was was 98% was specificity and Sensitivity ® 1 Lepto detects IgM antibodies antibodies IgM detects Lepto -specific antibodies in canine canine in antibodies -specific 34 ® 35 Lepto when compared to to compared when Lepto ® In clinical practice, the the practice, clinical In L e p t o ( I D E X X ) t e s t 2 . When MAT MAT . When The point-of- 34 32 Vaccinal ®
Partners In Care Care In Partners n Erpa suy oprn WITNESS comparing study European a In of testing. time the at known not usually is which serovar, infecting the and/or infection after timing sample to related be may usually occurs within 2-4 weeks of starting dialysis dialysis of starting weeks 2-4 within occurs usually PCR test returns. returns. test PCR a positive unless considered are titers MAT paired history, vaccinal any with positive is test of-care apoint- If of disease. suggestive highly be would this history, vaccinal no with positive, is test apoint-of-care If +/- Lepto) titers. MAT (Witness testing antibody as well as urine) and blood (typically test a PCR-based both recommend we generally instituted, been not has therapy antibiotic If patients. for of testing combination a at recommend typically we would such, Angell As important. is diagnosis definitive a obtaining injury, kidney of acute reversibility potential the and potential zoonotic the Given (~80-90%). rate including survival better amuch have leptospirosis, etiologies, infectious ~50%, only is treatment dialysis without or with injury kidney acute for survival overall the Though considered. be should dialysis for referral values, renal in rise progressive a having or overload, fluid of signs experiencing anuric, oliguric, be to suspected is apatient If distress). of respiratory signs are there if support (i.e., oxygen signs of clinical severity the on dependent be will therapies Other acid). (e.g., ursodeoxycholic choleretics SAMe) and (e.g., antioxidants as such needed, as administered also are liver the for therapies Supportive nutrition. providing and treatments, anti-vomiting and nausea anti- providing imbalances, electrolyte and fluid correcting is therapy of supportive mainstay The therapy Supportive of testing. results the for waiting while withheld be not should treatment (ideally), therapy antibiotic to prior collected be should samples test Although patients. azotemic in considered be should reduction dose but used be Gcan penicillin or ampicillin tolerated, not is doxycycline If time. this at unknown remains of therapy duration optimal true The penicillins. unlike state, carrier renal the eliminate itwill as of choice treatment the is 2weeks for q12 hrs IV or PO 5 mg/kg at doxycycline Leptospirosis, on Statement 2010 Consensus the on ACVIM Based therapy Specific PREVENTION TREATMENT/MANAGEMENT/ Test-it and Lepto had not been performed. been not had testing convalescent if positives ofof true Care) 21.4% 24% (Point in and overlooked (MAT) been have would flowofassay, leptospirosis adiagnosis 37,38 Recovery of adequate renal function function renal of adequate Recovery ™ Winter 2020 Winter 2020 Leptospira Canine IgM lateral lateral IgM Canine Leptospira 36 Volume 14:1 Volume ®
INTERNAL MEDICINE infection requires further study. study. further requires infection acute of aknown absence the in leptospirosis and disease kidney chronic between relationship Partners In Care Care In Partners 80-90%. be to reported are rates Survival therapy. antibiotic appropriate to responsive very typically is Leptospirosis Prognosis phase of leptospiremia. acute the survive that of 50% patients to up in develop may disease kidney chronic Additionally, patients. some in longer take may recovery hepatic 10-14 in days, resolve will often azotemia While resolution. for monitor to visits follow-up require and weeks several for persist may abnormalities laboratory improvement, clinical Despite losses. fluid of these replacement adequate ensure to warranted is outs and of ins measurement precise more so polyuric, severely be may failure renal non-oliguric with Dogs measurements. weight body serial as well as intake fluid versus catheter) urinary (indwelling output urine quantitative through primarily accomplished is overload fluid and anuria, oliguria, for Monitoring hours. 24 every evaluated are profiles biochemistry leptospirosis, acute with For dogs electrolytes. stable ensure to and involvement, hepatic of development azotemia, of progression any for watch to daily monitored often most is work Blood monitoring. intense require involvement liver without or with injury kidney of acute signs with presenting Patients Monitoring therapies. of other benefit the determine to dogs in needed are Studies exchange. plasma and cyclophosphamide after outcome improved show LPHS with humans in Studies ventilation. mechanical even or therapy oxygen require may LPHS with Patients management. medical to responsive not are that of uremia signs or >80mg/dL, BUN hyperkalemia, overload, volume developing output urine inadequate with patients in considered be should consensus statement, renal replacement therapy the Per stays. hospital shorter and survival increased with associated been in has humans hemodialysis Early occurs. polyuria before 1-3 need treatments only may patients some and poorer prognosis.poorer a have involvement multi-organ and disease severe renal disease and poorer outcomes. poorer and disease renal severe more with associated been also has Pomona leptospirosis, were positive on urine PCR. urine on positive were leptospirosis, of infection prior known no and disease, kidney chronic with dogs many that showed leptospira, for endemic be to known area an from report CONTINUED FROM PAGE FROM 12 CONTINUED INTERNAL MEDICINE 1,21 Infection with serogroup serogroup with Infection Winter 2020 Winter 2020 38,39 25 Dogs with pulmonary pulmonary with Dogs Interestingly, a recent Volume 14:1 Volume 24 40 The The infection with other serovars. other with infection from leptospirosis post-vaccinal develop to possible still itis so disease, cause can that serovars other against cross-protective completely not are other vaccines administered to dogs. to administered vaccines other than reactive more no be to considered are vaccines these leptospirosis, with vaccination after occur can reactions Although annually. administered be must Vaccines 12 for months. protection report some and months, 6-8 least at for vaccine the in serogroups against protect to shown been have Vaccines infection. challenge to immunity demonstrating studies numerous with intervals, week 2-3 at injections 2-3 involves immunization Initial for and some, leptospiuria. leptospiremia, rates, mortality in reduction significant a show vaccines the for studies Challenge uncommon. is patients vaccinated in However, disease Leptospires are sensitive to many disinfectants disinfectants many to sensitive are Leptospires of disease. suspected patients with cages on placed be must be should labels warning and runs routinely disinfected and Cages dogs. hospitalized handling when used be should protection eye and boots, gloves, clothing, Protective known. not is duration exact the but started is therapy antibiotic after 2-3 for days urine or blood in present likely are Organisms made. been has diagnosis alternate an until leptospirosis suspected as managed be should disease, chronic and acute including failure, renal acute with dogs All people. immunocompromised and children are as risk increased at are workers system sewer and caretakers, animal water swimming). Veterinarians, farmers, fresh (boating, exposure recreational or occupational through infected become can People disease. zoonotic a is Leptospirosis ZOONOTIC POTENTIAL measures. control rodent and by ofuse fencing contact animal wild minimizing and water standing and/or areas marshy as such of infection, sources potential to access decreased include of prevention methods Other preventativeOther measures 1year. to up for protection provide to shown been has and of leptospirosis prevention for America North in available Pomona) is (Canicola, Grippotyphosa, Icterohaemorrhagiae, serogroups four containing a bacterin Currently Vaccination MEASURES PREVENTIVE animals should be avoided. be should animals infected from urine with contact so people, for of infection source apotential are leptospirosis currently available quadrivalent vaccines. quadrivalent available currently the and bivalent original the with vaccinated dogs in reported been has leptospirosis occurring 42,43 41 These vaccines vaccines These 42 2,19 Dogs with with Dogs 1,2 Naturally Naturally 1,41
shedding by the time of discharge is likely low. likely is of discharge time the by shedding of urinary risk the though even completed is treatment antimicrobial until dog’s urine their contacting when hands wash and gloves wear should owners discharged, is apatient Once body. the handling when continue should measure away, protective passes patient a If bedding. the handling individuals by worn be should clothing protective but leptospires inactivate will Laundering washed. be should soaked urine is that hair any and immediately disinfected and by other dogs. other by used areas in urinate to allowed nor areas/hallways can common in walked be not should Dogs occur. leptospires of aerosolization since areas kennel clean to used not is washing Pressure drying. and ammonias) quaternary (e.g., iodophors, bleach, any positive cases. cases. positive any with contacted be should veterinarian state The disease. areportable considered is Leptospirosis titers. convalescent and of acute monitoring with ideally recommended, is environment the in of leptospires source a to exposed coincidentally been have may that household the in dogs of other Treatment access. have will children), (especially people or animals other no where water, standing from away urinate still should Patients REFERENCES 6 5 4 3 2 1 2016 Vol 63 (4) 328-36. pp. Public Health Zoonoses Dogs. Domestic in Leptospirosis with Associated of Factors Meta-Analyses G. Monti L, Azócar-Aedo (8)248 908-15. pp. 2007-2011. Oregon, in dogs among of leptospirosis EE: Characterization DeBess SE, Grayzel 1 (2) 32-36. pp. J Microbiol Iran Iran. Tehran, in leptospirosis of feline study Serologic al. et N, Maazi MA, Akhavizadegan S, Jamshidi Conference Western Veterinary Prevention. and Treatment Diagnosis, 2010: on Update Leptospirosis Canine RE: Goldstein 2012 431-47. pp. Louis St. Saunders, Elsevier 4ed. Cat, and Dog of the Diseases Infectious Leptospirosis. al. et GE, Moore JE, Sykes CE, Greene prevention. and treatment, epidemiology, onstatement leptospirosis: diagnosis, consensus animal 2010 small ACVIM KF, al. et Lunn K, Hartmann JE, Sykes 2011 Med J Vet Intern Vol (1) 25 1-13. pp. 42 Any urine spills should be cleaned cleaned be should spills urine Any 2016 Vol Vol 2016 Vet JAm Assoc Med 2010. 2010. (CONTINUED ON PAGE ON 14) (CONTINUED 2018 Vol Vol 2018 13. :
1
INTERNAL MEDICINE 14. 19 18 17 16 15 14 13 12 11 10 9 8 7 PAGE FROM 13 CONTINUED INTERNAL MEDICINE 1657-1884. Vol 2007 (11) 230 VetJ Am Assoc Med pp. dogs. healthy in serovars Leptospira six against antibodies of serum Prevalence al. et WD, Schall JB, Kaneene JE, Stokes 779-788. 2000-2010. 2014; States, 28: United the in dogs in seropositivity leptospira of variations temporal and Regional C. Guptill-Yoran M, Levine HS, Lee Vol (0) 222 29-35. pp. J Vet of America. States United the in leptospirosis of canine Hotspots al. et T, AW, Allen C, White Zambrana-Torrelio 2017 Vol 58 (10) 582-88. pp. with leptospirosis. dogs 99 in outcome and findings imaging laboratory, of clinical, Evaluation al. et E, Luge A, Mayer-Scholl S, Knöpfler 33: 141-150. 33: Involvement. Renal Prominent Without Infections Leptospiral Hepatic al. et AJ, Kortum F, Constantino-Casas KE, McCallum 2005; 66 (10) 66 2005; 1816-22. JVet Am Res Bratislava. and Pomona serovars interrogans by Leptospira caused leptospirosis canine Experimental DP, JJ, al. Alt et CA, Bolin Greenlee 2010 Vol 237 (3) 293-8. pp. States, 2000-2007. United the in dogs in tests agglutination microscopic via serovars Leptospira against of antibodies Detection al. LF, et Guptill Wu CC, R, Gautam Vet Emer Crit Care 2016; Care Crit Vet (4): 26 Emer 559-567. (1995-2012): dogs in J failure 49 cases. liver of acute evaluation Retrospective al. et RM, J, Peters Cooper C, Lester Med Top Dogs. Anim Companion Working Seroprevalence of Leptospirosis in SF, al. et Lau Wong KH, JY, Khor Invest leptospirosis. fatal canine of acute cases occurring 10in naturally features CA: Diagnostic Brown DR, Rissi Assoc (2000-2010). 51dogs: Vet JAm cases Med in leptospirosis occurring of naturally features atypical and Clinicopathologic MP: Littman LE, Tangeman J Vet Intern Med 2014; Med J Vet Intern 28: 294-299. 1970 2009. and between leptospirosis canine in changes Signalment al. et AJ Johnson L, Guptill HS, Lee Intern Med Intern Vet Jof hospitals. teaching two between leptospirosis canine with associated findings of clinical Comparison PJ. J, Armstrong Bryan JE, Sykes 2017 Vol 32 (4) 121-225. pp. 2013 Vol 243 (9) 1316-22. pp. 2014 Vol (6) 26 799-804. pp. 2007; 21: 642. 2019; 2019; Med J Vet Intern J Small Anim Pract Anim JSmall J Am Vet Med Assoc Vet JAm Assoc Med J Vet Diagn JVet Diagn 2017 2017
32 31 30 29 28 27 26 25 24 23 22 21 20 Intern Med Intern Vet J dogs. owned client healthy in testing PCR time real blood whole on vaccination Leptospira of recent Effects al. et AM, Midence JN, Leutenegger CM, Chandler Symposium 2016. Symposium Diseases Infectious Animal Companion for Society International New? Fourth –What’s B: Leptospirosis Kohn Early Detection Of Leptospira-specific Leptospira-specific Of Detection Early Tests for of 3Serological Evaluation al. et Weber A, S, J, Velineni Lizer Intern Med 2017 Med Intern Vol 31 (1) 69-80. pp. Vet J Study. AProspective Leptospirosis: of Diagnosis aClinical 35 with Dogs in Disorders Thromboelastometric and Hemostatic, Hemorrhagic, al. et C, Pouzot-Nevoret M, Magnin A, Barthélemy 2006 Vol 2006 (3) Med 20 Vet 489-94. pp. Intern J dogs. in of leptospirosis features clinical on serogroup infecting of Influence al. et CE, RC, Langston Lin RE, Goldstein (0) pp. 37-42. pp. (0) J Vet dogs. in leptospirosis of acute diagnosis the for tests of-care point- of rapid evaluation Prospective al. et S, Zamagni A, Balboni Troìa R, Vol 59 (1) 98-106. pp. leptospirosis. with in dogs 35 findings ultrasonographic of abdominal evaluation Prospective al. et Goy-Thollot I, A, J, Barthélemy Sonet 2013; 242: 1373-1380. 1373-1380. 242: 2013; Vet JAm Assoc Med center. areferral in dogs in leptospirosis of acute diagnosis for assay reaction chain a polymerase and testing microagglutination serologic of value diagnostic of the T. Evaluation Schweighauser A, Francey CK, Fraune Veterinary Conference 2010. Coast Atlantic C: Leptospirosis. Langston 2004). (2001- of cases 20 study retrospective a dogs: in infection serogroup australis interrogans of Leptospira predictors outcome and features Clinicopathologic al. F, et C, Dondi C, Angoli Mastrorilli, 248 (8)248 908-15. pp. 2007-2011. Oregon, in dogs among of leptospirosis EE: Characterization DeBess SE, Grayzel 24 (6)24 1277-82. pp. leptospirosis. with dogs in abnormalities Pulmonary al. et G, Arndt K, Steinicke B, Kohn pp. 928541.pp. syndrome? haemorrhagic pulmonary leptospiral human the to similar dogs: in syndrome haemorrhagic pulmonary emerging An al. et S, B, Plog R, Kohn Klopfleisch 2017; 21 (1): 3-10. (1): 21 2017; Med JVet Inten 2012; (1): 26 149-152. 2016 Vol Vol 2016 VetJ Am Assoc Med 2010Vet Int Med Vol 2010 (0) Vet Radiol Ultrasound 2010 Vol Vol 2010 Med J Vet Intern 2018 Vol 237 2018 2018 Partners In Care Care In Partners 35 37 36 38 43 42 41 40 39 34 33 2) 26-9. pp. Immunol Immunopathol Vet infection. against immunity months 12 least at provides vaccine leptospirosis canine tetravalent Anew D, al. et Sutton Van Veen M, der HLBM, Klaasen based rapid in-clinic ELISA (SNAP ELISA in-clinic rapid based LipL32 of arecombinant Performance al.: et PS, Smith PC, Foster KM, Curtis Vet Med Vet Res JAppl Int dogs. in leptospira against of antibodies detection the for Lepto) Intern Med 2014; Med 28: 789-792.Intern JVet dogs. owned client in antibodies Leptospira Vaccine-associated al. et SA, KT, Wennogle Wiggans LER, Martin 2017; 15 (9): 91. Clinician's Brief Risk? at Owners Are Leptospirosis: MR: Lappin GE, Moore pp. 201-207. Dogs. Infected Experimentally in Antibodies cases cases (1990-1998). 36 leptospirosis: with of dogs outcome and LD. Treatment Cowgill CA, Adain 2000; 216: 371-375. 2000; 2005 Vol2005 15 (3) 201-205. pp. Leptospirosis. with 5Dogs in Failure Renal of Acute Management the in Dialysis Peritoneal al. et EA, NF,Beckel O’Toole Rozanski TE, studies. studies. of meta-analysis caseproportional series A dogs: and cats in injury kidney Acute al. et E, Legatti R, El Dib SAM, Legatti Blackwell Publishing 2011 157-164. pp. Publishing Blackwell Ames Zoonoses Animal Companion Diseases. Bacterial M: Fulford Weese JS, 58: 154-161. 58: leptospirosis. canine of acute diagnosis the in tests “patient-side”chromatographic commercial of two value Diagnostic al. et T, Francey A, Schweighauser CI, Gloor et al. Evaluation of SNAP Evaluation al. et RE, Goldstein Tasse SM, SI, Winzelberg Vet Med Vet diagnosis of Leptospirosis. 2019; 62: Disease 64-67. Infect and disease. kidney chronic canine with associated is infection leptospiral Asymptomatic al. J, et Oliveira AS, Vieira R, Sant’Anna 2018 Med JVet Vol Intern 32 (1) 2015; 13 (3): 182-89. 2015; 13 (3): 193-98. PLoS One PLoS Comparative Immunology, Micro Immunology, Comparative Winter 2020 Winter 2020 J Small Anim Prac Anim J Small J Vet Emerg Crit Care Crit J Vet Emerg 2018; 13 (1): e0190772. J Am Vet Med Assoc Vet JAm Assoc Med 2014 Vol 158 (1- ® Lepto in the the in Lepto Int J Appl Res Res JAppl Int Volume 14:1 Volume t 2017; 2017; t , ®
INTERNAL MEDICINE C Partners In Care Care In Partners mass. given a for behavior biological predict to attempt an in 2011), in al. et by Kiupel system 1984 two-tier or in al. et Patnaik by established system (three-tier schemes grading published both or one using graded are dogs in tumors cell mast Cutaneous tumors. differentiated poorly in granules of presence for the assess to reminder helpful frequently a are cells, mast canine which neoplastic accompany Eosinophils, granules. are often well differentiated or have discernible cells mast neoplastic the as challenge a diagnostic the present not do tumors cell Histologically, mast of canine majority size. tumor fluctuant of ahistory is as common, are ulceration and cells) neoplastic by structures of adnexal displacement (from 1). Alopecia (Figure margins discrete without or with mass subcutaneous to adermal or raised, minimally is which thickening plaque-like a nodule, dermal raised a discrete including manifestations, of gross a range with present can tumors cell mast Canine 80%. approaches tumors cell of mast proportion the cats, In tumors. cell mast are population Angell recent this in histologically evaluated subcutis and skin the in tumors cell round of canine 80% than More CELL TUMOR MAST Angell in the past 4.5 years. 4.5 past the in Angell to submitted tumors cell round subcutaneous cutaneous/ total the to relative type tumor of each percentages including skin, of the tumors cell round on specifically focus will article This group. (fourth) own their represent may therefore and morphologies, of these all or any overlap may tumors melanocytic pigmented Poorly origin. cell round or mesenchymal/spindloid, epithelial, morphology: using groups three into neoplasms stratify pathologists Most differentiation. tissue or the histogenesis, on based process characterize further then and – occasion! on challenging surprisingly be can which – neoplastic truly is mass the if determine first must pathologist the microscope, At the excised? itcompletely Is itbehave? How it? will is What include: masses skin for answered be to questions PATHOLOGY As with any tumor type, the clinical clinical the type, tumor any with As histopathology. for submitted samples surgical common most the among are masses subcutaneous and utaneous 5,6
Winter 2020 Winter 2020 Anatomic Pathologist |angell.org/lab Pathologist Anatomic DACVP MS, DVM, Mouser, Pamela Tumors Cell Canine Feline and Cutaneous Round Volume 14:1 Volume
binucleate, multinucleate, and karyomegalic karyomegalic and binucleate, multinucleate, have commonly tumors these Microscopically, extremities. distal and head of the skin the favor tumors cell plasma histiocytomas, alopecic to similar 2). Also (Figure nodule raised dermal discrete a by characterized below), are and (discussed histiocytomas cutaneous resemble tumors cell plasma cutaneous most Grossly, tumors). cell round cutaneous (about 8%of canine timeline this during dogs in diagnosis frequent most next the is (plasmacytoma) tumor cell plasma Cutaneous CELL TUMOR PLASMA for feline mast cell tumors. cell mast feline for system grading of atwo-tier application suggests study Arecent eosinophils. accompanying no or few have may tumors cell mast feline addition, In stains. routine with pronounced visually as not are granules cell mast feline dogs, to contrast In nodules. skin raised discrete, single, as occur often tumors cell mast cutaneous Feline cell tumors classified as high-grade in this study of 349 days. time study survival this amedian had in high-grade as classified tumors cell mast Feline tumors. cell mast cutaneous feline commonly predicted for well-differentiated is as behavior, biological benign to corresponds designation using this system essentially follicles by infiltrating mast cells. mast infiltrating by follicles hair of disruption possibly and to separation due alopecic appears right the on mass the while surface, skin overlying the of ulceration has left the on mass The protrusive. 4 1 FIGURE
Two cutaneous mast cell tumors. In both examples, the tumors appear nodular and and nodular appear tumors the examples, Inboth tumors. cell mast Two cutaneous 8 A low-grade A low-grade one retrospective study. retrospective one to according times survival shorter experience may plasmacytosis, cutaneous termed tumors, cell plasma cutaneous multiple with presenting Dogs myeloma. multiple with associated rarely are and dogs in behavior biological benign have typically tumors cell plasma Cutaneous sarcoma. histiocytic as such lesion aggressive amore suggest may morphology pronounced, is pleomorphism nuclear and appreciated not is differentiation plasmacytoid where tumors In mass. of the margins the near particularly cells, neoplastic some in seen be may pallor) paranuclear with nuclei clock-faced (eccentric features Plasmacytoid mononuclear population. background the among distributed cells commonly addressed by primary care primary by addressed commonly more be may histiocytomas as type, tumor of this proportion relative the underestimates likely percentage This submissions. Angell recent in dogs from tumors cell round cutaneous 4% of about represent histiocytomas Cutaneous HISTIOCYTOMA CUTANEOUSCANINE tumors are rare in cats. in rare are tumors (CONTINUED ON PAGE ON 16) (CONTINUED 1 Cutaneous plasma cell cell plasma Cutaneous 15.
PATHOLOGY 16. pathologist. the by such as diagnosed be may and inflammation, mononuclear from indistinguishable sometimes are histiocytomas Regressing intervention. surgical require may inflammation and ulceration associated the although occur, may regression Spontaneous 2). (Figure behavior biological benign have appearance, gross nodular raised discrete their to due tumors “button” as to referred sometimes histiocytomas, Cutaneous old. years of 6.2 mean of 6and amedian 1-12 old with from years range group Angell the in animals affected although dogs, of young alesion considered generally is tumor This service. Angell’sby surgery often as removed not therefore and veterinarians neoplastic dermatopathies. neoplastic non- of those with overlap may lymphoma cutaneous of lesions gross how Note ulceration. to coalescing multifocal with thickened also lip is upper the of Skin planum. nasal the of cracking and crusting, thickening, has right the on dog The procedure. biopsy the to guide clinician the by made were marks V-shaped black The nodules. to plaques raised and scaling, erythema, showing skin abdominal affected of up view 4 3 FIGURE fixation. for mass the through slices serial with formalin-fixed been has right the on tail distal amputated The lesion. the of manipulation clinical or to self-trauma related be may left the on tumor cell plasma the around Erythema masses. alopecic raised, are discrete, lesions (right). Both histiocytoma 4 2 FIGURE PAGE FROM 15 CONTINUED PATHOLOGY
Shows two manifestations of cutaneous lymphoma in dogs. The left panel is aclose- is panel left The in dogs. lymphoma cutaneous of manifestations two Shows cutaneous and left) (plasmacytoma, tumor cell plasma cutaneous Compares Histologically, neoplastic lymphoid cells in in cells lymphoid neoplastic Histologically, affected. be may membranes mucous and junctions 3). Mucocutaneous (Figure nodules or ulceration, erosion/ skin, thickened erythema, scaling, include may which appearance clinical variable a have and widespread or multifocal, solitary, be may lesions Grossly, fungoides. mycosis called also is and of origin, T-cell typically is lymphoma epitheliotropic cells). Cutaneous lymphoid neoplastic by affinity (epithelial epitheliotropism demonstrating tumors of these majority the with as lymphoma, classified are population this in tumors cell round cutaneous 4% of canine About LYMPHOMA Partners In Care Care In Partners (unconfirmed) in the Angell population. Angell the in (unconfirmed) cases suspect few with cats, in common less is sarcoma Histiocytic 1year. around time survival amedian had sarcoma) histiocytic for cutaneous/subcutaneous presentation common (which is the sarcoma histiocytic localized study, over the tarsus. the over develops lymphoma of cutaneous variant unique were compatible with tarsal lymphoma (Figure 4). (Figure lymphoma tarsal with compatible were submissions lymphoma cutaneous feline the Angell of half than more Interestingly, days. 190 was lymphoma tarsal with cats for time survival median The disease. metastatic developed or had frequently study retrospective published 130 days. was lesions cutaneous with dogs for time survival median the lymphoma, epitheliotropic with of dogs study retrospective arecent In structures. adnexal and epidermis the within plaques broad into coalesce may which nests form and size to medium small are lymphoma epitheliotropic (canine cutaneous histiocytoma) to aggressive aggressive to histiocytoma) cutaneous (canine potentially self-resolving benign lesions from range tumors cell round Cutaneous FINAL TAKE-HOME POINTS immunohistochemistry. following excluded were origin of histiocytic be to suspected originally tumors many that noted authors the sarcoma, of histiocytic prognosis evaluating study Inoneretrospective inflammation. granulomatous and histiocytosis cutaneous/reactive from distinguished be also should sarcoma Histiocytic origin. leukocytic their confirm to immunohistochemistry require ultimately may and histologically, spindloid ovoid to to round from range may cells neoplastic fact, In sarcoma. tissue soft or tumor cell mast a subcutaneous to similar appearance aclinical with extremities, the on often mass, subcutaneous expansile a single presents typically of histiocytes tumor malignant This sarcoma. histiocytic as diagnosed were years 4.5 past the from tumors cell round cutaneous/subcutaneous 2-3% of canine Between SARCOMA HISTIOCYTIC reported at injection sites in cats, in sites injection at reported been has lymphoma Cutaneous/subcutaneous nonepitheliotropic. often more is cats in lymphoma cutaneous dogs, to contrast In population. feline of Angell the in tumors cell round 9% cutaneous about composed Lymphoma study. retrospective the in time survival median the increased significantly also Chemotherapy of 491time days). survival (median lesions mucosal mucocutaneous/ of with 231 dogs did days), as time survival (median prognosis a better had lesion 3 Dogs presenting with a solitary skin skin a solitary with presenting Dogs 2 Cats with tarsal lymphoma in the the in lymphoma tarsal with Cats Winter 2020 Winter 2020 7 and a seemingly a seemingly and Volume 14:1 Volume 4 In the same same the In
PATHOLOGY Partners In Care Care In Partners sinuses in the left popliteal lymph node. lymph popliteal left in the sinuses distend also which cells, lymphoid large neoplastic comprises mass the Histologically, joint. tarsal the surrounding mass subcutaneous multinodular a 4 4 FIGURE PAGE FROM 16 CONTINUED PATHOLOGY
This left hind limb from a cat has has acat limb from hind left This at MSPCA at 4 Chiropractic Massage Hydrotherapy Current include: rehabilitation physical services patients. canine our on work of their impact of the angell.org/rehab Visit team. Rehabilitation Rehabilitation Physical CCRT, DVM, our lead Straut, Amy (CCRT), and Canine Therapist Certified DVM, Palmer, Jennifer week. per days seven services offers Rehabilitation West Physical MSPCA-Angell rehabilitation. physical from benefit substantially can dogs issues, mobility facing or training, cross or injury, an from recovering Whether conditions. neurological and orthopedic of variety awide treat to used is rehabilitation physical Canine Manual therapy Manual
Physical Rehabilitation Physical Winter 2020 Winter 2020 -Angell West assistive devices assistive of fitting and Consultation treatment laser Therapeutic exerciseLand-based Volume 14:1 Volume for details and video footage footage video and details for widely within this group. this within widely differs prognosis and behavior the as tumor, cell round acutaneous classify completely more to [PARR]) rearrangement receptor antigen for PCR or immunohistochemistry, stains, (special tests diagnostic ancillary recommended pursue to hesitate not Do quality. better in detail cellular retain may preparations cytologic as pathologist, the to valuable prove may biopsy of the smears impression or aspirates needle Fine histopathology. on obvious immediately be not may of origin cell clear-cut, relatively often is entities these between distinction While lymphoma). (cutaneous malignancies REFERENCES 3 2 1 Clinical outcome and prognosis of dogs of dogs prognosis and outcome Clinical AS. Moore AE, Frimberger CM, Chan 2014;244:1429-1434.Vet Assoc Med (2000-2012). JAm cases 23 cats: in tarsus of the lymphoma Cutaneous KE. Burgess CA, Clifford JH, Keating HD, Burr 2017;31:1074-1080. Med (2005-2015).21 JVet cases Intern plasmacytosis: cutaneous Canine al. et CJ, DeRegis AS, BO, Moore Boostrom 8 7 6 5 4 2011;48:147-155. Vet behavior. Pathol biological predict accurately more to tumors cell mast cutaneous canine for system grading histologic of a2-tier Proposal al. et KL, Bailey JD, Webster M, Kiupel 2019;56:43-49. Vet Pathol tumors. cell mast cutaneous G.Grading Bettini S, Sabattini 2016;53:823-832. Pathol Vet 17 in cats. characterization molecular and immunophenotypical, pathological, sites: injection at lymphoma Cutaneous al. et A, P,Robbabianca Avallone Rodriguez G, Vet 1984;21:469-474.83 dogs. Pathol in time survival and grading morphologic tumor: cell mast cutaneous Canine EG. WJ, MacEwen Ehler AK, Patnaik 2017;15:1171-1180. Vet Oncol Comp sarcoma. histiocytic canine in factors prognostic Clinical L. Cesario Q, Qin M, Kiupel NG, Dervisis 2015). 2018;29:154-e59. Vet Dermatol (2003- of 148 cases study retrospective a lymphoma: epitheliotropic with consistent features histopathological with
17.
PATHOLOGY CHIEF STAFF OF 617 Referrals: 522-5011 978 577-5992 Nashoba: at 617 Phone: |Veterinary |Angell (Waltham) Main 522-7282 |781 902-8400 (Boston) 18. [email protected] Waltham Officer, Medical Chief DACVECC Sumner, DVM, Catherine [email protected] Jessica Seid, DVM [email protected] DVM Rose, Lauren [email protected] DACVECC DVM, Peck, Courtney [email protected] DVM McChesney, David [email protected] DVM Lohin, Amanda [email protected] DVM Fetto, Jordana WALTHAM MEDICINE, CARE 24-HOUR EMERGENCY & CRITICAL [email protected] Officer Medical Chief DACVECC, CVA DVM, Whelan, Megan [email protected] Turley,Kelsey DVM [email protected] DVM, DACVECC Sinnott-Stutzman Virginia [email protected] DVM Magestro, Susan [email protected] DVM Koontz, Caitlin [email protected] DVM Koid, Audrey [email protected] DVM Kelley, Morgan [email protected] DVM Dorsey, Kate [email protected] DVM Brandifino, Maria [email protected] Co-Director Service DACVECC Bracker, DVM, Kiko [email protected] Becker, DVM Jami [email protected] DVM Bartling, Justina [email protected] Alison Allukian, DVM BOSTON MEDICINE, CARE 24-HOUR EMERGENCY & CRITICAL [email protected] DACVECC DVM, Greenleaf, Marie Ann
We encourage you to contact Angell’s specialists with questions. with Angell’s specialists contact you to We encourage STAFF DOCTORS ANDSTAFF RESIDENTS DOCTORS
[email protected] DAVDC DVM, Riehl, Jessica [email protected] DVM McCarthy, Colleen [email protected] DVM Ekerdt, Alice DENTISTRY [email protected] DVM Zarin, Joseph [email protected] Wiley,Elizabeth DVM [email protected] Medicine) & Internal (Cardiology DACVIM DVM, Quinn, Rebecca [email protected] &Waltham) (Boston DVM Morgan, Natalie [email protected] (Waltham) (Cardiology) DACVIM DVM, Malakoff, Rebecca [email protected] &Waltham) (Boston DVM Lindholm, Julia [email protected] (Boston) (Cardiology) DACVIM DVM, Hogan, Katie (W/B) CARDIOLOGY [email protected] CAAB BCBA-D, PhD, Terri Bright, BEHAVIOR (W/B) [email protected] (Waltham) (Avian Practice) DABVP DVM, Sullivan, Patrick [email protected] (Avian DABVP Practice) DVM, Simone-Freilicher Elisabeth [email protected] &Waltham) (Boston (Avian Practice) DABVP DVM, Noonan, Brendan (W/B) MEDICINE &EXOTIC AVIAN [email protected] DACVAA DVM, Krein, Stephanie [email protected] DACVAA DVM, Cummings, Kate ANESTHESIOLOGY
Partners In Care Care In Partners [email protected] (Waltham) DVM, DACVIM Vrabelova Ackley Daniela [email protected] Spear, DVM Daisy [email protected] Director Service DACVIM DVM, O’Bell, Susan [email protected] DACVIM DVM, Mariotti, Evan [email protected] DACVIM DVM, Kearns, Shawn [email protected] DACVIM DVM, Johnson, Kirstin [email protected] (Waltham) DACVIM DVM, Gorman, Lisa [email protected] Duddy, DVM Jean [email protected] DACVIM DVM, Papp, de Erika [email protected] DACVIM DVM, Crouse, Zach [email protected] DACVIM DVM, Carroll, Maureen [email protected] DVM Bryce, Alyssa [email protected] DVM Brum, Douglas [email protected] Beehler,Michelle DVM (W/B) MEDICINE INTERNAL [email protected] DACVR DVM, VanRuth Hatten, [email protected] DACVR Tsai, DVM, Steven [email protected] DACVR DVM, Ford, Naomi (W/B) IMAGING DIAGNOSTIC [email protected] &Waltham) (Boston Trained) (Residency DVM Simon, Brooke [email protected] DVM Loft, Klaus (W/B) DERMATOLOGY
Winter 2020 Winter 2020
Volume 14:1 Volume
STAFF DOCTORS AND RESIDENTS
STAFF DOCTORS AND RESIDENTS
CONTINUED FROM PAGE 18
NEUROLOGY (W/B) OPHTHALMOLOGY SURGERY (W/B) STAFF DOCTORS DOCTORS STAFF RESIDENTS AND Rob Daniel, DVM, DACVIM (Neurology) Daniel Biros, DVM, DACVO Sue Casale, DVM, DACVS (Boston & Waltham) [email protected] [email protected] [email protected] Martin Coster, DVM, MS, DACVO Megan Cray, VMD Michele James, DVM, DACVIM [email protected] [email protected] (Neurology) Andrew Goodman, DVM, DACVS (Boston & Waltham) PAIN MEDICINE [email protected] [email protected] Lisa Moses, VMD, DACVIM, CVMA Michael Pavletic, DVM, DACVS Jennifer Michaels, DVM, DACVIM [email protected] [email protected] (Neurology) (Boston & Waltham) PATHOLOGY Nicholas Trout [email protected] (CLINICAL & ANATOMIC)* MA, VET MB, MRCVS, DACVS, DECVS Patty Ewing, DVM, MS, DACVP [email protected] ONCOLOGY [email protected] Lyndsay Kubicek, DVM, DACVR Emily Ulfelder, BVetMed Pamela Mouser, DVM, MS, DACVP (Boston and Waltham) (Radiation Oncology) [email protected] [email protected] [email protected] Ji-In (Jean) Lee, DVM PHYSICAL REHABILITATION Mallory Watson, DVM [email protected] (Board Eligible for Medical Oncology) Jennifer Palmer, DVM, CCRT [email protected] [email protected] Spencer Yeh, DVM [email protected] J. Lee Talbott, DVM, DACVIM Amy Straut, DVM, CCRT (Medical Oncology) [email protected] [email protected] ANGELL AT NASHOBA Jillian Waltz, DVM, DACVIM Laurence Sawyer, DVM (Medical Oncology) [email protected] (Board Eligible for Radiation Oncology) [email protected]
(W/B) Services also available at our Waltham location
4 Our Service Locations
BOSTON & WALTHAM BOSTON ONLY
Avian & Exotic Medicine Anesthesiology 617 989-1561 617 541-5048 Behavior Dentistry 617 989-1520 617 522-7282 Cardiology Oncology 617 541-5038 617 541-5136 Dermatology Ophthalmology 617 524-5733 617 541-5095 Diagnostic Imaging Pain & Palliative Care 617 541-5139 617 541-5140 Internal Medicine Pathology* 617 541-5186 614 541-5014 Neurology 617 541-5140 Physical Rehabilitation** 781 902-8400 Surgery 617 541-5048
24/7 Emergency & Critical Care Boston: 617 522-5011 Waltham: 781 902-8400
*Boston-based pathologists serve both Boston and Waltham locations **Available only in Waltham
Partners In Care Winter 2020 Volume 14:1 19. Nonprofit Org. US Postage PAID Permit No. 1141 Boston, MA
We mail one complimentary copy of our newsletter to each of our referring partners. Please circulate this copy within your practice. Winter 2020 | Volume 14:1 | angell.org | facebook.com/AngellReferringVeterinarians
MSPCA-ANGELL 350 South Huntington Avenue Boston, MA 02130 617 522-5011 angell.org
MSPCA-ANGELL WEST 293 Second Avenue Waltham, MA 02451 781 902-8400 angell.org/waltham
ANGELL AT NASHOBA 100 Littleton Road Westford, MA 01886 978 577-5992 angell.org/nashoba
ANGELL AT ESSEX 565 Maple Street Danvers, MA 01923 978 304-4648 angell.org/essex
ANGELL.ORG/DIRECTIONS (FREE PARKING) | ANGELL.ORG/HOURS | ANGELL.ORG/CE Please consider adding Angell’s main numbers to your after-hours phone message.
4 Angell’s Referring Vet Portal angell.org/vetportal
24/7 access to your referred patients’ records We are pleased to offer the Angell Referring Veterinarian Portal to our referring partners. The portal provides 24/7, secure, mobile-friendly access to your referred patients’ records through angell.org/vetportal. The system automatically updates throughout the day and provides 24/7 access to:
Online Medical Records Check-in Status SOAPs Diagnostic Images Lab Results Referral Reports Discharge Instructions Prescriptions
Settings can be customized within the portal to receive notices by email or fax, and you may list multiple emails to receive check-in, discharge, deceased, and update notices.
Visit angell.org/vetportal or call our referral coordinator at 617 522-5011 to gain access to your account.