The newSEE CE Schedule INSIDE & on a Referralremovable Contact postcard! Info Partners In Care Veterinary Referral News from Angell Animal Medical Center Fall 2015 π Volume 9:3 π angell.org π facebook.com/AngellReferringVeterinarians

CARDIOVASCULAR HEALTHY INTERACTION BETWEEN CANINE CUTANEOUS FELINE TOOTH BARTONELLA LEPTOSPIROSIS EFFECTS OF SYSTEMIC JUVENILE PET BIRDS AND MAST CELL TUMOR RESORPTIONS HYPERTENSION IN CATS VETERINARY PROFESSIONALS

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INTERNAL MEDICINE ONCOLOGY

Bartonella Canine Cutaneous Mast π Maureen C. Carroll DVM, DACVIM Cell Tumors: Updates angell.org/internalmedicine in Grading, Prognostic [email protected] 617-541-5186 Markers, and Therapy π Ivan Martinez, DVM, DACVIM (Internal Medicine and Medical Oncology) angell.org/oncology 617-541-5136 [email protected]

s veterinarians, we are expected to be experts in the field of ast cell tumors (MCTs) are the most common cutaneous infectious disease. As a result, we must now become learned in tumor in dogs, representing around 16-21% of all skin more and more infectious organisms that not only tumors, and may occur as solitary nodules or multiple affect our veterinary patients but can also infect the human masses.1 Mast cell tumors may also present at non- Acounterparts with whom these animals are associated. Flea and Mcutaneous sites, including a visceral form affecting liver, spleen, tick-borne diseases are at the center of our attention as veterinarians, and abdominal lymph nodes, bone marrow, or the gastrointestinal tract. our knowledge of Bartonella is evolving rapidly. Although much Overall, MCTs have an extremely wide range of clinical appearances, with has been learned about this organism in the past two decades, years varied biologic behavior and prognosis, and therefore therapy is not of research are likely necessary to fully understand the spectrum of uniform for all and must be tailored to the specific situation of each its pathogenicity. individual patient. This can add to confusion when discussing the various treatment options with pet owners. Bartonella was originally isolated from an HIV-infected person, and was first diagnosed in a dog (1993) diagnosed with endocarditis. In general For the particular case of cutaneous MCTs, multiple factors can help us this organism is now known to be associated with cases of endocarditis predict biologic behavior and therefore guide our therapeutic and myocarditis, granulomatous disease, chronic intravascular infection, recommendations. The most consistent and reliable of such factors is the and vasoproliferative disorders in humans and animals. tumor grade, which only can be determined from histopathology (not cytology) and therefore requires removal or biopsy of the tumor. Historically Today there are 32 named and many other unnamed species of Bartonella. MCTs are divided into 3 different grades (I-II-III or low-intermediate-high Among the many species, we do know that B. henselae and B. clarridgeiae based on Bostock and Patnaik grading systems), where low-grade MCTs are can be pathogenic in cats; B. vinsonii (berkhoffi i) and B. clarridgeae in relatively non-aggressive with a low chance of metastasis (<10-20%), high- dogs. Exposure to these serovars can be found throughout most of the grade MCTs are aggressive and have a metastatic potential of 55-96%, and and the world. intermediate-grade (or grade II) MCTs are a “gray area,” where some behave

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Bartonella is a very fastidious gram negative in dogs. B. vinsonii in dogs can cause chronic Sample submissions for all Bartonella testing rod that remains in a mammalian host as an intraerythrocytic and intraendothelial infections can go to Galaxy Laboratories or Colorado intraerythrocytic and interendothelial bacteria, that can result in vasoproliferative disease, in State University: and can remain so for a prolonged period of addition to endocarditis (Boxers over represented), time. Other cell targets for this organism myocarditis, peliosis hepatis, granulomatous www.galaxylaboratories.com include: microglial cells, macrophages, and disease, granulomatous hepatitis, lymphadenitis, csu-cvmbs.colostat.edu CD34 bone marrow progenitor cells, which rhinitis, epistaxis, encephalitis, skin lesions, may play a role in cytopenias we can observe vasculitis, panniculitis, polyarthritis, uveitis, TREATMENT with Bartonella (humans and dogs). and meningitis, among others. Sometimes Azithromycin is no longer recommended, as dogs can present with only fever of unknown TRANSMISSION Bartonella develops rapid resistance to this drug. origin and epistaxis. Bartonella spp is transmitted by more vectors The recommended therapy includes Doxycycline than any other infectious agent: ticks, Hematologically, monocytosis and eosinophilia 10 mg/kg po/12-24 combined with a sandflies, human lice, cat fleas, rodent fleas, can be observed in ~1/3 of dogs; thrombocytopenia fluoroquinolone for 4-6 weeks. and horn flies. In cats Bartonella is found most in ~50%, and anemia is also common. As in cats, frequently in flea-infested animals; in dogs biochemical abnormalities are uncommon. Doxycycline as a sole therapeutic will not clear the tick is the usual vector of transmission, most Bartonella infections. although fleas are also a vector. In flea endemic DIAGNOSIS areas, seroprevalence in cats can be as high as PUBLIC HEALTH As a rule of thumb for the diagnosis for any 90%; bacteremia rates 50% and greater. As this disease: A “positive” result on a blood test or a Bartonella spp can be transmitted to dogs, cats, organism can live in flea dirt for >9 days, culture does not necessarily prove causation for and humans via flea or tick bites, or via the year-round flea control is very important. bite, lick, or scratch from a bacteremic animal. Transmission between animals and humans disease. We can observe false positive and false negative results in both bacteremic and non- Infected flea dirt in the mouths, fur, or nails of can occur via scratch with a claw contaminated animals are also risk factors to humans. Flea with flea dirt, or via open wounds in contact bacteremic patients. and tick control is therefore imperative in with flea dirt, or from biting or licking from preventing transmission of this organism to infected animals. Dogs: Serology for antibodies to B. vinsonii (berkoffii) is a very specific test, as <4% of sick humans. As mentioned earlier, the human BARTONELLA IN CATS dogs are seropositive. Therefore, a positive is disease manifestations are very similar to the canine, and therefore can result in significant Although controlled studies in cats are limited, indication of exposure and/or active disease and should be treated. Because the sensitivity morbidity to the human population, veterinarians our knowledge continues to evolve. Bartonella most importantly! Any fluid—blood, body of antibody detection is so low, combined henselae lives in the cat flea. Cats infested with cavity, joint, cerebrospinal fluid, etc.—from an testing is recommended for dogs. The tests of fleas are 40% more likely to be Bartonella infected animal can harbor live organisms. choice are a combination of 1. and 2. below: positive on serology or PCR than cats without Proper and safe specimen handling at all times fleas. Alternatively, there is a high prevalence 1. PCR (blood) is of paramount importance among those in rate in non-clinical carriers in the general cat the veterinary community. population, thereby hindering our ability 2. BAPGM culture (insect medium) to establish disease causation, regardless of on blood flea status. Cats: Testing should be reserved for cats with For more information, please contact Angell’s Although we often associate Bartonella with suspected clinical disease due to prevalence of Internal Medicine service at 617-541-5186 or [email protected]. endocarditis and myocarditis, these manifestations subclinical carrier state in this species. are usually observed in research settings in cats. Cats who present with clinical signs associated Serology for antibody detection in cats can be with naturally acquired Bartonella usually suffer useful for determining exposure; however, due from fever and lymphadenopathy, lethargy, to the carrier state, its usefulness as a sole test uveitis, gingivitis, and sometimes neurological is questionable. PCR on whole blood for DNA symptoms. If one examines a patient with these detection, however, is often positive before symptoms that is flea-infested, Bartonella should seroconversion occurs, so using this diagnostic be on the list of differentials. in addition to serology will be of better Interestingly, Bartonella in cats usually does diagnostic utility in sick cats. Culture on blood not result in any biochemical or hematological can also be performed in lieu of PCR. abnormalities. Therefore, testing of choice in cats is a combination BARTONELLA IN DOGS of 1. and 2. below: Although the full spectrum of disease 1. PCR or BAPGM culture on blood manifestations in dogs is unclear, we do know that human bartonellosis mimics what we see 2. Serology for antibody detection (blood)

2. Partners In Care π Fall 2015 π Volume 9:3 F For more information, please contact Dr. [email protected] Rosenblad at contact please information, more For extracted. are teeth affected these after food dry eating resume cats most and tough quite be it can heals, tissue gingival the Once removed. are teeth diseased painful, the after “better!” often is answer The teeth. fewer with chew will cats how their ask often owners Pet remnants. root problematic or any teeth affected of the extraction is treatment recommended current The unsuccessful. generally been have lesions these or treat repair to Attempts teeth. affected of the palpation by elicited be often can twitching) jaw, local lower of or the other (movement 6) “Chattering” (Fig. teeth. opposing the with abnormally occlude and luxated resorptions tooth by weakened teeth when occur can malocclusions painful Acute, grooming. decreased and halitosis, mouth, of morethe on one side chewing food), of undigested (especially vomiting chewing, food dry decreased are lesions these with seen be may that body. Signs of the areas other affect potentially and more pain cause may disease periodontal secondary the and humans) than teeth their in endings more nerve have (cats painful very be can lesions These versa. vice and canines, the are so affected, are incisors the when often, 5) Quite (Fig. radio-opaque. less and or wispy striated appear will root tooth the occurs, of lesion type this When off. broken have to appearing off, falls tooth of the top, or crown, the that enough resorbed is root the times, Other socket. inflamed infected, open, an leaving out, falls and loosened completely is tooth the 4) Eventually (Fig. radiographs. dental on noticeable usually is separation bony The inflamed. it becomes as weakens root tooth the surrounding bone the because happens 3) This (Fig. extrusion). term the prefer (I super-eruption as to referred sometimes longer, become or “grow” to seem teeth these Sometimes swelling. asupra-gingival as seen be often can This inflamed. becomes root the around bone the affected, are teeth these When margin. gingival the below root, the along affected more commonly are teeth canine The roots. infected behind leaving sometimes lost, eventually are teeth diseased 2) These (Fig. disease. more periodontal have often lesions these by affected teeth buildup; calculus and plaque to tooth that predisposes margin gingival normal at the damage or gingival tooth Any 1) (Fig. tooth. the in defect the into grows hyperplasia gingival as noticed be first may and gingiva the below or just along begin usually molars and premolars of the lesions The teeth. any affect can lesions These etiology. no known is There radiographs. dental with otherwise prove Ican until affected, be will cat every that expect Igenerally affected). are cats domestic of 65% as many as that estimate studies (research common very are They Care In Partners DENTISTRY line lesions and are sometimes inappropriately called “feline cavities.” cavities.” “feline called inappropriately sometimes are and lesions line cervical and lesions, neck Lesions), Resorptive Odontoclastic (Feline FORL lesions, resorptive as known previously been have They teeth. of cat disease destructive aprogressively are resorptions tooth eline 2015 π Fall Volume 9:3 π Volume 617-524-5643 [email protected] angell.org/dentistry π Resorptions Feline Tooth π William Rosenblad, DVM Rosenblad, William

or 617-524-5643.

3rd premolar in acat. in premolar 3rd upper the of lesion Resorptive a to secondary proliferation) 4 become loose. become tooth the allows and is weak the Resorptive lesion process from root its around bone inflamed the as shifted has tooth This tooth. canine lower of gum into digging tooth, 4 Resorptive lesion process. the to due inflamed becoming root tooth the around bone the is actually swelling This cat. a in tooth canine upper the of recession gum secondary with swelling line) gum the 4 FIGURE 1 FIGURE FIGURE 5 FIGURE 3 FIGURE 4 4 4 Deviated upper left canine canine left upper Deviated (above Supragingival Gingival hyperplasia (gum (gum hyperplasia Gingival

lesions in acat. in lesions Resorptive to secondary roots), two the between area exposed the just is actually which root, the molar tooth (note the “hole” in 1st lower the of recession gum the upper 4th premolar tooth and 4 (and painful!) root remnants. (and root painful!) exposed leaving often tooth, the of off falls crown the Eventually, roots). tooth the to look wispy (the is resorbed structure root the which in teeth canine cats’ of lesions Resorptive of version 4 the other upper canine tooth. of bone normal the to Compare tooth. canine upper the of root the along process Resorptive the to secondary bone the of swelling/inflammation significant 4 FIGURE 2 FIGURE FIGURE 6 FIGURE 4 FIGURE 4 4 4 Significant calculus buildup on on buildup calculus Significant This radiograph shows the the shows radiograph This The slightly less common 3.

DENTISTRY the MI is higher than 5. than higher is MI the if 3months vs. of MI 5or less, an MCTs with for months 70 of over time survival median a with prognostic, be to shown been also has factor asingle as used fields) microscope high-power 10 in counted figures of mitotic =number (MI tumor of the index mitotic The recommendations. therapeutic make us help for MCTs some and better prognosis predict help may This reports. histopathology in old systems and new the on both based grade describe usually who pathologists, by used more frequently becoming it is and methods, previous the than behavior biologic with correlate better to appears system two-tier This nuclei. or large bizarre and cells, multinucleated of presence index, mitotic the as such factors tumor as well as its size and growth rate. Tumors rate. growth and size its as well as tumor of the location anatomic the include importance prognostic with features clinical Some it. evaluate to stains special perform to no need is there and reports histopathology all in reported be it should as 4. category. intermediate an without or high-grade, low-grade either into divided MCTs are cutaneous which in al, et Kiupel by proposed was scheme grading tier two- anew Recently, difficult. be can sometimes behavior biologic their predicting 80%, for up to of MCTs, accounting majority vast the represent tumors II grade Since malignant. more are some and manner abenign in 4 Continued from page 1 page from Continued ONCOLOGY FIGURE 1 FIGURE 4 Mast cell tumor in the muzzle of adog. of muzzle the in tumor cell Mast 2 This is done based on on based done is This 3 This is a useful marker marker auseful is This compared to those with expression pattern 1. pattern expression with those to compared time survival overall and time survival free disease- lower have 3may 2and pattern KIT with Dogs of c-Kit. 11 8and of exons mutations detect to PCR or by staining), cytoplasmic or diffuse focal/stippled, on membrane, or 3based 2, (1, of expression pattern its analyze to by immunohistochemistry both evaluated be can KIT importance. special holds KIT markers, these Of fee. histopathology initial of on the top associated cost additional is there and return, to weeks 2-3 take often results Test laboratory. preferred the to directly submit to tumor the from block or atissue slides unstained request to possible often it is test, the offer directly not does laboratory particular a If laboratories. commercial many through available and University State Michigan by others among offered is This practice. clinical in used more commonly becoming are and Panel”), Tumor Prognostic Cell a“Mast as to referred (often apacket as useful or more individually either removal), tumor or (biopsy samples of out tissue performed are tests of MCTs. These 20-40% in occur which of KIT, mutations activating detect to PCR “KIT,” and kinase tyrosine receptor the and AgNOR) and (Ki67 markers proliferation for (immunohistochemistry) stains special for MCTs some are prognosis evaluate to aspect useful another importantly, but Finally prognosis. aguarded with associated commonly more are melena), vomiting, anorexia, (i.e. signs systemic causing those MCTs, and growing rapidly and large Likewise, behavior. aggressive with associated been have perineum, and cavity oral the including sites, mucocutaneous other and muzzle, region, (nailbed) subungual area, prepucial/inguinal/scrotal the in panel is particularly useful in two situations: two in useful particularly is panel This times. survival decreased and prognosis aworse with associated been have AgNOR) and (Ki67 activity proliferation high with MCTs ac-Kit mutation. without those than time survival disease-free ashorter shown have c-Kit mutations MCTs with addition, In • • • •

consistent with a more aggressive tumor. amore aggressive with consistent are panel of the results if chemotherapy systemic for follow-up need the vs. radiation), +/- (surgery therapy local of only use on the made be to needs adecision where tumors cell mast For intermediate-grade with c-Kit mutations are more likely to to more likely are c-Kit mutations with 3) or those 2and (patterns expression KIT aberrant MCTs with that fact the to due is This option. chemotherapy best the choose us MCTs, help to of aggressive case the In 4

[email protected] 617-541-5136 Service Oncology Angell contact please information, more For MCTs. treat to armamentarium of the part as at Angell used currently Dr. Martinez at [email protected] at Dr. Martinez nonresectale MCTs. nonresectale with dogs in control disease long-term shown MCTs with KIT mutations. KIT MCTs with in up 69% to response and included), tumors stable (60% if of dogs 42.8% in responses complete and partial MCTs, with high-grade or intermediate or metastatic recurrent against efficacy demonstrated has Palladia studies clinical In okay). is (prednisone chemotherapy or radiation prior any received not have or II MCTs III that grade or recurrent, resectable for non- only approval conditional has currently Kinavet while drug, approved afully is Palladia Science). AB (Kinavet/Masivet, Masitinib and Pfizer) (Palladia, Toceranib TKIs, approved veterinary- two are There disregulation. KIT MCTs with in interest particular of are therefore and receptors), other (among KIT through signaling inhibit that molecules small oral are of drugs class latter This (TKIs). inhibitors kinase of tyrosine use the years recent in and corticosteroids, chemotherapy, involves This recommended. be also may therapy systemic grade, histologic or high locations, anatomical certain metastasis, or internal node of lymph presence the by determined MCTs, as for “high-risk” addition, In modality. treatment local main the as used be may radiation MCTs, For unresectable obtained. be cannot margins wide if therapy radiation tumor/s, plus the remove to surgery with therapy local involves MCTs often of cutaneous Treatment Care In Partners chemotherapy, as discussed below. discussed as chemotherapy, traditional than rather inhibitors, kinase tyrosine with therapy targeted to respond 2015 π Fall . You can also reach 6 Both of these drugs are are drugs of these Both 5 Masitinib has also also has Masitinib or e-mail e-mail or Volume 9:3 π Volume .

ONCOLOGY ANGELL IMAGE ONCOLOGY TRANSFER EXPRESS

Continued from page 4 Angell Animal Medical Center is pleased to announce Angell Image Transfer Express for both our Boston and Waltham locations. Referring veterinarians now can send diagnostic images to [email protected] which automatically feeds the images into Angell’s new central repository REFERENCES for transferred diagnostic images. This is not for online imaging 1 London CA, Thamm DH. Mast cell tumors. In consultations or fee-based radiograph interpretation. This repository Withrow SJ, Vail DM, Page RL, editors: Withrow makes images quickly and easily retrievable by all Angell clinicians, and McEwen’s Small Animal Clinical Oncology, avoids confusion over where to send images, and prevents the need to ed 5, St. Louis, 2013, Elsevier-Saunders. resend images when multiple specialists collaborate on a case. 2 Kiupel M, Webster JD, Bailey KL, et al. Proposal of a 2-tier histologic grading system for canine [email protected] cutaneous mast cell tumors to more accurately Please email images to [email protected] and to include in the email predict biologic behavior, Vet Pathol 48:147- subject line (in this order) 155, 2011 π the PATIENT’S FIRST NAME (in all caps) 3 Romansik EM, Reilly CM, Kass PH, et al. π the owner’s first and last name Mitotic index is predictive for survival for canine cutaneous mast cell tumors, Vet Pathol π a 1-3 word description 44:335-341, 2007. π the Angell doctor’s last name 4 Webster JD, Kiupel M, Kaneene JB, et al. The EXAMPLE: use of KIT and tryptase expression patterns as prognostic tools for canine cutaneous mast cell “FIDO, Bob Smith, lung tumor, Martinez” tumors, Vet Pathol 41:371-377, 2004. Referring clinicians may cc other applicable email addresses 5 London CA, Malpas PB, Wood-Follis SL, et al. (e.g. the Angell clinician’s direct email, the service email such as Multi-center, placebo-controlled, double-blind, “[email protected],” etc.), but [email protected] must be included. randomized study of oral toceranib phosphate For more information, please contact a client liason at 617-522-7282. (SU11654), a receptor tyrosine kinase inhibitor, for the treatment of dogs with recurrent (either local or distant) mast cell tumor following surgical excision, Clin Cancer Res 15:3856- 3865, 2009. 6 Hahn KA, Legendre AM, Shaw NG, et al. Evaluation of 12- and 24-month survival rates COMPLIMENTARY CALL SERVICE after treatment with masitinib in dogs with nonresectable mast cell tumors, Am J Vet Res & EMERGENCY REPORTING 71:1354-1361, 2010.

ANGELL DIRECT CONNECT PROGRAM We are pleased to offer our Angell Direct Connect after-hours call service to referring partners. This free service expedites your clients’ ability to reach a live operator during an emergency and promptly provides you with call information to keep you informed of your patients’ needs. This program enables better service for both you and your clients in the following ways: Client does not need to hang up the phone after receiving the voice message at your practice; instead, they can just press a number and connect to Angell Boston. Live person answers the phone to immediately assist your client (no phone tree). The morning reporting information we provide to you, the referring doctor, allows you to preemptively reach out to your client the following day. The information will provide you with statistics regarding after- hours call volume for your practice and demand for services.

To sign up for this program, please call Grace at 617-541-5181.

Partners In Care π Fall 2015 π Volume 9:3 5. EMERGENCY EMERGENCY Leptospirosis ππKiko Bracker, DVM, DACVECC angell.org/emergency 617-522-7282

eptospirosis is a bacterially caused FIGURE 1 disease that commonly affects the kidney and the liver. The causative 4 organism is motile spirochete 4Recumbent female dog with urinary catheter in place. L(Leptospira) that can affect a wide array of mammals including dogs, humans, rarely cats, and a range of . Although there are well over 100 pathogenic serovars of Leptospirosis that are adapted to different hosts1,2, the most commonly identified serovars found in the United States include Icterohemorrhagiae, Canicola, Pamona, Bratislava, Grippotyphosa and Hardjo. Leptospires are shed in the urine of infected individuals, and the bacterium can persist in the environment in moist areas of limited sunshine. Infection occurs when the oral, ocular, or nasal mucous membranes of susceptible animals contact the bacteria in free standing water, vegetation, urine-contaminated soil, or other similar settings. Infection likely can also be spread by direct contact with vaccine.3 Some owners may elect not to vaccinate infection, but that is only true in about 50% of infected individuals through grooming, fighting, their dogs for leptospirosis since they are not cases (human data).5 The absence of a convincing or consumption. Since urbanized wildlife considered ‘at risk’. The routine vaccination of all serologic diagnosis should not prevent (raccoons, skunks, coyotes, rodents, etc.) may dogs, though, is generally recommended. We appropriate treatment if the clinical picture carry and shed leptospirosis, even animals that have seen clinical leptospirosis in small breed strongly supports a diagnosis of leptospirosis. do not venture into more rural settings should dogs coming from an urban/suburban setting, be considered potentially at risk. The late suggesting that our assessment of what ‘at risk’ Paired PCR tests of urine and blood are gaining summer and early fall show a spike in means may need updating. popularity as a reliable and expeditious way to leptospirosis cases nationwide, but it can be seen confidently arrive at a diagnosis of leptospirosis. year-round and it tends to be more prevalent in DIAGNOSIS Samples must be collected before any antibiotic warmer, wetter climates. Hawaii has the most Leptospirosis can prove to be a diagnostic is given or false negative results can occur. 1 human cases in the United States. frustration. The most common diagnostic test False negatives can also result if organisms are is the microscopic agglutination test or MAT in too low a concentration. PREVENTION that is commonly referred to as ‘lepto titers’. A tetravalent vaccination for leptospirosis is MAT results are often negative during the first We commonly submit both Leptospirosis titers available in North America that includes the week of illness.1 This test can take 7 days for a (MAT) and PCR since the PCR is the more serovars Icterohemorrhagiae, Canicola, Pamona, final result and it is significantly affected by specific test and MAT is more sensitive. and Grippotyphosa. Immunity lasts for at least 12 prior vaccination with vaccine induced titers months. Vaccination breaks allowing vaccinated which are usually less than or equal to 1:800, ILLNESS dogs to develop naturally occurring infections but up to 1:3200 can be seen 2-4 weeks post The typical clinical picture of leptospirosis is that are not well documented. If clinical disease does vaccination.4 Titers of greater or equal to 1:800 of acute renal and hepatic dysfunction, but renal develop despite vaccination, then it likely would or a fourfold titer increase in 2-4 week or liver failure may also occur alone. Azotemia is be mild.2 There has been some anecdotal concern convalescent titers often suggest infection.8 noted in 80-90% of dogs with leptospirosis.1 ALP that the leptospirosis vaccine results in a greater Clearly there is some significant overlap and bilirubin elevations are the most common frequency of anaphylactoid reaction among small between vaccine induced titers and infection hepatic analytes to be affected.1 Respiratory breed dogs. A larger study of vaccine reactions titers. Generally, it has been thought that the dysfunction is also relatively common and was from 2005 did not show a greater risk with this highest serovar titer reflects the serovar of noted in 70% of dogs in one study, and has been

6. Partners In Care π Fall 2015 π Volume 9:3 EMERGENCY EMERGENCY

6 found in 9-93% of dogs in other studies. FIGURE 2 PROGNOSIS Thrombocytopenia was present in 73% of The prognosis for dogs treated promptly and patients in the same study.6 Most dogs do not 4 aggressively for leptospirosis is favorable (80% present with signs attributable to the urinary 4Photomicrograph of canine kidney with leptospirosis. Numerous leukocytes infiltrate the survival rate).1 Anuric dogs not responding to tract but instead have complaints of lethargy, interstitium, separating and sometimes effacing medical management require hemodialysis to anorexia, vomiting, diarrhea, and a painful renal tubules. This pattern is compatible with survive. Dogs that develop respiratory abdomen. A diagnosis of leptospirosis is rarely tubulointerstitial nephritis. An intact glomerulus complications have a survival rate closer to 40%.8 suspected based on physical exam and history is identified at the center of the image. alone, and clinicopathologic data is generally needed to create that suspicion. For more information, please contact Dr. Bracker at TREATMENT [email protected] or [email protected], The preferred treatment for leptospirosis is or call 617-522-7282. Doxycycline 5mg/kg PO/IV twice daily for 2 weeks.1 Doxycycline eliminates the organism from the renal tubular cells. Penicillin drugs including Amoxicillin and Ampicillin are also REFERENCES effective against leptospires. If it is not possible 1 JE Sykes, K Hartmann, KF Lunn, GE Moore, RA to give doxycycline, then Ampicillin 20mg IV Stoddard, RE Goldstein. 2010 ACVIM small animal QID is used as a common alternative. Ampicillin consensus statement on leptospirosis: diagnosis, should not be used orally due to poor epidemiology, treatment, and presvention. J Vet bioavailability by that route. Other symptomatic Intern Med. 25(1);Jan-Feb 2011:1-13 therapies (antiemetics, H2-blockers, proton 2 Andre-Fontaine. Diagnosis algorithm for pump inhibitors, appetite stimulants) are used 4. Conversion of oliguric (or even anuric) leptospirosis in dogs: disease and vaccination on an as-needed basis. renal failure to polyuric renal failure can be effects on the serological results. Vet Rec. May 2013;172(19):502 facilitated by the use of IV diltiazem at a Fluid therapy can be a great challenge for patients rate of 1-5 mcg/kg/min.7 We have had very 3 GE Moore, LF Guptill, MP ward. Adverse with Leptospirosis. Oliguric or anuric renal positive experiences using Fenoldopam (an events diagnosed within three days of vaccine failure is common and can be a life-threatening administration in dogs. JAVMA. 227;2005:1102-1108 development for many of these patients. A fluid analog of dopamine) at 0.8mcg/kg/min. therapy algorithm is outlined below. 4 SC Barr, PL McDonough, RL Scipioni-Ball, JK Starr. 5. Although the diuretic furosemide is often Serologic response of dogs given a commercial used with oliguric or anuric renal failure vaccine against serovar Grippotyphosa. Am J Vet 1. Fluid deficit (dehydration) should be to manage volume overload, it does not Res. 66;2005:1780-1784 replaced over 12-24 hours. hasten improvement in renal function. 5 PN Levett. Usefulness of serologic analysis as a 2. Maintenance fluid needs are usually 6. If medical management of oliguric/anuric predictor of the infecting serovar in patients with supplied with a balanced crystalloid like severe leptospirosis. Clin Infect Dis. 36;2003:447-452. LRS or Normosol-R. renal failure is not successful, then hemodialysis has proven to be a very 6 B Kohn, et al. Pulmonary abnormalities in dogs with 3. Urine output should be quantified by use of effective way to manage these patients leptospirosis. J Vet Intern Med. 24;2010:1277-1282 a urinary catheter. This also prevents until their renal function improves 7 KA Mathews, G Monteith. Evaluation of adding exposure of veterinary personnel and other (2-4 weeks). diltiazem therapy to standard treatment of acute animals to potentially infectious urine. renal failure caused by leptospirosis: 18 dogs Once the patient is rehydrated, IV fluid Most patients with leptospirosis require (1998–2001). Journal of Veterinary Emergency and input should roughly match urine output. If Critical Care. 17(2);2007:149–158 urine output lags behind IV fluid input and hospitalization for 7 days or more. Many of them the patient is gaining weight, this is a sign of also need to have nasogastric or esophageal 8 Leptospira Serology, P Ewing. Clinical Veterinary Advisor: Dog and Cat, 3rd Ed., Elsevier, 2015. oliguria and the IV fluid rate should be feeding tubes place due to reluctance to eat slowed down to better match urine output. during the period of clinical illness.

Partners In Care π Fall 2015 π Volume 9:3 7. S ischemia, fibrosis), and the heart. heart. the and fibrosis), ischemia, (proteinuria, kidneys edema), (hemorrhage, brain damage), nerve optic loss, (vision eyes the include can organs Affected damage. organ end severe to lead can HT untreated, HT. left If to or contribute cause may acromegaly as such conditions other theory, In myeloma. multiple Cushing’s disease, hyperaldosteronism, and pheochromocytoma, include can cats in HT of secondary causes more unusual Other, disease. kidney chronic and hyperthyroidism are HT feline of causes common most the secondary; is cats in HT all Almost process. disease underlying an to due HT as defined is HT Secondary population. human the in of HT cause common most the is HT primary identified; be cannot cause underlying an when diagnosed is HT Primary secondary. 8. arterial high which in strokes, hemorrhagic experience also may People organs. vital to travel and dislodged become may or plaques flow, blood of arterial loss complete in result to enough narrow become may Arteries platelets. and of cholesterol build-up associated and tears wall artery of microscopic aresult as occurs This infarction. myocardial and stroke with associated often is HT medicine, human In SYSTEMICUNCONTROLLED HYPERTENSION CARDIOVASCULAR CONSEQUENCES OF mentation. abnormal or sounds lung abnormal have may patients Some arrhythmia. or an murmur, heart systolic asoft sound), S4 heart of an presence (the rhythm agallop include or stress damage of cardiovascular suggestive findings exam Physical or collapse. epistaxis, difficulties, breathing intolerance, exercise include can These damage. cardiovascular home indicating at symptoms clinical develop may HT with Cats FINDINGS EXAM AND CARDIOVASCULAR SYMPTOMS CARDIOLOGY be defined as either primary or or primary either as defined be can hypertension Systemic medicine. feline geriatric in condition recognized a well- is (HT) hypertension ystemic angell.org/cardiology π Systemic Cats in Hypertension Cardiovascular Effects of π  Rebecca Quinn, DVM, DACVIM (Internal Medicine and Cardiology)) and Medicine (Internal DACVIM DVM, Quinn, Rebecca

these patients undergo full medical evaluations. evaluations. medical full undergo patients these that important very it is illnesses, other with associated commonly so is HT feline Because of HT. diagnosis the support mmHg 180 than of greater readings pressure blood systolic account, into taken be must effect” coat “white the While pressure. blood elevated persistently indicate readings repeat after and setting, quiet and acalm in obtained are pressures blood patient when made be should of HT Diagnosis sphygmomanometry. or Doppler system) automated (an technique oscillometric the either using non-invasively obtained commonly most are cats in measurements pressure Blood DIAGNOSIS & TREATMENT threatening. life potentially considered are and rupture, aortic to lead can dissections Aortic itself. aorta of the wall the within flow to blood allow and aorta, ascending of the length the along extend can tear The tear. and separate to aorta of the layers the causes HT when occurs dissection Aortic reported. been have cats in HT of complications cardiovascular More unusual arrhythmias. cardiac develop to likely more be also may cats these and stimulation, sympathetic to more sensitive is muscle ventricular thickened the Additionally, failure. heart congestive experience to more likely be may changes these with Cats enlargement. atrial left and flow, blood coronary poor abnormalities, relaxation in results hypertrophy ventricular uncontrolled, left If thicker. become must walls heart the adapt, to heart the for order In heart. of the workload the increases turn in which arteries, of the narrowing with associated is hypertension Systemic cats. in HT prolonged of consequence cardiovascular common most the likely is hypertrophy ventricular Left rare. very considered are HT, they feline in occur may events these while Therefore, infarction. myocardial and stroke to greatly contribute that factors disease, vascular or primary cholesterol high have rarely cats people, Unlike artery. vital of a bleeding and rupture to leads pressure [email protected] 617-541-5038

with appropriately treated underlying diseases diseases underlying treated appropriately with cats some that recognize to important It very is frame. time appropriate the within rechecked pressure blood the and initiated be should condition of that treatment identified, be can process disease underlying an If cats. some in required be may imaging additional or ultrasound Abdominal needed). as testing +/- urine protein:creatinine, and endocrine urinalysis T4 +/- T4, free panel, chemistry count, blood (complete labwork includes typically This 617-541-5038 at Service call Cardiology or the [email protected] at inbox cardiology general Quinn [email protected] at Dr. Rebecca contact please information, more For patients. feline our in morbidity decreased and of life quality improved to linked been has HT of control importantly, most Perhaps structure. wall ventricular left improved with associated is of HT control resolve; may sounds gallop as such findings exam physical and symptoms Patient changes. of cardiovascular reversal, or even improvement, to lead may HT and process disease underlying the of control adequate Long-term PROGNOSIS HT. control appropriately to order in one medication than more require may patients Some atenolol. as such β or selective (amlodipine), blockers channel calcium benazepril), (enalapril, inhibitor enzyme converting angiotensin an include may options treatment cause, underlying on the Depending therapies. anti-hypertensive require still Care In Partners 2015 π Fall , send a message to the the to amessage , send Volume 9:3 π Volume blockers blockers . ,

CARDIOLOGY ANGELL WELCOMES CARDIOLOGY NEW STAFF MEMBERS

Angell Animal Medical Center is pleased to announce that Ashley Jones, DVM, DACVIM (Cardiology) has joined our Cardiology Service and J. Lee Talbott, DVM, (Practice Limited to Medical Oncology) has joined our Oncology Service. Both Drs. Jones and Talbott will be practicing at Angell Boston.

ASHLEY E. JONES DVM, DACVIM (CARDIOLOGY) Dr. Jones is a board-certified cardiologist. She completed her cardiology residency at the University of Florida in 2014. Her residency research project described a novel technique for atrial pacemaker implantation in dogs, and she was awarded a Resident Research Award at the 2013 ACVIM Conference in Seattle, WA. Prior to her residency, she earned her Doctor of Veterinary Medicine degree and completed a one-year small animal rotating internship at the Ontario Veterinary College in Guelph, Ontario, Canada. Given her research experience and training at the REFERENCES: University of Florida, Dr. Jones has a particular interest in congenital heart disease and interventional cardiac procedures, such as balloon valvuloplasties, PDA occlusions and Bonagura JD and Twedt DC. Kirk’s Current Veterinary Therapy XV, 2014. pacemaker implantations. Dr. Jones maintains a strong passion for advancing the specialty of veterinary cardiology and thoroughly enjoys the variety of challenges she is Brown, AL, Beatty JA, Lindsay SA, Barrs VR. Severe presented with each day when managing cardiovascular disease. systemic hypertension in a cat with pituitary dependent hyperadrenocorticism. Journal of Small EDUCATION Animal Practice 53(2): 132-135, 2012. π Ontario Veterinary College, University of Guelph, DVM, 2010 Ettinger SJ and Feldman EC. Textbook of Veterinary Internal Medicine, 7th Edition, 2010. SPECIALTY TRAINING Roderick AA, Harvey AM, Tasker S. Primary π Ontario Veterinary College, University of Guelph, Internship in Small Animal hyperaldosteronism in the cat. Journal of Feline Medicine & Surgery, 2010-2011 Medicine and Surgery 7(3): 173-182, 2005. π University of Florida Small Animal Hospital, Residency in Cardiology, 2011-2014 Syme H. Hypertension in small animal kidney disease. π University of Florida Small Animal Hospital, Cardiology Fellowship, 2014-2015 Veterinary Clinics of North America Small Animal CERTIFICATION Practice 2011; 41 (1): 63 – 89. π Diplomate, American College of Internal Medicine (Cardiology), 2014 Thompson J. Management of hypertension in a geriatric cat. Canadian Veterinary Journal 45: 427-429, 2004. WeyFIGURE AC, Atkins 1 CE. Aortic dissection and congestive heart failure associated with systemic hypertension in a cat. Journal of Veterinary Internal Medicine 14(2): 208-213, 2000. J. LEE TALBOTT, DVM (PRACTICE LIMITED TO MEDICAL ONCOLOGY) Dr. Talbott received her veterinary degree from Oklahoma State University College of Veterinary Medicine in 2011 followed by a small animal rotating internship in Denver, Colorado at Wheat Ridge Animal Hospital from 2011-2012. Dr. Talbott received advanced training in medical oncology at the University of Florida, as part of a comprehensive oncology department that combined the use of surgical oncologists, radiation oncologists, and medical oncologists—one of only two academic training programs in the U.S. to offer this type of oncologic training. Dr. Talbott is passionate about using a multi-modal cancer treatment approach including immunotherapy, optimizing nutrition, acupuncture and integrative medical therapies for pain management and palliation, in addition to traditional treatments utilizing chemotherapy, radiation, and surgery. It is an exciting time to be in the field of veterinary oncology especially with the advancement of molecularly targeted drug therapy for treatment of cancer in our companion animals. EXPANDED CARDIOLOGY APPOINTMENTS EDUCATION AT ANGELL WEST π Oklahoma State University College of Veterinary Medicine, DVM, 2011 Angell is pleased to offer expanded Cardiology π Pennsylvania State University, BS in Animal Sciences, 2004 appointment hours at Angell West in Waltham, including regular Saturday appointments. Rebecca Malakoff, DVM, SPECIALTY TRAINING DACVIM (Cardiology) practices full time at our Waltham π University of Florida, Residency in Medical Oncology, 2012-2015 facility and provides echocardiograms and other π Wheat Ridge Animal Hospital, Rotating Internship in Small Animal Medicine Cardiology services on site. and Surgery, 2011-2012

Partners In Care π Fall 2015 π Volume 9:3 9. AVIAN & EXOTIC AVIAN & EXOTICAVIAN Social Enrichment for Healthy Interaction Between Juvenile Pet Birds and Veterinary Professionals ππElisabeth Simone-Freilicher, DVM, DABVP (Avian practice) angell.org/avianandexotic [email protected] 617-989-1561

ccasionally during their lives, pet as Poicephalus species. The practitioner and FIGURE 1 birds will visit the vet. There are staff should enter the examination room many components to this calmly and quietly to avoid startling a bird, 44The pediatric patient may stand calmly cupped in experience to which a young bird particularly if the bird is out of the carrier, as an assistant’s hand, and allow a thorough physical Oshould be gradually and gently acclimated: the injury may occur. examination including oral and caudal coelomic palpation, with the veterinarian softly speaking to carrier, the car ride (or other mode of the patient and maintaining eye contact. transportation), towels, and restraint. Actual restraint should be as brief and gentle as possible. With many pediatric patients, this Most young birds have not yet had an opportunity author often finds toweling and restraint is not to become phobic of towels, although they may necessary at all. The pediatric patient may stand exhibit neophobia (fear of novel objects). Ideally, calmly cupped in an assistant’s hand (Fig. 1), and the towels used during the veterinary visit allow a thorough physical examination including should not be highly patterned and should be of oral and caudal coelomic palpation, with the a neutral color; remember that psittacine birds veterinarian softly speaking to the patient and can see into the ultraviolet and infrared portions maintaining eye contact. This author prefers to of the spectrum, so a plain white towel might use words and sounds recognized and enjoyed by seem disturbingly bright to them. If the owner the parrot if these are known, or those commonly has acclimated the bird to towels at home, the preferred by the species if the individual bird may have a preferred towel that it is used to, preferences are not known (such as soft clicks for and the owner should be encouraged to bring the African species). Additionally, as noted this to the visit. previously, sidelong glances with slow blinks are more psittacine and less threatening than the When seeing pet birds, behavioral considerations While the technique of quickly grabbing the unblinking forward stare of a predator. during the veterinary visit can make the bird with a towel from above and behind Stethoscopes are occasionally somewhat experience much less stressful for the patient unfortunately may sometimes be needed in alarming (possibly because of their resemblance and much more pleasant for owners and staff. the case of an adult bird that is not tame to snakes or simply because they are novel), and if When the patient is a juvenile parrot, keeping (especially in many small species), this is not at the bird is seen to withdraw or appear the examination low-stress can help prevent a all necessary and may be extremely frightening apprehensive, this author will often stop and lifetime of fearful and phobic behaviors for the pediatric patient. Instead, the towel may demonstrate the harmlessness of the instrument associated with the annual examination. be offered to the young bird to explore and by tapping the bell lightly on her own cheek, and chew, and then gently wrapped around the bird possibly that of the assistant as well, all while starting from the front. Some avian maintaining an encouraging eye contact and behaviorists recommend speaking to the bird speaking softly to the patient. Once the young Contact Angell’s Avian and Exotic service at first, calmly explaining what will happen next.1 bird seems to accept this, the bell of the 617-989-1561 or [email protected]. You can also reach Dr. Simone-Freilicher at While different species and individuals may stethoscope is lightly stroked over the bird’s toes, [email protected]. vary widely in how much of this monologue until this too is accepted, and only then is they may understand, it often does seem to auscultation of the heart and lungs attempted. have a remarkably calming effect. If the owner has already acclimated the young patient to When returning the bird to the owner, it is REFERENCES towels, the owner may prefer to wrap the bird helpful to allow the bird to run across the table to herself and hand him or her to the veterinarian. the owner for comfort; this also can strengthen Adapted from: Simone-Freilicher, E, and Rupley A. “Juvenile Psittacine Environmental Enrichment” in the owner-parrot bond. However, for any Rupley A (Editor): Veterinary Clinics of North America: Handling during the veterinary visit must be juveniles that seem highly stressed by the Exotic Animal Practice, Volume 18, Issue 2, May 2015. gentle and practiced; aggressive handling examination, returning the bird directly to the during the veterinary visit may precipitate owner sometimes seems to result in an 1 Wilson, L. Considerations on Companion Parrot phobic behaviors in psychologically sensitive association made by the bird between the owner Behavior and Avian Veterinarians. JAMS 14-4 (2000): 273-276. species such as rose-breasted, citron-crested, and the visit, and phobic behavior toward the and triton cockatoos and African greys1 as well owner can ensue.1

10. Partners In Care π Fall 2015 π Volume 9:3 STAFF DOCTORS

ππWe encourage you to email Angell’s specialists with questions. Main Phone: 617-522-7282 (Boston), 781-902-8400 (Waltham) Veterinary Referrals: 617-522-5011 STAFF DOCTORS STAFF CHIEF OF STAFF CARDIOLOGY (W/B) NEUROLOGY (W/B) Ann Marie Greenleaf, DVM, DACVECC Ashley Jones, DVM, DACVIM (Cardiology) Rob Daniel, DVM, DACVIM (Neurology) [email protected] [email protected] [email protected] 24/7 EMERGENCY & CRITICAL CARE (W/B) Nancy Laste, DVM, DACVIM (Cardiology) Allen Sisson, DVM, MS, DACVIM (Neurology) [email protected] [email protected] Charles Amuguni, BVM [email protected] Rebecca Malakoff, DVM, DACVIM NUTRITION (Cardiology) Lauren Baker, DVM Dana Hutchinson, DVM, DACVN [email protected] [email protected] [email protected] Kiko Bracker, DVM, DACVECC Rebecca Quinn, DVM, DACVIM [email protected] (Cardiology and Internal Medicine) ONCOLOGY [email protected] Lyndsay Kubicek, DVM, DACVR Finn, DVM (Radiation Oncology) [email protected] DENTISTRY [email protected] Jessica Hamilton, DVM Erin Abrahams, DVM Ivan Martinez, DVM, DACVIM [email protected] [email protected] (Medical Oncology and Internal Medicine) Roxanna Khorzad, DVM William Rosenblad, DVM [email protected] [email protected] [email protected] J. Lee Talbott, DVM Megan Krauth, DVM (Practice Limited to Medical Oncology) [email protected] DERMATOLOGY [email protected] Tamara Kremer Mecabell, DVM Klaus Loft, DVM [email protected] [email protected] OPHTHALMOLOGY Amanda Lohin, DVM Daniel Biros, DVM, DACVO [email protected] DIAGNOSTIC IMAGING* [email protected] Courtney Peck, DVM Rebecca Manley, DVM, DACVR Martin Coster, DVM, MS, DACVO [email protected] [email protected] [email protected] Brooke Simon, DVM Joan Regan, VMD, DACVR PAIN MEDICINE [email protected] [email protected] Lisa Moses, VMD, DACVIM, CVMA Virginia Sinnott, DVM, DACVECC Steven Tsai, DVM, DACVR [email protected] [email protected] [email protected] Catherine Sumner, DVM, DACVECC PATHOLOGY (CLINICAL & ANATOMIC)* INTERNAL MEDICINE (W/B) [email protected] Patty Ewing, DVM, MS, DACVP Daniela Ackley, DVM, DACVIM [email protected] Megan Whelan, DVM, DACVECC [email protected] [email protected] Pamela Mouser, DVM, MS, DACVP Doug Brum, DVM [email protected] ANESTHESIOLOGY [email protected] SURGERY (W/B) Ashley Barton-Lamb, DVM, DACVAA, CVA Maureen Carroll, DVM, DACVIM Sue Casale, DVM, DACVS [email protected] [email protected] [email protected] Erika de Papp, DVM, DACVIM Stephanie Krein, DVM, DACVAA Michele Kudisch, DVM, DACVS [email protected] [email protected] [email protected] AVIAN & EXOTIC MEDICINE (W/B) Jean Marie Duddy, DVM Michael Pavletic, DVM, DACVS [email protected] Brendan Noonan, DVM, DABVP [email protected] (Avian Practice) Kirstin Johnson, DVM, DACVIM Meghan Sullivan, DVM, DACVS [email protected] [email protected] [email protected] Elisabeth Simone-Freilicher, DVM, DABVP Shawn Kearns, DVM, DACVIM Nicholas Trout, MA, VET MB, MRCVS, (Avian Practice) [email protected] DACVS, DECVS [email protected] Susan O’Bell, DVM, MPH, DACVIM [email protected] BEHAVIOR (W/B) [email protected] Terri Bright, Ph.D., BCBA-D Cynthia Talbot, DVM [email protected] [email protected]

(W/B) Services available at our Waltham and Boston locations. Behavior appointments are available in Waltham upon request. *Boston-based radiologists and pathologists, serve both Boston & Waltham locations.

Partners In Care π Fall 2015 π Volume 9:3 11. 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. Fall 2015 π Volume 9:3 π angell.org π facebook.com/AngellReferringVeterinarians

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Please consider adding Angell’s main numbers to your after-hours phone message. See page 5 for complimentary after-hours phone services.

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MSPCA-Angell West hospital services* currently include… 4 COURTESY SHUTTLE TO/FROM BOSTON FOR 24/7 EMERGENCY & CRITICAL CARE ANGELL WEST PATIENTS AVIAN & EXOTIC MEDICINE

BEHAVIOR**

Our Waltham facility has a complimentary shuttle CARDIOLOGY that will transport patients to and from Boston if further specialized care is needed. INTERNAL MEDICINE Please call 781-902-8400 to book appointments or referrals, or visit angell.org/waltham for a full list NEUROLOGY of expanding Waltham services. SURGERY

* Boston-based radiologists and pathologists serve both Boston and Waltham locations. **Behavior appointments are available in Waltham upon request.