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Case Report Suspected Idiopathic Intestinal Lymphangiectasia in Two Foals with Chylous Peritoneal Effusion F

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Case Report Suspected Idiopathic Intestinal Lymphangiectasia in Two Foals with Chylous Peritoneal Effusion F 172 EQUINE VETERINARY EDUCATION / AE / april 2010 Case Report Suspected idiopathic intestinal lymphangiectasia in two foals with chylous peritoneal effusion F. B. Cesar*, C. R. Johnson and L. G. Pantaleon Woodford Equine Hospital, 3550 Lexington Road, Versailles, Kentucky 40383, USA. Keywords: horse; idiopathic intestinal lymphangiectasia; ascites; chylous; peritoneal effusion; foal Summary chylomicrons, lymphocytes and proteins, including albumin and immunoglobulins (Melzer and Sellon 2002). Two foals were examined for signs of abdominal Clinical disease of IL with chylous peritoneal effusion can discomfort. Transabdominal ultrasonography revealed an be observed as abdominal discomfort, protein-losing increased amount of free peritoneal fluid and thickened enteropathy and electrolyte disturbances (May and Good small intestine walls. Abdominocentesis yielded an 2007). In horses, in vivo IL diagnosis has been based on odourless, white-to-yellow, opaque, homogeneous clinical signs, peritoneal fluid analysis, ultrasonographic peritoneal fluid with elevated triglyceride levels. Based on findings and/or exploratory celiotomy (Hanselaer and the findings, diagnosis of chylous ascites was made. Nyland 1983; Mair and Lucke 1992; Edwards et al. 1994; Idiopathic intestinal lymphangiectasia was suspected to Campbell-Beggs et al. 1995; May and Good 2007). be the cause for the condition. Both foals responded well Treatment involves conservative or surgical correction of the primary problem, metabolic and dietary support and the condition resolved.eve_58 172..178 (Melzer and Sellon 2002). Introduction This report describes the clinical findings, diagnosis, treatment and outcome associated with suspected Chylous peritoneal effusion is a rare form of ascites resulting idiopathic IL with chylous peritoneal effusion in 2 foals. from the accumulation of lymph in the abdominal cavity caused by an interruption in the lymphatic system Foal 1 (Almakdisi et al. 2005). Chylous peritoneal effusion may arise as a result of unidentified factors, or as a result of the History rupture caused by increased luminal pressure (intestinal lymphangiectasia) or trauma, abnormal permeability, A 10-day-old, male, Thoroughbred foal weighing obstruction or hypoplasia of the mesenteric lymphatic approximately 50 kg was admitted to the hospital after 1 h vessels (Campbell-Beggs et al. 1995). Other aetiologies of severe abdominal pain. Prior to referral, the foal had include malignancy, inflammatory lesions and abdominal been treated with i.v. flunixin meglumine (1.1 mg/kg bwt). surgery (Chye et al. 1997). Three days prior to admission the urachus was surgically Intestinal lymphangiectasia (IL) is a rare disorder in man removed. The foal was still under post surgical treatment 1 and in domestic animals and its aetiology has not been with ceftiofur sodium (Naxcel) (4 mg/kg bwt, i.m., b.i.d.); 2 fully elucidated (Vignes and Bellanger 2008). Intestinal omeprazole (Gastrogard) (4 mg/kg bwt, per os, s.i.d.); 3 lymphangiectasia is characterised by dilated mesenteric and flunixin meglumine (Flunixiject) (1.1 mg/kg bwt, per lacteals with engorgement of intestinal lymph vessels in the os, s.i.d.). mucosa and submucosa (Melzer and Sellon 2002; Vignes and Bellanger 2008). When pressure in the mesenteric or Clinical findings intestinal lymph vessels increases, the intestinal villous lacteals dilate, become more fragile, and rupture. Lymph At presentation, the foal was bright, alert and comfortable. leaks from the ruptured lacteals into the abdominal cavity The body score was 5/9. On physical examination the and intestinal lumen, carrying all its contents, such as heart rate was 80 beats/min, respiratory rate was 66 breaths/min with a normal pattern, and rectal temperature was 38.3°C. Mucous membranes were pink, *Author to whom correspondence should be addressed. moist and the capillary refill time was <2 s. Skin tent was © 2010 EVJ Ltd EQUINE VETERINARY EDUCATION / AE / april 2010 173 (rr Յ 1.5 ¥ 109/l) with 0.5 ¥ 109 lymphocytes/l and 0.1 ¥ 109 neutrophils/l. Peritoneal fluid analysis revealed total protein of 10 g/l (rr < 16 g/l), creatinine of 61.9 mmol/l (rr < 176.8 mmol/l) and lactate of 0.39 mmol/l (rr < 0.111 mmol/l). The triglyceride level was elevated to 4.49 mmol/l (rr <1.24 mmol/l). Cytological examination revealed lymphocytes with normal morphology, and no bacteria were seen. A sample was submitted for aerobic bacterial culture and yielded no growth. Medical treatment consisted of ceftiofur sodium (Naxcel)1 (4 mg/kg bwt, i.m., b.i.d.), probiotic (Probios)5 (20 ml, per os, s.i.d.), flunixin meglumine (Flunixiject)3 (1.1 mg/kg bwt, per os, s.i.d.) and omeprazole (Gastrogard)2 (4 mg/kg bwt, per os, s.i.d.). The foal was allowed to nurse freely and exhibited no further signs of colic. Trans-abdominal ultrasonography performed on Days 2 and 3 revealed no further evidence of increased peritoneal fluid (Fig 3). On Day 3, complete blood cell 9 Fig 1: Ultrasonogram of the ventral abdomen obtained from Foal 1 at count showed a white blood cell count of 6.2 ¥ 10 /l with admission. Several loops of small intestine with thickened walls 5.1 ¥ 109 neutrophils/l and 0 ¥ 109 bands/l. Fibrinogen level (arrows) can be seen suspended in anechoic fluid. The image was decreased to 1.18 mmol/l. Serum biochemistry revealed no obtained with a 5 MHz convex transducer and a 7 cm display depth. significant findings. At that time, it was considered safe to discontinue the medical treatment and the foal was within normal limits. Peripheral pulses were normal and discharged from the hospital. extremities were warm. Auscultation of the abdomen revealed watery intestinal borborygmi. Lung and trachea Follow-up auscultation was unremarkable. Abdominal distension was not seen. Hernias were not identified. After the foal was discharged from the hospital, regular communication with the owners revealed that the foal Diagnosis and treatment remained healthy at the farm until the age of one year. The yearling was then sold in public auction, thus no further Trans-abdominal ultrasonography was performed using a follow-up was possible. high resolution 3.5–5 MHz convex transducer (Biosound My Lab 30)4. An increased amount of anechoic fluid was observed within the peritoneal cavity. Several loops of small intestine with thickened walls, measuring 0.44–0.66 cm (reference range [rr] 0.3 cm), were imaged (Fig 1). The bladder was not visualised. Complete blood count revealed a white blood cell count of 7.9 ¥ 109 cells/l (rr 5.5–12.5 ¥ 109/l) with a neutrophil count of 6.2 ¥ 109 cells/l (rr 2.2–8.1 ¥ 109/l) and 0.08 ¥ 109 bands/l (rr 0 ¥ 109/l). Serum biochemistry revealed a total protein level of 49 g/l (rr 60–86 g/l), with globulin level of 20 g/l (rr 28–44 g/l) and albumin level of 29 g/l (rr 24–36 g/l) creatinine level of 79.6 mmol/l (rr 0.0–176.8 mmol/l), triglyceride level of 0.85 mmol/l (rr < 2.8 mmol/l), sodium 135.0 mmol/l (rr 134.0–150.0 mmol/l), potassium 4.29 mmol/l (rr 3.0–4.7 mmol/l) and chloride 100.1 mmol/l (rr 92.0– 111.0 mmol/l). Fibrinogen level was 17.6 mmol/l (rr < 11.8 mmol/l). The foal’s IgG level was adequate (7.37 g/l). Venous blood gas analysis showed no acid-base abnormalities with lactate of 2.2 mmol/l (rr 0.4–2.5 mmol/l) and glucose of 7.1 mmol/l (rr 4.6–6 mmol/l). Blood sample was submitted for aerobic culture and yielded no growth. Abdominocentesis yielded an odorless, white-to- yellow, opaque, homogeneous fluid (Fig 2). The total Fig 2: Macroscopic aspect of chylous peritoneal fluid yielded on nucleated cell count in the peritoneal fluid was 0.8 ¥ 109/l abdominocentesis from Foal 1. © 2010 EVJ Ltd 174 EQUINE VETERINARY EDUCATION / AE / april 2010 Diagnosis and treatment Trans-abdominal ultrasonography was performed using a high resolution 3.5–5 MHz convex transducer4. A large amount of anechoic fluid within the peritoneal cavity was observed (Fig 4) and a meconium-like structure was identified within the small colon. The bladder was visualised to be intact. A complete blood count revealed a low white blood cell count of 1.2 x 109/l (rr 5.5–12.5 x 109/l) with a low neutrophil count of 0.6 x 109/l (rr 2.2–8.1 x 109/l) and 0.05 x 109 bands/l (rr 0 x 109/l). Serum biochemistry revealed total protein of 47 g/l (rr 60–86 g/l), globulin of 17 g/l (rr 28–44 g/l), creatinine of 97.2 mmol/l (rr 0.0–176.8 mmol/l) and triglyceride level of 0.58 mmol/l (rr < 2.8 mmol/l). Electrolytes levels were within the normal ranges (sodium 140.7 mmol/l, rr 134.0–150.0 mmol/l; potassium 3.34 mmol/l, rr 3.0–4.7 mmol/l; chloride 106 mmol/l, rr 92.0–111.0 mmol/l). Fig 3: Ultrasonogram of the cranio-ventral abdomen obtained from IgG level was adequate (8.9 g/l). Venous blood gas analysis Foal 1 on Day 2. No evidence of increased peritoneal fluid was showed no acid-base abnormalities with lactate of imaged. Normal loops of small intestine (arrows) were seen in cross section immediately adjacent to liver and body wall. The image 2.5 mmol/l (rr 0.4–2.5 mmol/l), glucose of 7.1 mmol/l was obtained with a 3.5 MHz convex transducer and a 8 cm (rr 4.6–6 mmol/l) and magnesium of 0.27 mmol/l display depth.
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