Problem Solving in Reptile Practice Paul M

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Topics in Medicine and Surgery Problem Solving in Reptile Practice Paul M. Gibbons, DVM, MS, Dip. ABVP (Avian), and Lisa A. Tell, DVM, Dip. ABVP (Avian), Dip. ACZM

Abstract Problem-oriented reptile medicine is an explicit, definable process focused on the identification and resolution of a patient’s problems. This approach includes gathering case information, clearly defining the problems, making plans to address each problem, and following up with the case over time. Case information and published literature serve as evidence to support clinical decisions and pathophysiological rationale. This article describes the problem-solving process used to diagnose and treat a green iguana (Iguana iguana) that presents with ovostasis. © 2009 Published by Elsevier Inc.

Key words: evidence-based veterinary medicine; follicular stasis; green iguana; Iguana iguana; preovulatory ovostasis; problem-oriented veterinary medicine

roblem-oriented veterinary medicine is a logi- Objective evidence is quantitative and includes vital cal process directed toward the explicit iden- signs and the results of laboratory tests. A case sum- Ptification and resolution of a patient’s prob- mary is limited to information that is pertinent to lems. A complete, problem-oriented, veterinary the problems, but the problem-oriented, veterinary medical record includes evidence about the case, a medical record includes a complete record of all problem list, plans, and progress notes. Each prob- information related to the case. lem is described at the highest possible level of di- For purposes of illustration, the case described in agnostic refinement, and plans are developed to this article involved a 2.2-kg green iguana of unknown address each problem. This process is repeated over age that was determined to be female by observation of time during patient reevaluations until the problem secondary sex characteristics. The current owner had resolves, an etiologic diagnosis is identified, or both. obtained the animal 3 weeks before presentation. The purpose of this article is to illustrate problem Chief complaints included presumed ovostasis for 15 solving in reptile practice by describing the medical weeks, no defecation for 3 weeks, and burn wounds on evaluation and treatment of a green iguana (Iguana the palmar and plantar surfaces of 3 weeks’ duration. iguana) with ovostasis.

Information Gathering From the Exotic Species Specialty Service, Animal Emergency Center and Specialty Services, Glendale, WI USA, and the De- Problem-oriented case management begins by col- partment of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA USA. lecting evidence about the case. Many clinicians di- Address correspondence to: Paul M. Gibbons, DVM, MS, Dip. vide case information into subjective and objective ABVP (Avian), Exotic Species Specialty Service, Animal Emer- evidence, although this division is only useful to gency Center and Specialty Services, 2100 W. Silver Spring Dr, acknowledge the level of diagnostic reﬁnement. Sub- Glendale, WI 53201. E-mail: [email protected]. jective evidence is descriptive and includes the pre- © 2009 Published by Elsevier Inc. senting complaint(s), medical history, pertinent hus- 1557-5063/09/1803-$30.00 bandry concerns, and physical examination ﬁndings. doi:10.1053/j.jepm.2009.06.013

202 Journal of Exotic Pet Medicine, Vol 18, No 3 ( July), 2009: pp 202-212 Problem Solving in Reptile Practice 203

The iguana had never laid eggs and was not in a Pharmaceuticals, Inc., Bristol, TN USA) applied topi- breeding program. The primary care veterinarian had cally to the affected areas, and bandages. The owner’s presumptively diagnosed ovostasis 15 weeks before pre- description of thermal gradient, light quality, humidity, sentation based on the presence of soft tissue masses in water provision, caging, and diet were appropriate for the reproductive tract that were observed on radio- the species, but information about husbandry before graphic images. The owner reported that the iguana acquisition 3 weeks before presentation was not avail- had become progressively anorectic during the course able. The owner was concerned that the iguana might of illness. For treatment, the owner had provided a require surgery because the eggs did not appear to be litter pan with moist soil as a potential nesting site, but resorbing after more than 3 months, and he had not did not observe nesting behavior. The burns occurred observed the animal defecating over a 3-week period. when the iguana escaped from its cage and was discov- The only notable external physical examination ﬁnd- ered in direct contact with the heating element on top ings included a mildly distended abdomen and full- of another iguana’s enclosure. These wounds were thickness ulcerations on the palmar and plantar sur- being treated by the primary veterinarian with ceftazi- faces of the distal limbs. dime (20 mg/kg intramuscularly every 72 hours, Fortaz The diagnostic screening protocol included a injectable; GlaxoSmithKline, Research Triangle Park, complete blood count and plasma biochemical NC USA), silver sulfadiazine cream (Thermazine, King panel. The results are presented in Table 1 under

Table 1. Assay Result 28 Jan Result 02 Feb Reference Range Unit Uric Acid 4 ND 1.2-2.4 mg/dL Total Calcium 121.2 ND 8.8-14 mg/dL Ionized Calcium 1.51 ND 1.37-1.58 mmol/L Phosphorus 39.6 ND 1.3-3.0 mg/dL Glucose 296 ND 169-288 mg/dL Total Protein 9.2 ND 5.0-7.8 g/dL Albumin 1.6 ND 2.1-2.8 g/dL Globulin 7.6 ND 2.5-4.3 g/dL AST 64 ND 5.0-52 IU/L Creatine Kinase 3342 ND 0-3995 IU/L Lactate Dehydrogenase 145 ND 0-1091 IU/L Cholesterol 704 ND 0-437 mg/dL Blood Urea Nitrogen 2 ND 0-4 mg/dL RBC 1.04 1.06 1.0-1.9 106/ul Hemoglobin 8.1 8.2 6.0-10.0 g/dL PCV 31.5 38 25-38 % MCV 302.9 358.5 165-305 ﬂ MCH 77.9 77.4 48-78 pg MCHC 25.7 21.6 20-38 g/dL RBC Morphology Slight aniso Slight aniso WBC 11000 11000 3,000-10,000 cells/uL Bands 550 0 cells/uL Heterophils 7040 5390 350-5,200 cells/uL Lymphocytes 1980 4730 500-5,500 cells/uL Monocytres 880 440 0-100 cells/uL Eosinophils 110 0 0-300 cells/uL Basophils 440 440 0-500 cells/uL Thrombocytes Adequate Adequate Refractometer plasma protein 10.7 9.5 g/dL Plasma ﬁbrinogen 200 400 mg/dL Icterus index Moderate Slight 204 Gibbons and Tell

questions. No single electronic search engine will offer a complete search of all available published literature. Textbooks on herpetological medicine may be borrowed from veterinary school libraries or purchased from the Internet or veterinary booksell- ers. Useful online search engines include PubMed (no fee), ISI Web of Knowledge (subscription re- quired), BioONE (no fee), and Google Scholar (no fee). Figures 3, 4, 5, and 6 demonstrate the different results obtained when searching these databases using the keyword “dystocia” together with either “reptiles” or “reptil*”. The PubMed (http://www.ncbi. nlm.nih.gov/pubmed) database includes articles published in many bioscience journals, and, although it is available at no charge to the user, it excludes important sources of evidence in herpetological medicine (Fig 3). ISI Web of Knowledge is an umbrella of databases that includes PubMed, CAB Direct, Zoological Record, Web of Science, and BIOSIS previews (Fig 4). It can be accessed at Thomson (ISI) Web of Knowledge (http://www.isiwebofknowledge. com) and allows searching of some additional sources of information that are important to herpetological medicine including both the Journal of Her- Figure 1. Dorsoventral radiographic projection of the coelom of an petological Medicine and Surgery and the Proceedings of adult female green iguana (Iguana iguana) with a 15-week history of the Annual Conference of the Association of Reptilian and reduced appetite and lack of defecation for 3 weeks. Note the cluster Amphibian Veterinarians. BioONE (http://www.bioone. of round, soft-tissue-density masses ﬁlling the caudal one third of org/search) includes a number of journals not the coelomic cavity (arrows). found in PubMed, including Copeia, Current Herpetol- ogy, Herpetologica, and Journal of Herpetology. It provides access to important background information; the 28 January heading with reference ranges.1-3 in this case, however, it did not identify a source of Reference ranges were selected by reading the information on reptile dystocia (Fig 5). Google primary references to determine how this patient Scholar (http://scholar.google.com) includes a wide best matched the study populations in terms of array of periodicals and textbooks, allows simple or age, sex, and husbandry conditions. Orthogonal advanced use of search terms, and allows cross-ref- radiographic views of the body were taken to eval- erencing of citations (Fig 6). In addition, Veterinary uate the current status of the previously diagnosed Information Network (http://www.vin.com) has a ovostasis and revealed a cluster of round, 1.0 to 1.5 searchable library that offers free abstracts of articles cm, nonmineralized, soft-tissue masses in the cen- from many relevant veterinary journals and full text ter of the caudal third of the coelom (Figs 1 and2). Whenever necessary, published information is used to learn background information about anat- omy, physiology, behavior, and husbandry. Then foreground information is sought to answer questions about diagnostic test interpretation, pathophysiological rationale, treatment plans, and prognosis. The utility of published information must be ap- praised in terms of veracity and applicability to the case at hand. For example, in this case, textbooks,1,4-12 conference proceeding abstracts/manu- Figure 2. Horizontal-beam lateral radiographic projection of the 13-15 16 coelom of the same green iguana in Figure 1. Note the generally scripts, roundtable discussions, narrative review uniform soft-tissue-density region ﬁlling the mid-caudal coelom articles,17,18 and journal articles2,3,19-23 were used to (white arrows) and displacing the gastrointestinal tract cranially and answer the clinician’s background and foreground dorsally (black arrowheads). Problem Solving in Reptile Practice 205

Figure 3. Computer screen image of the search results on PubMed (http://www.ncbi.nlm.nih.gov/pubmed) showing the results of a search on the keywords “dystocia” and “reptiles.” Thirteen publications were found; note that search results using other keywords returned fewer results. 206 Gibbons and Tell

Figure 4. Computer screen image of the search results with the keywords “dystocia” and “reptil*” using “all databases” in the Web of Knowledge search engine (http://www.isiwebofknowledge.com). Note that the results include many conference proceedings, articles, and journals not included in the results from the PubMed website shown in Figure 3. of many conference proceedings articles. Download- or database, membership in an afﬁliated organiza- ing published articles from the Internet is available tion, or personal afﬁliation with a university. In some via these search engines for a fee, and may be al- cases, articles must be obtained by physically visiting lowed with an individual subscription to that journal a local or university library and placing an order. Problem Solving in Reptile Practice 207

Figure 5. Computer screen image of the search results of BioONE (http://www.bioone.org/search) using the keywords “iguana” and “repro*” because no articles were identiﬁed using a search using “dystocia” and “reptile*” and 982 articles were found using “repro*” and “reptile*”. Note that the titles are of articles describing natural history and free-ranging lizards. 208 Gibbons and Tell

Figure 6. Computer screen image of the search results with the keywords “dystocia” and “reptiles” using Google Scholar (http:// scholar.google.com). Note that 247 publications were identiﬁed. These results include many of the publications that were identiﬁed using the search engines depicted in Figures 3, 4, and 5 as well as references within publications. Problem Solving in Reptile Practice 209

Problem Deﬁnition

Problem List It is important to avoid overstating problems, and rule-outs should not be included in the problem list. Problems should, however, be stated at the highest possible level of diagnostic refinement based on jus- tifiable rationale and evidence. The levels of diagnostic refinement include: (1) subjective evidence, (2) objective evidence, (3) pathophysiological syndrome, and (4) etiologic diagnosis. For example, the initial problem list in this case includes burn wounds and ovostasis. The etiologic diagnosis of burn wounds is supported by the history, current examination findings, and inflammatory leukogram. The pathophysiological syndrome of ovostasis is sup- Figure 7. Problem-solving algorithm for a reptile with presumed ovostasis. ported by: (1) the history of decreased appetite, decreased defecation, and radiographic interpretation of coelomic images from the primary veterinarian, (2) physical examination findings, (3) mild daily soaking in shallow (ϳ5 cm), tepid (25°C-30°C) hyperuricemia, (4) marked increase in nonionized water for 15 minutes every 24 hours; and continued calcium with hyperphosphatemia and hyperglobu- ceftazidime (20 mg/kg intramuscularly every 72 linemia, (5) hypercholesterolemia, and (6) current hours) administration as prescribed by the primary radiographic findings of multiple, round, soft-tissue- veterinarian for the burn wounds. density structures in the mid coelom. Client Education Plan and Prognosis Problem Planning Some of the causes of ovostasis that are described in the above literature include husbandry concerns The plan for the burn wounds was not altered from such as nutritional deficiencies, inappropriate heat that prescribed by the primary veterinarian, so this provision, lack of basking sites, inadequate UVB problem is not discussed further in this article. spectrum light, and dehydration caused by insuffi- Diagnostic Plan for Ovostasis cient humidity or water provision. Information about the best possible husbandry practices for Ovostasis is a pathophysiologic syndrome. It can be green iguanas was discussed with the client because attributed to many different causes, and the differ- it can be difficult to determine with certainty that ential diagnosis list will differ depending on whether husbandry problems exist. The owner was directed the ovostasis is preovulatory (follicular stasis) or pos- to www.anapsid.org, which is the source that the tovulatory (dystocia). The algorithm in Figure 7 is authors rely on for green iguana care information, used to determine whether the ova are preovulatory even though the information is generally not scien- or postovulatory. In this case, no eggs had been tific. In addition, the client’s concern that ovostasis is oviposited (laid), the ova were not mineralized on likely to be a serious health concern after more than radiographic images, and the ova were clustered. 3 months and that ovariosalpingohysterectomy may Further imaging was necessary to differentiate be necessary to resolve the current problem and whether the ova were preovulatory or postovulatory, avoid future reproductive problems was validated. so coelomic ultrasound was scheduled 5 days after The nest box was maintained during the interim initial presentation. before diagnostic ultrasound to provide continued opportunity for oviposition in case the ova were Treatment Plan for Ovostasis postovulatory. A good prognosis was reported to the Initial empirical therapy for ovostasis was not depen- client because the patient was in good body condi- dent on whether the ova were preovulatory or pos- tion, and complicating disease factors were not evi- tovulatory. The treatment plan included subcutane- dent. This prognosis was based on recollection of the ous crystalloid fluids (30 mL/kg subcutaneous every outcomes of similar cases and textbook informa- 72 hours, lactated Ringer’s solution); continued tion.6,8,12 210 Gibbons and Tell

Follow-up

Primary Follow-up Information Gathering The patient was presented again as scheduled, 5 days after the initial presentation. The owner reported no changes in the animal’s behavior, appetite, or defecation since the last visit. The only change noted in the physical examination findings was tacky saliva. The results of a recheck complete blood count (CBC) included heterophils decreased into reference range, increasing lymphocytes, and decreasing monocytes (Table 1). Coelomic ultrasound revealed variably echogenic, round structures clustered in the mid coelom and a moderate amount of flocculent coelomic fluid.

Primary Follow-up Assessment The recheck CBC was consistent with resolving inflammation. Ultrasonic examination of the coelom was consistent with multiple caseated ovarian follicles and a diagnosis of preovulatory ovostasis with coelomic fluid. Differential diagnoses for preovulatory ovostasis include inappropriate husbandry (see above), improper nesting site, stress, hormonal disturbances, infectious oophoritis, egg yolk coelomitis, infectious coelomitis, and oviduct obstruction. Husbandry concerns were being addressed, a nesting site had been provided, and Figure 8. Problem-solving algorithm for a reptile with preovulatory stressors were minimized to the best of the owner’s ovostasis (follicular stasis). ability. In this case, a problem-solving algorithm for preovulatory ovostasis led to exploratory surgery as the next diagnostic step (Fig 8). Explor- intramuscularly every 24 hours for 7 days, Torbug- atory surgery provides an opportunity to examine esic; Fort Dodge Animal Health, Fort Dodge, IA the coelomic cavity, collect diagnostic samples, USA), ketoprofen (1 mg/kg intramuscularly every and resolve the problem by removing the paired 24 hours for 7 days, Ketofen; Fort Dodge Animal ovaries, oviducts, and uteri. Hormonal distur- Health), 60 mL lactated Ringer’s solution subcu- bances would not be addressed in this case be- taneously every 24 hours for 5 days, enrofloxacin cause this animal was not intended for breeding. (7.5 mg/kg intramuscularly every 24 hours for 7 days, Baytril; Bayer Corporation, Shawnee Mission, Primary Follow-up Plans KS USA), and continued ceftazidime 20 mg/kg Coelomitis, a new problem, was identified during intramuscularly every 72 hours. Client education surgery. Findings included diffuse serosal fibrin plans included no soaking for 30 days, restricted deposition; moderate, diffuse, fibrinous, flocculent, activity to a small cage, leafy green vegetables start- beige coelomic fluid; necrotic ovarian follicles; and ing 2 days postoperatively, and continued moni- free-floating inspissated yolk-like material (Fig 9). toring of fecal production. The prognosis was re- Both ovaries and oviducts were removed with hemo- ported to the client as fair in cases of ovostasis that clips because of the adherent fibrin and debris. The are complicated by infectious coelomitis or sepsis, coelomic cavity was explored and thoroughly la- based on the same sources of evidence as the vaged with sterile saline solution. Tissue samples initial prognosis. Follow-up imaging and CBC were were collected for histopathological characterization planned in 7 days to ensure that the coelomitis of inflammation and cultures to differentiate be- would be resolving. Further diagnostic and thera- tween infectious and egg yolk causes of coelomitis. peutic plans would be based on the patient’s re- Therapeutic plans included butorphanol (1 mg/kg sponse to treatment. Problem Solving in Reptile Practice 211

the disease process. It is plausible that empirical antibiotic therapy prevented secondary bacterial infection. Butorphanol was administered for analgesia after surgery. New research evidence has shown that it has questionable efficacy for analgesia in conscious lizards at the chosen dose (1 mg/mL), so in the future a primary mu agonist such as morphine will be chosen instead.24,25 Blood calcium was measured 3 months postoperatively but not before. The attending clinicians relied on pathophysiological rationale to presume that hypercalcemia was a result of vitel- logenesis instead of gathering case evidence to ensure there was no other source of hypercalcemia. The authors and all involved personnel learned the importance of thorough exploration of the coelomic Figure 9. Intraoperative photograph of the coelomic cavity of the cavity during surgery, because the patient might green iguana described in Figures 1 and 2 through a ventral have recovered if no yolk material had remained paramedian incision. Note the beige fluid, the fibrinous material after the exploratory coeliotomy. adherent to the coelomic membranes, and the light brown, discol- ored follicles. Conclusion

Summary of Continued Follow-up This case demonstrated how problem-oriented veterinary medicine can be used to confidently decide The patient initially improved for a few weeks but when surgical intervention is necessary for green then declined. No aerobic, anaerobic, or fungal or- iguanas with presumed ovostasis. The case also shows ganisms could be cultured from samples collected how follow-up evaluation is essential to modify plans during surgery, and histopathology confirmed a di- according to patient response to treatment. In this agnosis of egg yolk coelomitis. Two remaining inspis- case, the owner eventually elected to euthanize the sated masses of yolk material were discovered on animal, a decision that was consciously chosen by follow-up ultrasound and continued to serve as nidi integrating the attending veterinarians’ clinical ex- for coelomitis. Approximately 3 months after initial pertise, the best-available evidence, the client’s val- presentation, the client declined a second explor- ues, and the individual patient’s needs. atory surgery to remove the remaining yolk material and elected for euthanasia. Final diagnoses included fibrinous and granulomatous egg yolk coelomitis; Acknowledgments mild nephritis; moderate endocardiosis; and aortic mineralization with chronic lymphocytic arteritis. The authors would like to thank Drs Jennifer Gra- ham and Anna Osofsky for their work on the clinical Self-assessment and Learning case, and Dr James Wellehan for his help in prepar- ing the manuscript. This case demonstrates the process of problem solving that was used for a case of follicular stasis and egg References yolk coelomitis. The initial good prognosis was based on unsystematically recorded experiences and text- 1. Diethelm G: Reptiles, in Carpenter JW (ed): Exotic book reports. These unreliable sources of evidence Animal Formulary (ed 3). St Louis, Elsevier Saun- were incorrect in this case. Client expectations could ders, 2005, pp 53-132 2. Harr KE, Alleman AR, Dennis PM, et al: Morpho- have been more accurate if more reliable sources of logic and cytochemical characteristics of blood cells evidence, such as retrospective studies or case-con- and hematologic and plasma biochemical reference trol studies, had been available to provide more ranges in green iguanas. J Am Vet Med Assoc 218: accurate probabilities of the possible outcomes. Egg 915-921, 2001 yolk material (vitellin) stimulates an inflammatory 3. Dennis PM, Bennett RA, Harr KE, et al: Plasma con- centration of ionized calcium in healthy iguanas. response and causes coelomitis. Although not com- J Am Vet Med Assoc 219:326-328, 2001 plicated by bacterial infection in this case, bactere- 4. Barten SL: Differential diagnoses by symptoms: liz- mia can cause secondary infection and contribute to ards, in Mader DR (ed): Reptile Medicine and Sur- 212 Gibbons and Tell

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