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Distal Leg Necrosis in a Green Iguana, Iguana Iguana HISTORY

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Distal Leg Necrosis in a Green Iguana, Iguana Iguana HISTORY W h a t’s Y our D iagnosis The purpose of this section is to provide cases that challenge the reader to develop diagnostic plans, therapeutic regimens and case diagnoses. Both medical and surgical cases are encouraged. Figures, such as radiographs or ultrasounds, are highly recommended, but not necessary. Submissions should include an introduction, diagnosis and discussion of the case. Please contact Dr. Byron de la Navarre, DVM, Section Editor, Misener-Holley Animal Hospital & Exotic Creatures Care Clinic, 1545 West Devon Avenue, Chicago, Illinois. 60660-1313, Phone 773-743-3322; Fax: 773-274-5264; E- mail: [email protected], regarding publishing Downloaded from http://meridian.allenpress.com/jhms/article-pdf/10/1/48/2206286/1529-9651_10_1_48.pdf by guest on 01 October 2021 requirements or radiographs, histopathology and clinical pathology results. Distal Leg Necrosis in a Green Iguana, Iguana iguana HISTORY A 10-year-old, 3.63 kg (8.0 lb) male green iguana, Iguana iguana, was evaluated by a referring veterinarian for signs of lethargy and decreased appetite of one month duration. The lizard was kept in a large, custom built cage made of wood and screen wire. An incandescent spot light was used to cre­ ate a focal hot spot of 32°C (95°F), and a fluorescent light manufactured for reptiles (manufacturer unknown) provided ultraviolet B light. The diet was a wide variety of chopped, leafy, dark green vegetables, dusted with multivitamin and calcium supplements marketed for reptiles (manufacturers and composition unknown). Physical examination at that time was unremarkable but there was an elevated white blood cell count (44,000/pl; reference range 2,000 - 10,000/pl). Plasma biochemistry analysis results were within reference ranges. Amikacin sulfate (Amiglyde-V, 50 mg/ml, Fort Dodge Animal Health, Fort Dodge, IA) was prescribed at 5.0 mg/kg IM followed by 2.5 mg/kg IM q 72 hr for two weeks. Injections were administered in the front legs. The iguana improved only slightly as a result of treatment and subsequently developed lameness and discoloration of the left hind leg. At this point the referring veterinarian examined the lizard a second time. The affected leg was discolored black, with a sharp line of demarcation between healthy and affected tissue at the level of mid-femur. The distal leg was dry, stiff, malodorous, and had fused joints. The leg was diagnosed as necrotic and amputation was recommended. The iguana was referred for further evaluation. Our examination revealed a robust, alert iguana with good muscle tone and bone structure, and confirmed the presence of a necrotic left hind leg. Results of a complete blood count Figure 1: Dorsoventral view of the whole body and close up of the (CBC) and plasma biochemical analysis are listed in Table 1. affected leg of a 10-year-old male iguana, Iguana iguana, evaluated Radiographs were taken (Figure 1). because of necrosis of the left hind leg. 48 Journal of Herpetological Medicine and Surgery Volume 10, No. 1,2000 pathway may be neural or hormonal but results in increased Table 1. Complete blood count and plasma biochemistry peripheral vascularization and production of connective tissue analysis from a green iguana, Iguana iguana, presented with followed by diffuse periosteal proliferation (Johnson, et al, a necrotic hind leg. 1995). In 180 canine cases, 174 (98%) had intrathoracic dis­ ease, and 165 (92%) of these had neoplasia. Only four (2%) Hematocrit 24% of the 180 cases lacked intrathoracic disease, three of which WBC 24,000/pl had urinary rhabdomyosarcoma and one had hepatic carcino­ ma (Johnson, et al, 1995). The association of intra-abdominal Heterophils 68%, 16,320/jj.I disease with HO is poorly understood. Treatment involves Lymphocytes 12%, 2,880/pl surgical resection of the primary thoracic or abdominal mass Azurophils 19%, 4,560/pl or unilateral vagotomy on the most affected side. Anti-inflam­ matory analgesics may ameliorate the pain associated with Monocytes 1%, 240/pl this condition. Pain, swelling, and lameness resolve quickly if Calcium 11.5 mg/dl the primary mass can be successfully removed (Harari, 1997; Phosphorus 5.5 mg/dl Johnson, etal, 1995). Downloaded from http://meridian.allenpress.com/jhms/article-pdf/10/1/48/2206286/1529-9651_10_1_48.pdf by guest on 01 October 2021 Metabolic bone disease is a generic term and there are sev­ Uric acid 1.5 mg/dl eral forms of this disease. Nutritional secondary Glucose 92 mg/dl hyperparathyroidism (NSHP) is more common in growing, AST 66U/L juvenile lizards than old adults. Renal secondary hyper­ parathyroidism (RSHP) is more common in adult lizards than ALT 12U/L juveniles. Other conditions associated with MBD include AP 24U/L fibrous osteodystrophy, osteomalacia, osteoporosis and rick- PLEASE EVALUATE FIGURE 1 AND TABLE 1. MAKE A LIST OF DIFFERENTIAL DIAGNOSES, DETER­ MINE IF ADDITIONAL DIAGNOSTIC TESTS ARE INDICATED, AND DEVELOP A TREATMENT PLAN FOR THIS PATIENT BEFORE CONTINUING. DIAGNOSIS The radiographic diagnosis is hypertrophic osteopathy. A thick, even layer of periosteal new bone is present on the cor­ tices of the long bones of all four limbs. The cortices are parallel and lack ballooning, but are moderately thinned with a somewhat mottled trabecular pattern. Subcutaneous emphy­ sema is present in the necrotic hind leg. No coelomic mass lesions are visible on the survey radiographs. The complete blood count demonstrates leucocytosis, heterophilia and azurophilia. The plasma biochemical analysis results are within reference ranges (Divers, 2000a; Divers, 2000b) COMMENTS The differential diagnosis in a reptile with generalized periosteal proliferation includes hypertrophic osteopathy (HO, secondary hypertrophic osteopathy), metabolic bone disease (MBD), osteomyelitis, multiple fractures and neopla­ sia. Hypertrophic osteopathy is a generalized production of Figure 2: Dorsoventral radiographs of two green iguanas, Iguana iguana, enlarged to show details of the bone structure of the hind periosteal new bone in long bones associated with neoplastic legs. Hypertrophic osteopathy, top, is characterized by uniform dis­ or infectious masses in the thoracic or abdominal cavity tribution of periosteal new bone affecting the long bones of the (Harari, 1997, Johnson, et al, 1995). It is seen primarily in limbs, without decreased bone opacity or ballooning of the cortices. dogs and occasionally in cats (Harari, 1997). The etiology is Nutritional or renal secondary hyperparathyroidism (NSHP and thought to involve an afferent neural pathway originating in RSHP, two forms of metabolic bone disease), bottom, is character­ the lung and joining the vagus nerve. An alternate afferent ized by asymmetrical distribution of periosteal new bone, accompanied by decreased bone density, thinning of the cortices and pathway may involve the intercostal nerves. Regression of ballooning of the cortices. Other changes seen in NSHP or RSHP signs occurs after removal of the primary mass, unilateral may include angular deformities of the long bones, pathologic frac­ vagotomy, or occasionally after thoracotomy and transection tures and distortion of the normal trabecular pattern. of the intercostal nerves (Johnson, et al, 1995). The efferent Volume 10, No. 1,2000 Journal of Herpetological Medicine and Surgery 49 ets (Boyer, 1996). In addition to periosteal new bone, radi­ of the hind leg, as there was no history of trauma. ographic changes seen with MBD may include decreased Reptiles lack a diaphragm and have a common coelomic bone opacity, thinning of the cortices, ballooning of the cor­ cavity rather than separate thoracic and abdominal cavities. tices, angular deformities of the long bones, pathologic No masses were located in the heart or lungs of the iguana fractures and distortion of the normal trabecular pattern reported here, but there were two coelomic masses: the (Boyer, 1996, Silverman and Janssen, 1996). Changes are dif­ abscesses attached to the walls of the colon and urinary blad­ fuse and tend to be irregular and asymmetric, whereas lesions der. The pathophysiology of HO in dogs with intra-abdominal in hypertrophic osteopathy tend to be confined to the long masses is poorly understood; in reptiles it is even less clear. bones and exhibit uniform distribution (Figure 2). With the HO was reported in a green iguana with pulmonary silicosis exception of mild cortical thinning and mottled trabecular related to exposure to commercial cat litter containing a high pattern, the iguana reported here exhibited none of the typical amount of silica (Frye and Williams, 1995). A second report features of MBD other than periosteal new bone. The report­ discussed a case of HO in a green iguana associated with ed husbandry did not support a diagnosis of NSHP. The lizard renal gout (Ball, et al, 1999). The author saw another case of also had normal plasma calcium, phosphorus and uric acid reptilian HO involving a savannah monitor, Varanus exanthe- levels and grossly normal kidneys on necropsy, which did not maticus, with coelomic sarcoma and pulmonary metastasis. support a diagnosis of RSHP. Downloaded from http://meridian.allenpress.com/jhms/article-pdf/10/1/48/2206286/1529-9651_10_1_48.pdf by guest on 01 October 2021 In reptiles, osteomyelitis results in bone lysis with less This report was submitted by Stephen L. Barten, DVM, periosteal response than is seen in mammals (Silverman and Vernon Hills Animal Hospital, 1260 Butterfield Rd, Janssen, 1996). Fractures in lizards heal with less radiopaque Mundelein, EL 60060. callus and less prominent periosteal new bone than is seen in mammals (Silverman and Janssen, 1996). It is unlikely that neoplasia would result in symmetrical periosteal new bone REFERENCES covering the long bones of all four limbs without significantly Ball RL, Dumonceaux G, MacDonald C. 1999. Hypertrophic affecting the cortices or trabecular pattern. The radiographic osteopathy associated with renal gout in a green iguana, Iguana changes seen in this case were not consistent with MBD, iguana. Proc ARAV, 49-50. osteomyelitis, multiple fractures, or neoplasia. Boyer TH.
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