„Slow Kill” – adulticide protocol in heartworm treatment! Can we use it? When to use it? How to use it?

13549281_10207110414020766_1752592814_oTodor Kalinov DVM

 

veterinary clinic “Vitalis”, Plovdiv, Bulgaria

drkalinov80@gmail.com

 

 

 

Heartworm disease is caused by Dirofilaria immitis. The disease is widely distributed throughout Europe. Species susceptible to infection are dogs, wolves, foxes, coyotes, cats, ferrets, muskrats, sea lions, and humans. The parasite is transmitted by over 70 species of mosquitoes.

Adult heartworms reside in pulmonary arteries and in cases of severe infections in the right ventricle. Mature female parasites produce microfilariae and release them into the circulation. The feeding female mosquitoes ingest these microfilariae, and they undergo two molts, L1 – L2 – L3, over an 8 to 17 dаy period. This process is temperature-dependent (at least 18 C are needed). The L3 are infective and are transmitted by the mosquito to the hosts. In the subcutaneous, adipose, and skeletal muscle tissue L3 molt to L4 for 1 to 12 days and L4 molts to S5 – immature adults, for 2 to 3 months. The Immature adults enter the vascular system, migrating to the heart and lungs, where final maturation and mating occur. Under optimal conditions, completion of the life cyclе takes 184 to 210 days.

The adult worms cause the following through mechanical, immune-induced, and through toxic substances: inflammation and proliferation of the pulmonary arteries, pulmonary thromboembolism, pulmonary hypertension, and right-sided heart failure. Clinical signs of the disease are weight loss, exercise intolerance, lethargy, poor condition, cough, dyspnea, syncope, abdominal distention.1

According to the guidelines of the American Heartworm Society2 treatment of the heartworm infection consists of doxycycline 10 mg/kg BID for 28 days, monthly use of macrocyclic lactones, and melarsomine at days 60, 90 and 91.

In other publication3, the authors suggest administration of melarsomine on day 30 , 60 and 61, to make the protocol shorter, and to better comply with the owner’s financial resources.

 

In certain circumstances, melarsomine dihydrochloride could be contraindicated, unavailable, or not affordable to the owners. In this situation the practicing veterinarian could use the so-called “Slow kill” or “Soft kill” protocol.  It consists of the use of macrocyclic lactones in prophylactic doses with and withоut doxycycline to kill adult heartworms4–6. In most of the studies, the results are not satisfactory. L. Venco et al.6 used ivermectin – 6mcg/kg, monthly and had 100% microfilaricidal efficiency after 7 months, and 71% adulticidal efficiency after 24 months. The authors do not recommend this treatment regime in patient with clinical, radiographic or echocardiographic signs. G. Grandi et al.4 used doxycycline – 10 mg/kg/sid for 30 days and ivermectin-pyrantel – 6mcg/kg-14mg/kg every 15 days. By day 90 one hundred percent of the dogs became negative for microfilariae, and 72.7% became antigen-negative by day 300.

The study of Savadelis et al.7from 2017 had results similar to melarsomine treatment for a relatively short period of time. They used topical moxidectin 2.5%+imidacloprid 10% monthly with combination of doxycycline 10mg/kg/bid for 30 days. All treated dogs became negative for microfilariae at day 21. Ten months after the beginning the adulticidal efficacy was 95.6%. Hence, the conclusion of the authors is that this treatment regimen is a relatively quick, reliable and safe option to treat canine heartworm infection as compared to other treatment regimens involving macrocyclic lactones, when the approved drug melarsomine dihydrochloride is unavailable, contraindicated or declined by an owner unable to afford the more costly treatment or concerned about the potential side effects”.

I used this protocol numeral times with very good results. Most of the dogs were with class 4 heartworm disease and caval syndrome. Probably the most severe case was a 10-year-old Bulgarian shepherd dog. At presentation, the dog was cachectic, could not walk, did not eat for several days, and had ascites. Blood work revealed slight leukocytosis, neutrophilia, and thrombocytopenia, slightly increase in ALAT, ASAT, BUN, decrease in albumin, and the test for HW antigens was positive. Echocardiographic examination revealed severely dilated right atrium and right ventricle, with heartworms in the tricuspid valve region(video 1).

photo2

photo 2

The left atrium and ventricle were collapsed due to severe pulmonary hypertension. Of course, in this situation surgical extraction of the worms is the first choise8, but this option was declined by the owners. So we started treatment with doxycycline 10 mg/kg/sid, moxidectin+imidacloprid topically, and sildenafil 1mg/kg/bid. Several days after the start of the treatment the dog was in better condition, and on the echocardiographic examination we found that the left ventricle is relatively dilated, compared with the previous exam, the number of worms in the tricuspid valve region was subjectively lower. However, on m-mode, the systolic motions of Interventricular septum and left ventricular free wall was weak(photo 2). Therefore we suggested that the dog has subclinical dilated cardiomyopathy, which contributed to the development of the caval syndrome. We added pimobendane – 0.25mg/kg/bid and benazepril – 0.5 mg/kg/bid and prednisolone – 0.5mg/kg/sid to the therapy for thromboembolism prophylactic. On the next control examination, the dog was feeling better, there were no heartworms in the right atrium and ventricle and in the pulmonary artery(photo 3,4).

photo4

photo 4

photo3

photo 3

photo 5

photo 5

After a month from the diagnosis we stopped the doxycycline and continued with other pimobendane, benazepril, topical moxidectin+imidacloprid, sildenafil, and prednisolone – 0.5 mg/kg/48h. After two more months we gradually stopped the prednisolone. Six months after diagnosis the antigen test for heartworms was negative. The dog still had severe pulmonary hypertension, exercise intolerance and coughed occasionally. We continued treatment with pimobendane, benazepril and sildenafil and monthly moxidectin+imidacloprid for heartworms prophylactic. The dog lived for two more years and died from noncardiogenic reasons. I have similar results with two other large-breed dogs, also with caval syndrome, with complete resolution of clinical signs and withdrawal of all drugs, only continuing with moxidectin+imidacloprid for heartworm prophylactic. A small-bred dog developed severe pulmonary hypertension and tricuspid valve granuloma after the third month probably due to damages of the tricuspid valve from heartworms(photo 5), and untreatable right-side heart failure. Soon after the dog was euthanized.

The “slow kill” protocol is arguably more suitable for large and giant breed dogs, where the surgical extraction is more challenging, and the treatment with melarsomine is more expensive. In caval syndrome, the worms could be moved back in the pulmonary artery with a combination of pimobendane and sildenafil. Sildenafil is a phosphodiesterase 5 inhibitor, and pimobendane is a phosphodiesterase 3 inhibitor. The combination leads to more profound reduction in pulmonary artery pressure. The pimobendane has positive inotropic effect, hence the combination of improved myocardial function and lower pulmonary artery pressure helps in movement of the heartworms from right heart in pulmonary artery9(photo 6, 7 – before and after administration of pimobendane and sildenafil).

photo 6

photo 6

photo 7

photo 7

In small and medium dog breeds the surgical extraction, when possible, is the best choice, however, do not exclude the use of macrocyclic lactones and melarsomine.

In conclusion, when we treat a dog with dirofilariosis, we should first rely on the American heartworm society guidelines2. When we decide to use the Slow kill protocol, the macrocyclic lactone of choice is topical moxidectin. It has a unique pharmacokinetic, establishing a peak several days after application, long half-life about 28 days, and steady-state levels after four monthly applications, ensuring constant and high exposure of the parasites to the drug10,11. Of course doxycycline is also mandatory for adulticide therapy. Last but not least, we always have to think of the patient, we have to treat the patient rather than the disease, and to ensure good quality of life to them.

FECAVA announced Didier-Noël Carlotti Award Laureate: Assistant Professor Dr. Bogdan-Alexandru Vitalaru from Romania

23131883_1723169741051257_1944002556383533163_nThe Didier-Noël Carlotti Award (DCA) is named after a veterinary surgeon who initiated, planned and inspired FECAVA and who served as its first President for four years. The Didier-Noël Carlotti Award is presented annually for ‘outstanding service in the fields of inter-professional communication and/or continuing education for companion animal veterinarians in Europe’.Capture d’écran 2017-09-05 à 15.30.43

In 2019, the DCA award will be received by Assistant Professor Dr. Bogdan-Alexandru Vitalaru from Romania.

He was selected for the Award by the DCA Committee and will receive it at the opening ceremony of the 25th FECAVA EuroCongress in St. Petersburg.

Assistant Professor Bogdan Alexandru Vitalaru graduated the Faculty of Veterinary Medicine of Bucharest in 2004, PhD since October 2009, and he has participated since then in numerous national and international conferences, both as a doctor and as a lecturer. Since January 2016 he became Assistant Professor at the Faculty of Veterinary Medicine of Bucharest.

Over the years he has written more than 100 scientific papers on topics related to oncologic surgery, dialysis, hemodialysis and emergencies. His 4 books about emergencies were sold in more than 2000 copies in Romania in the last 4 years. His last book it is completely dedicated to peritoneal dialysis in small animals and it has been released also in English in Italy, Bulgaria, Turkey, Greece, Croatia, Ukraine and Poland starting February 2018.28471893_1212686848867718_2541073989731187894_n 49848433_2438242006214507_5459535691056676864_n

Since January 2014, in collaboration with BBraun Romania, within the Faculty of Veterinary Medicine, he opened the first Veterinary Hemodialysis Clinic in Romania and one of the few in Eastern Europe.

Starting 2013, he established the Romanian Association of Veterinary Nephrology, Hemodialivet, who’s Chairman he is.

In the last 10 years, Dr. Vitalaru has been a lecturer for Hills Romania and KTL in Romania and Europe regarding urology, nephrology and renal replacement therapies. He is also leading the Emergency Department of the Faculty of Veterinary Medicine of Bucharest since 2015.22154250_1512540295490310_2300870383746233502_n

Starting 2014, Dr. Vitalaru has initiated a program of workshops and seminars regarding renal patients all over Romania (București, Iași, Cluj, Timișoara, Brașov, Constanța), Bulgaria (Varna, Stara Zagora), Poland (Krakow, Warsaw), Croatia (Zagreb), Italy (Perugia, Pisa) and in Turkey (Istanbul, Ankara, Antalya). He was awarded with the Continuing medical education prize – AMVAC/RoSAVA, Sinaia 12-14 November 2015 and SPEAKER OF THE YEAR – Romanian College of Veterinarians, Bucharest, 17 December 2015. He is a member within the board of some of the most prestigious publications in Romania: Cat life, 2015, Romanian Journal of Veterinary Orthopedics and Imagistic, 2015, Romanian Journal of Veterinary Medicine & Pharmacology, 2016, Romanian Cardiology Review. In 2016, Dr. Vitalaru has received the Special Prize for the best veterinary initiative of the year in Romania – Innovation in Health.39515211_2117230608311833_1547971329477574656_n 55811478_2440517709316453_3635058829533642752_n

Since November 2017 he is a board member of AMVAC (Small Animal Romanian Practitioners Association), FECAVA Director for Romania and since October 2017, Dr. Vitalaru is FECAVA Ambassador and ROVECCS Ambassador (Romanian EVECCS partener).

His passions are mountain hiking, fishing and nature and as a result of this, he has initiated in 2017 a Vet Camp in the Romanian mountains with vets all around Romania.

The greatest achievements of his life are Silvia his wife and his two beautiful daughters: Natalia and Sofia.40082786_10216876652047378_4749508800241729536_n 57384291_2505251306176426_5657680386600206336_n

Learn and Travel ….. story from vets

67509335_393199464955171_7827241570955952128_nDr Elena Nenciulescu from Romania has done her externship with Ana Nemec, DVM, PhD, Dipl. AVDC, Dipl. EVDC at our project LEARN AND TRAVEL with Vets on The Balkans.

We would like to express our gratitude as well to The University of Ljubliana, Faculty of Veterinary Medicine in Slovenia for the opporunity!

 

Let her tell us her story:

Last week I had the amazing opportunity to assist Dr. Ana Nemec during dental procedures and dental consultations. It really was AMAZING!learn and travel

I arrived in Ljubljana on Sunday, July 27th. I had a little rest and the next day my journey in the Slovenian world of veterinary dentistry began. The weekly schedule is usually like this: Monday, Tuesday, Thursday and Friday are for dental procedures (2-3 cases per day) and Wednesday is only for consultations.

On the first day, Dr. Nemec showed me the clinic (very well equipped, with ultrasound machine, X-ray machine and CT). What really impressed me was the dentistry room. It is fantastic: dental unit, dental X-ray machine, dental table (custom made) and all dental instruments and materials that you need for dental materials for exodontics, endodontics, orthodontics, orthopaedics and oral surgery. It was like heaven for me!

All the dental procedures that I assisted had the following steps:

  1. Dental consultation under anaesthesia and filling the dental chart (using the periodontal probe, every tooth was examined – mobility, gingival retraction, furcation exposure, gingivitis, periodontal depth)
  2. Full mouth dental X-rays and interpretation
  3. Sonic scaling and polishing
  4. Surgical extractions (the teeth were extracted based on the clinical and radiological findings)

It is important to perform all steps correctly and not to miss any of them. 90% of dentistry cases in general practice are periodontal patients that need periodontal therapy, so this is what all vets should learn to do properly.

Dental chart for cats Dental table prepared for the patient Dental unit, dental table, intraoral X-ray and equipment for anaesthesia

I had the chance to see a wide range of cases: mild to severe periodontal disease, stomatitis, tooth resorption, tooth avulsion, crown fractures, chin eosinophilic granuloma, peripheral odontogenic fibroma, intraosseous squamacell carcinoma, endodontic treatment re-check, but also cases of no dental disease that came in only to learn oral homecare which is also a big must for maintaining the oral health of our pets. All cases were discussed in detail.

Dr. Nemec is such a positive person, teaching dentistry is something natural for her. She answered all my questions (and there were many of them). I consider myself very lucky to be given this opportunity. I learned a lot!

But it was not all dental work for me last week, I also visited the city. Ljubljana is beautiful: the castle, the city centre, the museums, the Tivoli Park. It is worth visiting. I enjoyed my stay there very much. On Saturday, August 3rd I traveled back home.

Vets on the Balkans and Luba Gancheva, thank you for giving me this opportunity. Learn and Travel is a fantastic chance to grow professionally. Dr. Ana Nemec, thank you so much sharing all you knowledge with me! I am really grateful for this experience.

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Hypothyroidism- 2 case reports with different approach

 

72749_499770162813_6858159_nDr Dimitar Ivanov,
Veterinary surgeon, Neurology specialist. ESAVS Neurology courses
Dobro hrumvane veterinary clinics
Sofia, Bulgaria

Dr.d.ivanov.vet@gmail.com

 

 

Hypothyroidism endocrine disease that can be reason for very different neurological signs, varying from signs of polyradiculoneuritis to neurological signs from the brain and vestibular disorder.

The good news are that all of this neurological problems and deficits can be reverse with adequate treatment, good nursing and physiotherapy.

I will present 2 cases of hypothyroidism in dogs with very different neurological signs. In first case I did not believe that this disease can manifest so heavy clinical signs. In second case, I took blood sample for fT4 just to be sure that this is not hypothyroidism.

Scarlett

Signalment: Dog, F, 9 y.o., Samoyed

History: Two days ago while the dog is on a walk, the owner noticed small paresis with front legs but it was for few minutes and they went back home. The dog came in the clinic on 1st of December in lateral recumbency, not able to stand up and not able to stay on her legs, even with help. The dog could not eat without help and holding the head and the body.

General examination: no abnormalities, the dog was not vaccinated the last year. Orthopedic examination: no abnormalities.

Neurological examination:

-Hands off exam:

  • Consciousness – normal
  • Behavior – can’t find any abnormalities in this position
  • Seizers – no seizers
  • Body posture – lateral recumbency but the dog can move head and neck
  • Gait – symmetrical tetraplegia

-Hands on exam:

  • Cranial nerves – no neurological deficits
  • Postural reaction – can’t be checked in this position
  • Spinal reflexes – absent withdrawal reflex on both front legs, reduced extensor carpi radialis on the right front leg, there are no abnormalities in hind limbs spinal reflexes. Normal tail movement, there is a perineal reflex and normal deep pain sensation.

Localization: C6 – Th2

Differential diagnosis: Degenerative/Neoplastic/Vascular

At this point we were unable to make CT or MRI and the decision was to use steroids in dose 2 mg/kg, famotidine 0,5 mg/kg/12 h p.o., Omeprazole 1 mg/kg/24 h p.o. and to see what will happen on the next day. On the next day the dog was in the same condition and I repeat the steroid. After second injection the dog has profuse diarrhea so we stopped the steroid and treated the GI signs.

Two days later we made CT and there are no abnormalities.

 

 

On the next day was taken blood sample for biochemistry and fT4. The biochemistry showed no specific abnormalities, but fT4 was very low.

fT4 – 0,1 pmol/L (7,7 – 47,60 pmol/L)

 

Creatinin – 39 mmol/L (44,3 – 138,4 mmol/L)

Glucose – 6,2 mmol/L (3,4 – 6,00 mmol/L)

Creatin kinase – 298,1 U/L (13,7 – 119,7 U/L)

LDH – 576,9 U/L (24,1 – 219,2 U/L)

Magnesium – 2,00 mmol/L (0,7 – 1,1 mmol/L)

 

The algorithm was to start levothyroxine and if we don’t have any results may be the reason for this condition is polyradiculoneurtis.

I didn’t believe that the reason for so hard clinical signs is only hypothyroidism.

Eight days later the dog was with total areflexion of all four limbs.

 

The decision was to take CSF, muscle biopsy (from M. gastrocnemius, M. triceps brachii) and nerve biopsy (from n. peroneus). The samples (the biopsies and the CSF smear) were send to Laboklin Germany. The cells count, protein, glucose and microbiology of CSF were made in laboratory department of “Dobro hrumvane!” veterinary clinics.

The results were:

Number of cells – normal (<5)

Protein total – 2.4 (<25)

Glucose – 4.6 (80% of normal blood values)

Microbiology – negative

“The smears were cell free. Only few keratin flakes were present.
Diagnosis:
1:
– striated muscle with multifocal mild degenerative and regeneative
changes
– mild multifocal purulent perivasculitis (M. gastrocnemius)

2:
– histologically normal nervous tissue

Critical report:
Mild multifocal degenerative and regenerative changes of the        striated muscle was found. A specific cause was not detected. It    should be kept in mind, that in muscle pathology there may not be a strong correlation between histological changes and severity of the clinical symptoms.
Considering the purulent perivasculitis in the sample of the M.
gastrocnemius an inflammatory (possibly infectious) process in other
locations should be excluded clinically.
Signs for a polyneuritis have not been observed within the examined
locations.”

I had to resign that the most likely cause of Scarlett’s condition was hypothyroidism and we started physiotherapy procedures.

Meanwhile, the patient’s condition has begun to improve. First Scarlett started to move her head better, started to lay on her chest and started eating by herself. The muscle tone start to improve.

40 days later

 

The day that Scarlett left the clinic.

 

 

Chata

Signalment: Dog, F, 5 y.o., German shepherd dog

History: Everything started with variable appetite. The dog came in the clinic for second opinion on 06.06.2019.

Colleague already took blood samples and there were no specific abnormalities.

 

Neurological examination:

-Hands off exam:

  • Consciousness – abnormal
  • Behavior – abnormal
  • Seizers – no seizers
  • Body posture – abnormal, head tilt, from time to time head turn, opisthotonus
  • Gait – abnormal, symmetrical, general proprioceptive ataxia

 

 

-Hands on exam:

  • Cranial nerves – vision, oculovestibular and menace is absent, contraction of the pupils is normal but dilatation is reduced, increased jaw tone, reduced gag reflex and reaction of the tongue.
  • Postural reaction – proprioception and hopping are absent
  • Spinal reflexes – absent withdrawal reflex on the left front legs, reduced on the right front leg.

 

Localization: Central vestibular

Differential diagnosis: Metabolic/Inflammatory/Neoplastic

I took blood samples to examine fT4 just to be sure that this is not hypothyroidism.

We discussed with the owner that if there is no abnormalities in thyroid hormones we will take and make some tests with CSF.

The level of fT4 was 1,60 pmol/ L (7,7 – 47,60 pmol/L)L

I started levothyroxine and after two intakes of the medication the result was:

The next few weeks the dog was not still in perfect condition, but there was improvement.

Conclusion: Hypothyroidism is often over diagnosed condition, but is also misdiagnosed metabolic disease with lots of different signs and different manifestation in every part in veterinary medicine.

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Persistent right aortic arch

Presentation1Tsvetan Ivanov, Dimitar Ivanov, Vladi Kirilov – veterinary clinics “Dobro hrumvane!”- Sofia, Bulgaria

 

  1. Introduction:

The persistent right aortic arch (PRAA) is vascular ring which is formed by the aortic arch on the right side, with ligamentum arteriosum dorsolaterally, and pulmonary artery on the left and ventrally. This ring compresses the esophagus and trachea, which leads to swallowing difficulty. This malformation is with genetic prevalence and represents  error in embryogenesis of the dog. In 95% of the cases of this vascular ring anomaly, a constricting band prevents solid foods from passing to the stomach which prevents the puppy from thriving well.  In the remaining 5% of cases, a bizarre anomaly of the vessels is present (double aortic arch and aberrant subclavian artery), which may be difficult to correct and may not have a good prognosis.pic 1

 

 

 

 

 

 

Signs of this condition usually become apparent shortly after weaning, when a puppy begins eating semi-solid or solid food.  While milk will slide down nicely, bulky foods will “jam up” in the esophagus, leading to a stretched structure and the inability to get food down, hence the symptom known as regurgitation. Regurgitation involves the puppy producing undigested food and mucus through the mouth with no effort; the pup tilts its head down and the food and mucus simply roll out.  By contrastvomiting is an active process, meaning there are abdominal contractions (heaving) and a retching noise when food and mucus are expelled out the mouth.

Often complication of the regurgitation is aspiration pneumonia (AP), which leads to poor prognosis for the patient.

The standart therapy is surgical and is with good prognosis if there is no signs of AP. Before the surgery CBC and blood chemistry is required – WBC is important to rule out infection and the level of blood sugar should be in the reference values. The surgery can be open thoracotomy or thoracoscopy – the goal is to ligate and resect the fibrous annulus.

 

  1. Patient report

The patient is 2 months old german shepherd dog with history of vomiting after eating, according to the owners, but there is no problems with water drinking. The dog have diarrhea but is in good overall condition. When the dog sleeps there is strange noises from his neck and there is visible peristaltic waves in the level of 1-st rib.

We perform CPV/CCV/Giardia and the result was negative. The CBC and blood chemistry shows no difference from the reference values.

pic 2

pic 2

Then we made x-ray of the chest: pic 2

 

 

 

 

 

 

 

 

Because of the typical sign of the chest, we performed and BaSO4 examination, and this was the result:pic 3

pic 3

pic 3

So our diagnosis is PRAA with no signs of AP. We performed surgery on the next day – it was open thoracotomy with ligation of the annulus.

Differentiation of the fibrous ring:

pic 4 pic 5 pic 6

 

 

 

 

 

 

 

 

 

 

 

 

It’s was administrated antibiotics, pain killers, sedatives and assisted feeding. We didn’t use thoracic tube after the surgery.

On the fourth day after the surgery, the dog was discharged. Three months after the surgery the owners still make assisted feeding, but the dog is not vomiting and is in good condition.

Degenerative Mucinotic Mural Folliculitis in cat – first case in Bulgaria

IVDr. Ivelina Vacheva, DVM
Central Vet Clinic, Sofia, Bulgaria
ESVD member, BAVD bord member

Introduction

Degenerative Mucinotic Mural Folliculitis (DMMF) is a rare, poorly understood syndrome in cats, defined as an inflammatory reaction pattern. It is characterized by inflammation of the hair follicle, atrophy degeneration and mucin production. The inflammatory reaction, takes place on the follicle wall, primarily affecting the external sheath of the hair above the follicular isthmus. However it can also affect the infundibulum or the bulbar portion of the hair follicle.
Literature (incl. case studies) regarding feline DMMF is sparse. It can be briefly summarized as follows: All described cases are in middle aged to older cats, the majority of which are male, with no information on breed predisposition. The most characteristic features are: Alopecia of the face, head and neck and in a later stage affecting the body and limbs. Pruritus, if present, is mild to very intense. The diagnosis is confirmed by biopsy and subsequent histopathological examination.

Case Study

Mila is an approximately 1,4 years old spayed female cat. She used to be a stray cat, until a lady, regularly

1_1 Mila before the onset of her skin problem

pic 1-1

1_2 Mila before the onset of her skin problem

pic 1-2

feeding her, noted dramatic changes to the cat’s fur. The lady temporarily adopted the cat and took her to several veterinarians. The lady provided shelter to about 20 other cats. According to the owner all cats were treated monthly with Broadline (Merial).
Picture 1.1, 1.2 Mila before the onset of her skin problem

 

2_1 hypotrichosis of the face

Pic 2-1

2_2 hypotrichosis of the distal parts of the limbs

pic 2-2

3_2

3-2

3_3

3-3

3_4

3-4

3_5

3-5

3_6

3-6

3_7

3-7

3_8

3-8

 

 

 

 

 

 

 

 

First signs were: hypotrichosis of the face (pic. 2.1) and subsequent minor hypotrichosis of the distal parts of the limbs (pic. 2.2)
The cat’s skin condition gradually worsened. She showed progressive hypotrichosis, and alopecia, with severe pruritus. She was seen by a veterinarian and treated with Synulox (Zoetis) orally for 20 days, which reduced the inflammatory signs. Later she was seen by another veterinarian and underwent the following treatments (in a period of 3-4 months):
Pulse therapy (7 days of medication, 7 day break etc.) with oral itraconazole 5mg/kg q24h. Without good response.
Purina Pro Plan veterinary diets HA Hypoallergenic, for two months.
Ivermectin 0.3mg/kg q24h orally for 10 days.
According to the owner, the cat’s skin condition worsened. Described signs included: Pruritus, hypotrichosis, alopecia, skin hyperpigmentation and presence of scales and crusts.
The cat was admitted to our hospital for a second opinion. As as side note: Once admitted to our clinic, the lady signed the cat over to a local charity Redom.
Picture 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The cat presented with the following signs:

  • Symmetrical alopecia of the face and head. The skin had a thickened and swollen appearance.
  • Severe pruritus (9/10 – 10/10)
  • Hypotrichosis and alopecia of the entire body.
  • Hyperpigmentation, scales and crusts covering the dorsum.
  • Very passive and apathetic.
  • According to the owner the animal is not feeling well, has an increased water intake and softer stools, with more frequent defecation than usual.

 

 

 

 

 

 

 

 

Differential diagnoses (several)
Demodicosis; Notoedrosis
Feline atopic syndrome (allergies)
Feline sebaceous adenitis
Dermatophytosis
Degenerative mucinous mural folliculitis
FIV / FeLV
Thymoma-associated exfoliative dermatitis in cats
Lymphoma

The cat was hospitalized for further diagnostics and treatment was started, while waiting for the results of histopathology.
Results of clincial exam and diagnostic tests:
Skin scrape, hair plaque, tape strip: All negative for Demodex and Notoedres mites.
Tape strip cytology: Epithelial cells, but no neutrophils or Malassezia.
The ears have brown ear wax; Cytology – only epithelial cells, no Malassezia and no Otodectes cynotis.
CBC: WBC HH 58.24×109/L(5-19,5); NEU 25×109/L(2-12,5); LYM 16×109/ L; MONO 7,21 x109/L (0,15-1,7); EOS 8,58×109/L (0,1-0,79); BASO 0,13 x 109/L (0-0,1).
Blood Biochemistry: All parameters within normal range.
TT4= 18 nmol/l (10-80).
Urine: pH 7; PRO 30 mg/dl; GLU, KETO, UBG, BIL and BLOOD negative. No sediment.
Abdominal Ultrasound: Except for slightly enlarged inguinal lymph nodes, the other abdominal organs were unremarkable.
Chest radiographs: Bronchial pattern, possible cause could be lung worms. (Picture 4)
Fecal flotation: Negative
Bearman: Negative
PCR (antigen) Assays: FCoV, FIV, FeLV, Toxoplasma gondii and Giardia ALL negative.
Skin biopsy: Histopathology results below.
Lymph node biopsy: Histopathology results below.

Therapy

5_2

5-2

5_1 The cat is licking and biting her legs and tail as well as scratching her neck

5-1

5_3

5-3

5_4

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Picture 5 (5.1-5.4): The cat is licking and biting her legs and tail, as well as scratching her neck.

Intravenous fluids: Ringer’s lactate solution 10 ml/h for 5 days. Antibiotics: Ceftriaxone 30 mg/kg IV q12h and Enrofloxacin 5 mg/kg SC q24h for 14days each. Anti-parasitic: Fenbendazole 50 mg/kg PO q24h for 5 days. Antihistamine: Diphenhydramine 1,5 mg/kg SC q24h for 2 weeks. Continuation of Purina Pro Plan veterinary diets HA Hypoallergenic and supplementing this with 4 drops YuMEGA cat (omega-3, -6, -9 fatty acids) once daily. A single application of dexamethasone 0,25 mg/kg SC, resulted in a major reduction of the pruritus!

The CBC was repeated the next day, but did not show significant changes. However the CBC 48h after hospitalization did: WBC HH 44.8×109/L(5-19,5); NEU 19,5 x109/L (2-12,5); LYM 14,12 x109/L; MONO 1,96 x109/L (0,07-1,36); EOS 9,12 x109/L (0,06- 1,93); BASO 0,05 x109/L (0-0,1).
Clinically no evidence of polydipsia!
The charity agreed on taking biopsies (and subsequent histopathology) of the skin, spleen and enlarged lymph node.
Results – Histopathology
Spleen and inguinal lymphnode biopsy
(Dimitra Psalla, DVM, PhD)
Histopathological findings:
Spleen: Multifocally white pulp is composed of atypical round cells with distinct cell borders, scant to moderate amphophilic cytoplasm, round to ovoid nuclei with finely stippled chromatin and one large basophilic nucleolus. There is moderate pleomorphism and mitoses average 1 per HPF. Multifocally red pulp is infiltrated by small numbers of neutrophils.
Inguinal lymphnode: Focal presence of atypical cells similar to those described above. Lymphnode is infiltrated by few neutrophils.
Diagnosis :Spleen and inguinal lymphnode: Infiltration by atypical round cells (accompanied by neutrophilic inflammation)
Comments: The diagnosis of lymphoma cannot be confirmed since the distribution of the atypical cells is limited on the white pulp and the pleomorphism is not high. This population could reflect a hyperplastic conditionas well.

Skin Biopsies – face, lateral body and dorsum
(Dimitra Psalla, DVM, PhD)
Histopathological findings:
There is moderate irregular acanthosis that extends to follicular infundibula and is accompanied by mild spongiosis. Follicular isthmuses are severely infiltrated by the lymphocytes, histiocytes, neutrophils, and few eosinophils and multinucleated giant cells and the inflammatory infiltration is extending to the infundibulum. Parts of the follicular wall are widened due to accumulation of mucin (clear/basophilic spaces). Follicular atrophy is moderate to severe; normal anagen hair follicles are interspersed, particularly in less inflamed lesions. Moderate numbers of lymphocytes, histiocytes, neutrophils, and plasma cells surround hair follicles and infiltrate the superficial dermis. The histopathological features are similar in all the examined samples.
Diagnosis and Comments : The histopathological findings are compatible with the “Degenerative mucinotic mural folliculitis in cats”.

6 DMMF 1

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Picture 6 (6.1-6.3 pictures) Dimitra Psalla, DVM, PhD
Severely infiltrated Follicular isthmuses by the lymphocytes, histiocytes, neutrophils, and few eosinophils and multinucleated giant cells. Inflammatory infiltration is extending to the infundibulum. Accumulation of mucin. Follicular atrophy is moderate to severe. Moderate numbers of lymphocytes, histiocytes, neutrophils, and plasma cells surround hair follicles and infiltrate the superficial dermis.

Therapy continuation following the histopathology results:

The cat was started on oral prednisolone 3 mg/kg q24.Tapering off the prednisolone after 75% of the skin lesions had resolved and switching to cyclosporine, to avoid longer term adverse effects of corticosteroid treatment.

 

 

 

7_1 One week after the start of prednisolone

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Picture 7(7.1-7.3 pictures) – One week after the start of prednisolone.

Supportive therapy included: Once weekly bathing with Clorexyderm ICF shampoo (4% chlorhexidine); Ectoparasite treatment with Stronghold plus (Zoetis) every 4 weeks; Purina Pro Plan veterinary diets HA Hypoallergenic and supplementing this with 4 drops YuMEGA cat once daily.

To stop the cat from reaching her skin and further self-mutilation, caused by the severe pruritus she was experiencing, she was dressed in a suit. She readily excepted the suit and wore it without any problem.

8_1 Two weeks after the start of prednisolone

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Picture 8(8.1-8.3 pictures)Two weeks after the start of prednisolone.
Fur started regrowing on her head, body and legs.

There was a significant reduction in skin hyperpigmentation, scaling and crusting on the dorsum.
Gradually the pruritus decreased and the cat became more friendly, more active and was no longer apathetic.

After 3 weeks the prednisolone was tapered off gradually to an anti-inflammatory dose. (The oral prednisolone was decreased with 0.5 mg/kg every 5days, reaching 0,5 mg/kg q24h and finally after 5 days set on 0,5 mg/kg q48h).
Once the prednisolone dosage of 0,5 mg/kg q48h was reached, the cat was started on cyclosporine (suspension) 5mg/kg PO q24h simultaneously, for a duration of 10 days. Then the prednisolone was discontinued and the cyclosporine dosage increased to 7 mg/kg PO q24h.

9-1 Four weeks after the start of prednisolone

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Picture 9(9.1-9.5 pics.)Four weeks after the start of prednisolone.
Mila is much livelier and her fur is regrowing. However there are moments she is intensively licking herself, causing new skin lesions.

 

 

 

 

 

 

 

 

 

 

 

 

10_1 Two weeks after start of cyclosporin

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Picture 10(10.1-10.3 pics.)Two weeks after start of cyclosporin.
Mila while on cyclosporine – visibly improved. No more alopecia, no longer itchy and no new skin lesions.

 

 

 

 

 

 

 

 

11 Three weeks after start of cyclosporin-1

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11 Three weeks after start of cyclosporin-2

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11 Three weeks after start of cyclosporin-3

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Picture 11(11.1-11.6 pics.)Three weeks after start of cyclosporin.
Mila was feeling much better and was discharged after 12 weeks of inpatient care. She was now being cared for in a single-cat foster home. After discharging Mila she was monitored and followed up closely.
Mila was discharged and after two weeks came for her first check-up.

 

 

 

 

 

 

 

 

12 -1 2 weeks after discharging

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Picture 12 (12.1-12.4 pics.) Mila 2 weeks after discharging.

The cat progressed steadily, with normal fur regrowth on head, body, legs and tail. The skin of the dorsum was still very scaly.
The following supportive therapy was continued and slightly modified: Weekly washing with Clorexyderm 4% shampoo (ICF) , directly followed by washing with Allermyl (Virbac) shampoo. Topical treatment with Dermoscent Spot-on once weekly was added to the treatment protocol. Feeding Purina Pro Plan veterinary diets HA Hypoallergenic, but no longer supplementing with YuMEGA cat.

 

 

 

 

 

 

 

13_1 Mila in her foster home

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13_2 Mila in her foster home

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Picture 13(13.1-13.2 pics.) Mila in her foster home. Mila 8 weeks after discharging

The supportive therapy was continued and oral cyclosporine was reduced to 5 mg/kg q48h for another 2 months.
Her skin and coat were looking great and she was no longer itchy. She became active, friendly and very social.

 

 

 

Case Follow- up
Seven months after her last check-up Mila presented with dyspnoe. Diagnostics showed thoracic effusion and severe anemia. Thoracentesis was performed and she had several blood transfusions. However she didn’t improve. Feline Infectious Peritonitis was suspected. Eventually the decision was made to euthanize her.

Acknowledgments

I am particularly grateful for the cooperation with Dr. Rania Farmaki, Dp.ECVD, DVM and Dr. Dimitra Psalla, DVM, PhD. They provided me with invaluable advice and supported me throughout this difficult but interesting case. I would also like to thank the local charity Redom for their excellent care, trust and financial support. Finally, I wish to thank all my colleagues from the Central Veterinary Clinic in Sofia (Bulgaria) for their assistance.

REFERENCES:
Degenerative mucinotic mural folliculitis in cats- Gross TL, Olivry T, Vitale CB, Power HT. Vet Dermatol. 2001;12(5):279-8
Lymphocytic mural folliculitis and pancreatic carcinoma in a cat Remo Lobetti (Journal of Feline Medicine and Surgery 2015, 17 (6): 548-50)
Thymoma associated with exfoliative dermatitis in a cat. Jacqueline Vallim Jacobina Cavalcanti1, Mariana Pereira Moura1 and Fabio Oliveira Monteiro2 (Journal of Feline Medicine and Surgery 2014, Vol. 16(12) 1020– 1023)
First Case of Degenerative Mucinotic Mural Folliculitis in Brazil- Reginaldo Pereira de Sousa Filho, Veronica Machado Rolim, Keytyanne de Oliveira Sampaio, David Driemeier, Marina Gabriela Monteiro Carvalho Mori da Cunha, Fernanda Vieira Amorim da Costa
An anatomical classification of folliculitis-Gross LG, Stannard AA, Yager JA. Veterinary Dermatology. 1997;8147-156.

WSAVA and The Webinar Vet Collaboration Offers Free Access to Virtual Congress 2020

logo-white-backgroundArtboard-1The World Small Animal Veterinary Association (WSAVA) and The Webinar Vet have joined forces to offer free access to Virtual Congress 2020 to WSAVA members from countries in which companion animal practice is still developing. Discounted registration will also be offered to all other WSAVA members.

 

The Webinar Vet’s Virtual Congress is the world’s largest online veterinary congress. The 2020 Congress will take place on February 1 and will include webinars from global experts on a comprehensive range of topics, including companion animal medicine and surgery, dermatology, emergency medicine and veterinary wellness.

WSAVA works to enhance the clinical care and welfare of companion animals globally, representing more than 200,000 veterinarians around the world through its 110 member associations. Its core activities include the creation of Global Guidelines that set standards for veterinary care in key areas of practice, including nutrition, pain management and welfare.

 

Anthony Chadwick

Dr Anthony Chadwick

Set up by British veterinarian Anthony Chadwick BVSC Cert VD MRCVS to make continuous education (CE) easier, more accessible and affordable, The Webinar Vet is the largest online veterinary community in Europe and is rapidly extending into the North and South America, Asia and Africa.

 

Commenting, Dr Chadwick said: “The Webinar Vet aims to help veterinary healthcare team members to become more confident in their practice and to fit their learning into a busy life in the profession without having to take time out of work or to travel.

 

“Thanks to all the tickets sold to developed countries over the last five years, our 1-4-1 initiative, under which we donate a ticket to one veterinarian in a developing country for every ticket we sell, has already provided free access to Virtual Congress to more than 5,000 veterinarians from developing countries as part of our mission of making CE accessible to all. We hope that by partnering with the WSAVA we can increase this ten-fold and we are delighted to offer all of its members from developing countries free access to the vast array of learning on offer at the event.”

WSAVA President Dr Shane Ryan said: “Increasing access to veterinary CE is the most effective way to advance the skills and knowledge of veterinarians around the world. Online CE can be an affordable and convenient option for our colleagues in those countries where traditional CE access is limited. We anticipate that many of our members will take up the offer of free or discounted access to Virtual Congress 2020 and so take advantage of the great learning on offer.”

 

Record-breaking VET Festival Champions Wellness

Noel Fitzpatrick-minNotching up record delegate and exhibitor numbers for 2019, this year’s VET Festival, received an overwhelmingly positive response from delegates for the calibre of speakers and entertainment.  The event took place at Loseley Park, Guildford on 7-8 June.

With wellness a strong focus for VET Festival, the Wellness lecture tent was packed for Lara Heimann, an American who has achieved global recognition for her unique vinyasa yoga style and regularly leads international retreats and workshops.  Many delegates took their wellness into their own hands by visiting the Wellness Hub for a massage and yoga session while the Family Hub was busy throughout the two days.

Continuing the wellness theme but also embracing eco concerns, event sponsor MWI Animal Health offered delegates the opportunity to use their own energy by cycling on an exercise bike to create a fruit smoothie.  On the Friday night, delegates, many in 80s costumes, partied into the night with live music from MadHen.Vet Festival 1-min

Clinical speakers received with particular enthusiasm included Dr Ronaldo da Costa, Professor of Neurology and Neurosurgery at Ohio State University, USA, and Laurie Edge Hughes, a veterinary physiotherapist from Canada.

Professor Noel Fitzpatrick said: “It is a real joy to see the VET Festival growing and growing, not just in physical size, but from the immense goodwill that radiates from it. The weather didn’t get in the way of the wellness and there was nothing rainy about the atmosphere at VET Festival – in fact I think that the rain brought us closer together.

“I set out to build a community of compassion for our profession and I genuinely felt that there was a tangible sense of togetherness. There were loads of great conversations with each other and with the exhibitors. The educational content really was world class and the tents were packed. I hoped that VET Festival would be a breath of fresh air, where having an education event outdoors – combined with a focus on wellness of body and mind for all of us – could help vet professionals to be the very best that they could be – and so serve our patients better.VET Festival 2 - CPD-min VET Festival 3 - delegates-min

“Everyone there was part of something innovative and refreshing I felt – the delegates, the exhibitors, the team who have worked year-round to create the event, and the fantastic speakers. I’m very grateful to all of them and I sincerely hope that this feeling remains strong for each and every one all year round. The resonant theme this year was ‘kindness’ – to ourselves, to each other, to the families of animals and the animals we are lucky enough to take care of. Nobody is a nobody at VET Festival, and never will be. In that field, we’re all equal, no matter what we do in the vet profession – we all matter – we all want the same thing, which is wellness for each other and the animals we serve – and importantly, we’re all in it together for the greater good, rain or shine.”

Nicole Cooper, Managing Director, Events Division, Fitz All Media, said: “We are all delighted by the support of the industry and welcomed over 1,900 delegates, a 12% increase and 60 exhibitors – a 28% increase on 2018. VET Festival continues to grow because its unique format, half top-flight congress, half festival, offers a laid back and fun environment in which delegates can learn, catch up with friends and have fun.  We’re delighted with the response to this year’s event and are already planning to make next year’s event even better.”

 

Dermoid in eye of a dog

_SGD7444Dr Ivaylo Antonov

Varna,Bulgaria

 

 

This is the story of Josi. She is a female Pomeranian dog. She has a long history of epiphora, blepharospasm and ocular discomfort.

She has gone several treatments before including surgery of the eyelids with mixed success.

Josi is a well monitored patient with all his dewormings and vaccinations on time.

 

Josi was presented for second opinion for ocular exam and consultation.

 

On the physical exam I noticed much more pigment on the fur under the right eye.20190607_102249-01

With the direct ophtalmoscope I saw some hair in the right eye. Near the limbus there was a dermoid mass with very small size and 3 hairs growing on the cornea.

 

Then I did Jones test of the both eyes with some fluorescin stain and it was negative for more than 60 seconds. The STT time of the left eye was normal 20 mm / min.

Both eyes were negative for ulcers.

 

So in this case I decided to do keratotomy and to remove the dermoid from the right eye.20190607_105434-01

Meanwhile I did nasolacrimal flush of the ducts in the both eyes.

The dermoid was removed using Beaver scalpel blade and than on the after exam I noticed second dermoid in the conjunctiva under the upper eyelid.20190607_114715-01

 

So the second dermoid was resected and removed with scalpel blade.

Than I did nasolacrimal flush with IV catheter.

So Josi was sent for home management with some local Tobramycin drops and some hyaluronic gel for the cornea to heal fast.

Recheck will be done after 5 days.

Dr Cristian Marinescu- a man, a vet who try to change the management of veterinary clinic in Romania and not only

1. Who is Cristian Marinescu?61760359_2342641659342768_1709544142272462848_n
I am first of all a Vet, a member of this beautyfull community of veterinarians. I graduated Vet school in Bucharest in 2006 and in 2015 the Law school at Romanian-American University. All my carrier I was around sales, communication and people.  I have a passion for everything related to business and people management. And not in the end, I am a father and a husband :-).
2. Why you create VBA?61854886_681095332316340_3293742889531604992_n
I start to travel from one vet clinic to another since 2012 and I saw that everybody was talking or compleining about issues related to management and miscommunication. Take in consideration my experience I knew that together we can create a community and a network of people interested in this topic.  A lot of vet colleagues encourage me to start this project and give support for this. I could say that VBA is a project of veterinary community in Romania. I would like to mention the big support from dr. Nicolae Valentin and especially from Adrian Radulescu.
3.Why veterinarians nowaday need anoher kind of education as business management?31388060_444428835982992_1750491995400306688_n
Simply because in our activity 50% is medical knowledge and 50% is something else related to communication , people interactions and management. The Vet school prepare us how the deal with diseases, not with people or how to communicate between us or with pet owners or farms. Noone mentions nothing about business knowledge, and a big % of people after graduate,when they will start their own business. So….the NEED is clear.
4.What are your goals for the future?24991084_388955414863668_2847536289487733838_n
First, to make our community to understand that they need also to educated themselves in directions like : communication, people interactions, marketing and finance. This will not only help only their professional goals but will also impact their personal wellbeing. I know this because I experienced it and I know that vetlife is nice easy one. Especially for work&personal life balance.
Second, I would like VBA to become a relevant provider of help and knowhow in this area.
And in the nearest future, we will try also to provide individual support at vet clinic level. We start a pilot project with couple of clinics in Romania and I hope soon we will be able to extend the community.
5.How people from abroad can attend your events?61247103_681094738983066_1360617984078381056_n
Invite us in their country to see if  we have what to say or give , it will help them or not. I promise it will.
6.What is your oppinion about Vets on The Blakans?36041277_1690969690950908_4742900533495332864_n
I think is a great ideea that need support. I work also in some projects at european level. And I know that vets from the Balkans have a lot of similarities and we can find projects that can be run in our region ,that will increase the know how and the image of vets from our region all over the world.
So, keep up the good work. You also inspire us to start vetbusinessacademy.11986326_880349785387384_9043704249649535138_n