Non-epidermolytic ichthyosis in rabbit- case report

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Dr Spas Spasov

Dr Spas Spasov
United Veterinary Clinic
Bulgaria
Varna.

 

   Case presentation:

Rabbit nine months old , female  entire.She was presented  to the clinic with a history of progressive hair loss over the last two months. The rabbit came as a second opinion from another practice where she was treated for mange mites for a month with Doramectin and  a month treatment for dermatophytes without result of both treatments.
A clinical examination found:
Generalised alopecia, yellow crusty skin,pododermatitis over the pelvic limbs and  abnormal skin elasticity.

 

 Diagnostic approach.

*microscopic examination- Negative for ectoparasites
*Punch biopsy-  There is  diffuse thickening of the  epidermis characterized by laminated stratum corneum with disproportionate  thickness than the underlying nucleated epidermis. Focal parakeratosis is also present. The epidermis is mildly to moderately achantotic. The follicular infundibulum is greatly distended by keratin. The granular layer of the epidermis exhibits different sizes of keratohyalin granules (hypergranulosis). Superficial dermis  lacks  follicular and adnexal structures. Few intact sebaceous glands are present. There is  no evidence of  neoplastic cells, parasitic/mycotic/fungal or bacterial elements in the examinated sections. The histological appearace is consistent with non-epidermolytic ichthyosis.spas-1spas

 

   Treatment:

Treatment was undertaken to support body hydration, using megaderm( omega three  and six fatty acids,linolenic acid,GLA,EPA,DHA )in order to  strengthen the skin structure.  pain medication(meloxicam 0.2mg/kg ), and antibiotic therapy(Procaine penicillin 150,000 IU per mL. Benzathine penicillin 150,000 IU per mL. ) to control the bacterial infection of the feet.
There was an option for treatment microneedle therapy, but the sample for histopathological study did not showed hair follicles.

After one month of therapy the  rabbits skin had  significantly improved.  However pododermatitis had worsened and abscesses had formed  over the limbs.
Due to failure of antibiotic  therapy and deteriorationof pododermatitis, the decision was to euthanase the rabbit.

 

   Discussion

Ichthyosis is a inherited genetic disorder that occurs both in humans and in animals characterized by diffuse  keratinization  of the surface layer of the skin.  The disease develops as a result of gene mutation that is passed from generation to generation.
Ichthyosis studies are more for dogs and cats, and not so much about rabbits. There is not much information regarding the classification of rabbit Ichthyosis and details of treatment or maintenance therapy.
Affected BreedsThe West Highland White Terrier and the Golden Retriever are the breeds most predisposed to this disease

VOG? WHO ARE VOG? Meeting with 4 real orthopedic vets from The Balkans

 

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https://www.vog-vet.org/

Dr Mario Kreszinger, Croatia

Dr Vladislav Zlatinov, Bulgaria

Dr Marko Novak, Slovenia

Dr Zoran Loncar, Serbia

 

  1. Who are you?

 

 Dr Zoran Loncar:

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Dr Zoran Loncar

My name is Zoran Loncar I am a vet who dedicated his professional life to improve the knowledge and to push the borders of veterinary science.

 

 

Dr Vladislav Zlatinov:

I graduated from University of Forestry- Sofia, in 2005. I started externship attendance in a private small animal practice quite early-since my second year. Right now I am one of the chief surgeons in the Central Veterinary Clinic, Sofia- one of the busiest 24/7 practices in the region. Working already 6 years in this sophisticated facility, I had the chance to master skills and advance in the field of small animal surgery, and particularly orthopedics. I am happy to be involved in BAVOT (Bulgarian Association Veterinary Orthopedics and Traumatology)- the very first specialized guild vet organization in BG. We feel proud to be quite active and have organized some really great seminars, already.

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Dr Vladislav Zlatinov

At present, my focused interest is regional implementation of advanced care standards in the veterinary orthopedics- popularizing the routine use of minimally invasive technique (arthroscopy), Canine Total Hip Replacement and one special pioneering project- “Feline amputee prosthesis”.

 

Dr Marko Novak:

marko-poza

Dr Marko Novak

I am a vet working in a private small animal clinic Klinika Loka in the city Škofja Loka in Slovenia. I graduated in 2006 on School of Veterinary medicine in University of Ljubljana. Since than I finished multiple courses in Orthopedics and Neurology including four years of an ESAVS program, AOVet courses, ESVOT etc. Most of my today’s work are referring patients from other clinics. Concurrently I am a board member of VOG and a treasurer of VOG and active speaker and table instructor on Orthopedic courses.

Dr Mario Kreszinger:

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Dr Mario Kreszinger

Prof. Mario Kreszinger, DMV, MS, PhD
Veterinary Faculty, University of Zagreb

 

 

 

 

 

 

  1. What is VOG? What VOG means to you?

    vog

    VOG

 Dr Zoran Loncar:

VOG is a newborn that was created out of the frustration of the vets that are dealing in every day practice with neurology and orthopedic cases.

The idea was born after continuing education that we organized all around the world.

What we realized is that probably majority of orthopedics surgeries are done by general practitioners. The problem is that they don’t have guiding and possibility always to improve the skills.

This is what we found as a major frustration not only in east countries but also in developed ones. VOG role is to connect the knowledge, mentorship and to come close to the people who do orthopedics and neurosurgery in the practicesDr Zoran Loncar, Serbia.

Dr Vladislav Zlatinov:

When I joined the Veterinary Orthopedic and Neurology Group (VOG), I felt very thrilled. This newborn professional organization will face a bright future. It could not be different with so great open-minded co-founders, sharing the same sincere intentions.

The cradle of VOG may be Eastern Europe, but it is not confined geographically. It is open for all colleagues, interested in never ending process of learning and sharing. Standing for the evidence based approach, the group will encourage members to involve in clinical researches, too.

Nevertheless, the organization is focused just on veterinary orthopedics and neurology, the topics are still greatly diverse and laborious to explore. Unifying and sharing experience is the “enzyme” that fastens the growth of any vet community knowledge. Initiative like VOG may only make us better professionals and is a great chance for many new friendships to be started.

Dr Marko Novak:

A group of enthusiastic veterinarians who want to broaden the “knowhow” to other enthusiastic veterinarians in the region. By learning we evolve, by learning from those farther ahead and following “lege artis” we prosper as veterinary society.

Dr Mario Kreszinger:

VOG is regional orthopaedic Association established to promote and  organize orthopaedic, neurological and traumatological education with objective to connect the members and provide cooperation among each others. Establishing close contact and thrue friendship is one of main goal.15179126_666002020248637_6675110090243320994_nvog-1

 

  1. What means to be an orthopedic vet nowadays?

 Dr Zoran Loncar:

To be and orthopedic surgeon nowdays means that you learn and improve your knowledge and skills on a daily bases. The orthopedics is a mixture of knowledge and manual skills. That needs every day practice. On the other hand there is always a need to follow the new evidence based data in order to be updated.

Dr Vladislav Zlatinov:

The veterinary orthopedics was and still is tough field to work in, sometimes with quite ungratefully unforgiving obastcles. I have seen these: the vet staff staring at a radiograph with broken plate and shaking their heads meaningfully. Rarely you can see this with soft tissue surgeons’ work J

Indeed, the veterinary orthopedic surgeon is a person with serious proffesional responsibilties. Often, his work is not a matter of death or life. But almost always it affects the animal’s quality of life for many years. The job conatains a lot of not so obvious ethical issues behind many clinical decisions taken.

Speaking about “Nowadays”, there is a burst of companies that produce orthopedic implants and tools. Fortunately most of the products are faboulosly good and gives us a chance to help aniamls with “untreatable” conditions in the past. But for me I this also may raise a danger. Just because of a commercial emphasis, we can start easily implement new products without any evidence based justification. For me, there should be a carefull and responsible approach to the “ Fancies” in the sea of products offered to us.13245311_10206690540562329_7499136046518137278_n11986412_10153245936142960_4086193550529382361_n

Dr Marko Novak:

Well for one thing I am absolutly sure it takes a whole person ready to work, ready to work even more and finally uncompromisingly ready to work some more. :) And after you are finished working there comes a night shift… It takes a very, very loving and understanding wife. 😉
There comes a day when you want to quit but it always comes the next day when you want to get back and help some more. But I assume it is the same in any profession.

Dr Mario Kreszinger:

Being an Orthopaedist is one of the highest step in Veterinary speciality.

 

  1. What do you think about the level of veterinary orthopedic on The Balkans?

 

 Dr Zoran Loncar:

Unfortunately the level of knowledge at Balkan countries is low. The reason is old fashioned veterinary schools, the lack of continuing education at the field.

Dr Vladislav Zlatinov:

Our present status has a lot to do with the historical development of the region. I guess it is right to say that I am part of the “new generation” vets. At least in Bulgaria, this generation inherited the experience of very few small animal practitioners, working in the 90-ies. Unfortunately we cannot say that we have a long medical tradition in small animal care, as most Western Europe countries. But.. one way or another a new era has started. For me in the last ten years, the Balkan veterinarians put a hard work and did a huge development in every aspect of their work. The market was opened for Eastern Europe, the pet owners just demand and receive much better care. This includes also us- the orthopedic fellows in the region. I think that we already do quite a good job, with a real potential to shine for excellence

Dr Marko Novak:

I believe it has tremendously spiked in the last few years. There are still reserves, which is good. But what is most important is that people are more than willing to learn. Big thanks to many “good guys” who started teaching especially great orthopedic specialists like Allesandro Piras and Bruno Pierone, Massimo Petazoni etc.

Dr Mario Kreszinger:

The level is right now in extremely high learning curve, coresponds with highly developed western Countries.

 

  1. Your ” golden rules “to be professional orthoped ?

 

 Dr Zoran Loncar:

Learn, practice, learn, control your ego, learn, think out of the box and at the end, learn.
Dr Vladislav Zlatinov:

To be a good orthopedic, demands a lot. Vast stock of knowedge, skilled hands,  attention to the small details. Usually it takes so many years to develop qualities, a great determination is needed to bare the road. And the learning never stops. But this is the common knowledge. I am a believer that to become an especial orthopedic, you should be able to think “out of the box”. We should follow the great minds’ work, but there is always a place for personal contribution.  We should dare to fight paradigms; this is an essential “fuel” for medical science evolution.

Fianlly, our profession never works “good” without a sincere empathy to animals and fare etthical attitude to them and their owners15181147_10154094081597960_611406697039840077_n15181178_10154094095972960_9093230231692850684_n

Dr Marko Novak:

Be precise, train, learn, ask, always try to find mistakes and be better the next time, be objectively sharp to your work, take time for your family and for yourself. Charge your batteries regularly.

Dr Mario Kreszinger:

Be competely dedicated to your job with all efforts and breit knowledge.15181250_10154094080692960_1411178589932869639_n

 

 

  1. What do you think about  the online journal Vets on The Balkans?

Dr Zoran Loncar:

Vets on the Balkan is refreshment and result of people with good energy and wish to improve our region. We live in small countries and if we cooperate together we have better chance to improve ourselves.

 

Dr Vladislav Zlatinov:

It is so great to have such a professional forum, connecting Balkans (and not only) vets! I literally see people from different countries in the region, getting to know each other because of your journal.  The “Vets on The Balkans” deserve all the compliments for your great positive initiative and work!

Dr Marko Novak:

I came across VTB when I was scrolling down the facebook and I saw these interesting articles from guys doing great job. I think it is one of those starters that help people to become better at what they do.

Dr Mario Kreszinger:

It very usefull easy approachable source of infos we need in everyday Jobs routine.12072565_1159080807469853_2466737431594238709_n

 

 

 

 

Bronchial foreign body in feline patient – case presentation

emil

Dr Emil Ofner

Authors : Emil Ofner, DVM

                Marina Barižon, DVM

                Small Animal Veterinary Clinic More, Šibenik, Croatia

 

 

Bronchial foreign body in feline patient – case presentation

 

Introduction :

 

Male cat ( 4.5 kg ) with chronic gingivitis-stomatitis-pharyngitis syndrome was admitted to our clinic because of aspiration of loose tooth 15 days ago. At that time, the owner told us that cat first started to cough suddenly and because of coughing he received antibiotics. After a course of antibiotics, cough started to decrease, but didn’t stop completely. Thorax x-rays done on next physical examination revealed tooth inside the lungs.

 

 Case presentation :

 

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At the time of admission cat was stable with no apparent breathing problems. The cat was afebrile and blood work revealed elevation in leukocyte number. On x-rays we could see that the tooth (premolar) was stuck somewhere in the right caudal lung lobe (Picture 1). The x-ray scan also demonstrates a radio opaque area around the tooth, which represents fluid filled dilated bronchi ( Picture 2).

 

 Equipment and Methods :

 

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After initial examination, we decided to do a bronchoscopy to attempt endoscopic tooth removal. After intubation Olympus fiberoptic paediatric bronchoscope (3.6 mm diameter) with 1.2 mm working channel was introduced into the trachea (Picture 3 and 4). In level of segmental bronchi of right caudal ( posterior ) lung lobe we located bronchus plugged with white thick purulent material. In order to liquify this purulent material for aspiration we first lavaged it with warm saline. After successful aspiration of pus tooth was finally revealed. Grasping of the tooth was done with 0.9 mm diameter alligator forceps (Picture 5 and 6). After removal of the tooth rest of the pus was aspirated.

 

Discussion :

 

In cats most aspirated foreign objects will get trapped in the right caudal lung lobe. In our opinion the reasons for that are difference in right and left lung volumes, diameter of principal bronchi and bronchial tree anatomy. In cats average diameter of left principal bronchus is 6.0 mm, while the average diameter of right principal bronchus is 7.34 mm. Also, because of bronchial tree anatomy in the cats bronchial pathway which leads to right caudal lung lobe is more straight in comparison to left lung bronchial tree anatomy.

 

Conclusion

 

Majority lung foreign bodies in cats will be trapped somewhere along the right bronchial three because of anatomical differences of right and left lungs.

 

Cats with chronic gingivitis-stomatitis-pharyngitis syndrome may have an increase chance in aspirating foreign objects. Sudden attack of cough in cats with gingivitis-stomatitis-pharyngitis syndrome maybe can be aspirated foreign object.

 

Chronic lameness in a one and half year old German Boxer

marko-poza

Dr Marko Novak

Marko Novak, dvm

Department of Orthopedics and Neurology

Klinika Loka, refferal small animal clinic, Škofja Loka, Slovenia

 

Luna is a lively 1,5 year old German Boxer, weighing 28 kg. She was presented to us with chronic intermittent right front leg lameness of grade II lasting for almost a year. Her owners noticed a lump on her medial carpal site. The dog had a history of a car accident when she was only six months old. At that time Luna was treated conservatively with NSAIDs and rest. Luna became worse after time and she was reffered.

 

Anatomy

 

Carpal joint is a hinge joint. It is composed out of six carpal bones that are arranged in a proximal and distal row forming three levels of joint spaces; the antebrachiocarpal where most of the joint motion takes place, the middle and the carpometacarpal space.

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Image 1: Anatomy of carpal joint

Joint`s stability is provided by ligaments of the carpus. Carpal ligaments are very stiff and short mostly crossing only one joint level. (image 1), (1)

 

Clinical exam

 

Luna was afebrile, lame on her right front limb, grade II. Her right front limb was shaking while standing and her carpal joint was slightly flexed. Right carpal joint was obviously swollen on the medial side. Carpal range of motion was mildly decreased in flexion, distinct pain was observed on flexion of the carpal joint and by pressing on the firm medial swelling. No apparent instability could be observed while doing clinical exam but only slight valgus. The rest of physical and neurologic exam was normal.

 

Diagnostics

 

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Image 2 : orhogonal view of carpal joints

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Image 3: orhogonal view of carpal joints

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Image 4: stress view with apparent medial instability

Orthogonal and stress radiograms of both carpal joints were made and beside increased opacity of medial carpal soft tissue, extensive mineralisation near medial carpal compartment was noticed most apparently on the craniocaudal view. Stress radigraphs showed moderate instability on the medial side of all carpal joint levels. (image 2 to 4)

 

Therapy

 

Decision in making the right therapeutic approach was difficult. After taking under consideration all of the data especially chronicity of the problem, we advised the owners do a pancarpal arthrodesis. Chronic instability is by far the most common indication (in 76% of the cases) for (pan)carpal arthrodesis. (2)

We could also try to do a synthetic ligament reconstruction but since the problem was present for almost a year, the instability was present in multiple medial carpal levels and the dog did not improve, arthordesis seemed like a prudent decision.

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Image 5 : postop, with slightly suboptimal compression, but due to hybrid locking plate it healed uneventfully

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Image 6: postop, with slightly suboptimal compression, but due to hybrid locking plate it healed uneventfully

Hybride pancarpal arthodesis locking plate (Veterinary instumentation)  (2,7 – 3,5) was used for the procedure, taking care to cover 75 % of third metacrapal bone, which resulted in a strong stabile environment and rapid healing with quick return to good postoperative function. External coaptation with a splinted bandage added extra support for the first three weeks after procedure. (Image 5 and 6)

Follow up

Luna did have some problems with compensation for the first two weeks after the splint was removed, but than started to improve consistently. Follow up xrays at 4 and 8 weeks were unremarkable.

 

Discussion

 

Luna is a very active young German Boxer who was intermittently but progressively lame for the last year. A chance to reconstruct the torn medial ligaments of carpal joint was probably unknowingly lost when the instability was missed at the first veterinary visit almost a year ago.

Chronic instability is seldom succesfully solved by synthetic reconstruction which purpose is to achieve good and functionally strong stability. Unsatisfactory surgical stability again leads to pain and degenerative joint disease.

Dispite apparent instability prooved on xrays, we were not sure how much it contributed to a development of chronic tenosynoviitis but we presume that the proximity of two structures resulted in abductor pollicis longus tendinopathy as well or differentially looking could also be a sign of an old avulsion fracture.

 

Literature:

1 Fractures and Other Orthopedic Conditions of the Carpus, Metacarpus, and Phalanges, Part II: fractures and orthopedic conditions of forelimb, in BRINKER, PIERMATTEI, AND FLO’S HANDBOOK OF SMALL ANIMAL ORTHOPEDICS AND FRACTURE REPAIR, Fourth Edition, 2006, by Elsevier Inc., page 382, chapter 14

 

2 Pancarpal arthordesis in a dog: a review of forty-five cases, Robert B. Parker, DVM, S. Gary Brown, DVM and Alida P. Wind, DVM in American Collegue Of Veterinary Surgery.  

 

 

Green coat, hypothyroidism,lymphoma and carcinoma of the sebaceous glands.

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Dr Spas Spasov

Dr Spas Spasov

Unites Veterinary Clinic

City of Varna, Bulgaria

 

   Case presentation:


    A twelve year  old female, entire Labrador Retriever, presented with skin ulcers over the low lid region of the eyes, feet, face, back and legs.
According to  the owners  the animal has become more lethargic, less active  on walks and not as playful in the last twelve months.They attributed this to the age of the animal.
At referring vet took a  blood sample to do hematology and biochemistry, which did not show abnormalities. They  treated the animal with amoxicillin with clavulanic acid.123

   Diagnostic approach.


*microscopic examination- Negative for ectoparasites
* impression smear- Colonized neutrophils with cocci bacteria.
* microbiology- Staphylococcus aureus pure culture sensitive to amoxicillin with clavulanic acid* Level of TT4 in blood was Low <6 nmol/L

456
   Treatment:


   * Local therapy shampoo containing benzoyl peroxide. Name(Peroxyderm)
* Systemic antibiotic – amoxicillin with clavulanic acid.
* Levothyroxine 0.2mg / kg once daily.
  Follow up:
Two weeks after starting treatment, the owners reported that  Cleo feels much better  and has increased her exercise activity and she is playful.  There were fewer skin ulcers predominantly over the front legs and around the eyes but  ulcers were superficial.
The follow up examination showed a shiny healthy coat,  with  few skin lesions on the legs.

The only thing that worried the owners was that Cleo’s neck had turned green.
Blood was taken to test her TT4 levels and to determine whether we need to change the dose of levothyroxine.
I believe the reason for the green coat is probably heavily chlorinated water and frequent bathing at the beginning of therapy. (This is not proven by research).1112
The levels of levothyroxine were low at 11nmol/L  and so there was a need to increase the dose.
Due to personal reasons, the owners could not make a follow up consult for another month.Their next visit was actually about three months later and the situation with Cleo was extremely poor.131415
The skin ulcers were much larger and bleeding, and her lymph nodes were double the size. Ulcers on her face were approximately 5cm in diameter.
An abdominal ultrasound was performed and showed enlarged mesenteric lymph nodes. Fine needle aspirates of the enlarged lymph nodes and punch biopsies of the skin were taken at this time.
The result of the FNA revealed- The cell population is homogeneus excibiting several blastic cells, with granular cromatin and inconspicuous cytoplasm. Several mitotic figures are also present. Random, plasma cells are observed accompaniating  the neoplastic lymphoblasts.
The result of the skin punch biopsy revealed changes characteristic of Sebaceous carcinoma.
Based on the new evidence and the results, chemotherapy was recommended but the owners declined.
They agreed to a less aggressive therapy with oral prednisolone 2mg/kg , levothyroxine 0.3 mg/kg and gabanevral 10mg/kg  and local therapy with prednisolone.
Six months later, Cleo’s disease was stable, with significantly smaller lymph nodes and skin lesions.

Case 3 – Ruptured urinary bladder with radiopaque calculi free in the peritoneal cavity.

9 years old mix breed dog, F

 

History: not urinating for 24hours, apathy, lethargy

 

Technique: X-ray

 

Findings: Loss of serosal detail especially in the ventral abdomen.

There are multiple radiopaque mineral foreign bodies of varying sizes in the ventral abdomen not included in the digestive tract.

The urinary bladder it’s only partially visible.imaging-1imag-2

 

Conclusion: ruptured urinary bladder with radiopaque calculi free in the peritoneal cavity.

Digestive Endoscopy and Surgery Center on The Balkans! Such a nice place!

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Dr Constantin Ifteme

14292382_1587255881569229_4642655980848598184_nWhen we see something like this on The Balkans, we are so proud. 1st September was the grand opening of the biggest Digestive Endoscopy and Surgery Center on The Balkans. The guest was Dr Fausto Brandao who is emblematic vet in VeterinaryEndoscopy.

The owner and the main vet  is Dr Constantin Ifteme who is 36 years old and it is really impressive, so young and so successful. He creates his own team, full of professional and passionate to veterinary medicine. This clinic and Dr Constantin Ifteme are the evidence that veterinary medicine on The Balkans go straight ahead. They also include in their practice laparoscopic surgery, laser surgery and they have Fluoroscopy machine.14142055_1066264370118006_2189827722538370100_n14141528_1066260393451737_7711639442555236187_n14183920_1066268490117594_1144506886854683956_n14184405_1066259313451845_3993920618069092368_n

Fluoroscopy is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope allows the doctor to see the internal structure and function of a patient, so that the pumping action of the heart or the motion of swallowing, for example, can be watched. This is useful for both diagnosis and therapy and occurs in general radiology, interventional radiology, and image-guided surgery.

 

The good news is in the center have space for courses and workshops and I am sure most of you will visit this wonderful place and have a nice time with Dr Ifteme and his such a nice team.14232497_1066260993451677_8210426798575691986_n14199686_1066271100117333_3275478967349101097_n

 

The best news is that Dr Constantin Ifteme will support our Endoscopy section and as well the center is included in our project Learn and Travel with Vets on The Balkans.13895367_1576568542637963_3712823064786795165_n14141623_1583687971926020_2868042467176127778_n

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The team of Vets on The Balkans express their gratitude to Dr Ifteme and his beautiful and kind wife for their support of the journal, for the real friendship and hospitability.

 

 

Diagnosing the allergic patient: a practical approach.

unnamedAlberto Martin Cordero, D.V.M

VETDERM: Dermatologia Veterinaria Especializada.

                Argentina 690, Guadalajara, Mexico

                   vetderm25@gmail.com

Allergic disease in animals and humans is a common condition. In dogs and cats is considered one of the main dermatosis affecting around 10% of the population. It is a pruritic, inflammatory, chronic disease with breed predisposition (1). Understanding the physiopathology and clinical characteristics is mandatory not only for the clinician, but the owner itself, due to the fact, most of the long-term treatment and management it is done by clinician-owner collaboration.

 

First of all, one of the main characteristics we may find on an allergic patient is pruritus. Pruritus is defined as the unpleasant sensation that triggers the desire of itching, this may be manifested as chewing, biting, licking, scratching or rubbing in our patients; due to this manifestations the clinician must be aware that most owners will associate pruritus only with itching, by this matter, a correct approach for the clinical history should be done addressing this questions correctly to include most of the manifestations of pruritus.

 

We must try to obtain a complete clinical history of the patient condition.

 

The second step is to rule out the common causes of pruritus. Bacteria, yeast and scabies may enhance or be the main cause of pruritus in some patients, however, the first two, most of the time have an underlying cause.

 

The clinician must use basic tools like skin scraping and cytology in order to detect secondary infection or scabies.

 

Scabies and allergies

 

Scabies may be a “tricky” condition; is capable of emulate perfectly clinical signs associated with allergic disease, leading to a misdiagnosis and even to therapeutic mistakes. A negative skin scraping is not guarantee of absence of the Sarcoptes mite, by the other way, the chances of finding the mite or its ova are around 30% performing a correct superficial skin scraping technique.

 

Some tips we may use in order to detect scabies are: low response or non-response of pruritus to corticosteroids, positive pinnal-podal reflex, and ear margin affectation.

 

Allergic patients respond fairly well to corticosteroids administration, being one of the most used therapies for short and middle management of pruritus. Its use must be concomitant to cautions by the clinician about side effects. Nevertheless, patients with scabies normally have a poor respond to corticosteroids. The clinician must be aware of the existence of secondary infections by bacteria or yeast, due to the fact they are able to exacerbate itch.19181716

 

Pinnal podal reflex is obtained by vigorously rubbing the tip of one earflap on to the base of the ear for five seconds, and it is considered positive if the ipsilateral hind leg made a scratching movement. On a recent study the specificity of testing for scabies by the pinnal-pedal scratch reflex was 93.8 per cent, and the sensitivity was 81.8 per cent (2). This test is not pathognomonic for Scabies, however is really helpful in determining if we need to establish a therapeutic trial to diagnose scabies.20

 

In the same study ear margin affectation was evaluated 73% of the dogs with scabies had pinnal dermatitis. Crust or desquamation of the ear margin is characteristic of scabies in some pruritic patients.

 

Therapeutic trial in scabies is referred to the administration of therapy for scabies and observation of diminish of the clinical signs to confirm the disease.

 

Once scabies have been ruled out, secondary infections by bacteria or yeast must be eradicated using the respective therapy. Cytology must be performed on the affected areas of the allergic patients in order to detect microorganisms.11

 

            Clinical signs of allergic disease.

 

Dogs and cats manifest differently clinical signs related to allergy. Differentiating a patient with food allergy or atopic dermatitis only with clinical manifestations is not an exact or easy task.10

 

Dogs and cats with food allergy or environmental components of allergy react the same and may have the exact pattern of lesions.15

 

Lesions normally occurring in allergic dogs are: papules, pustules and epidermal collarets characteristics of secondary bacterial infection; ear disease: pinnal erythema, otitis externa; erythema of: periocular region, axilla, ventral neck, chest, flexor surface of the elbow, interdigital areas, inguinal region, perianal region (3).

 

If we carefully perform and examination of the ear canal we may find mild clinical signs of allergic ear disease as react of the ear canal glands, erythema or mild inflammation of the ear canal. The author recommends exploring the ears on all patients suspicious of allergic disease.14

 

Flea allergic dermatitis or a flea component in the allergic patient may show clinical sign on the dorsolumbar region; and in some cases, flea feces “flea dirt” or the flea itself may be found.

 

Some patients may develop moist acute dermatitis “hot spots” on the lateral aspect of the head (this may be related with otitis externa) or in the dorsolumbar region (related to flea allergy); however, we must recall that moist acute dermatitis is not solely related to allergic disease.698

 

Cats may be develop any of the eosinophilic granuloma complex lesions as well as military dermatitis, feline acne, excoriations of the neck and on the back of the head, alopecia by excessive grooming. Secondary bacterial infections are not common in cats as in dogs.12

 

 

 

            Otitis externa in the allergic patient.

 

Otitis externa is defined as the inflammation and subsequent infection of the external ear canal. The causes and factors of otitis externa may be divided in 4 according to a classification proposed by Griffin. Predisposing, primary, secondary and perpetuating factors of otitis externa is the most accepted classification at this moment and is currently used by the author in patient classification.

 

Predisposing factors include: anatomical characteristics of the ear canal, such as hairy or stenotic ears, excessive moisture, and overtreatment with ear cleaners or swabs.

 

Primary factors include allergies, keratinization disorders, autoimmune and immune mediated conditions, endocrine diseases, and foreign bodies. Being allergy one of the main causes for recurrent otitis externa especially in dogs (4).

 

Secondary factors are related to bacteria or yeast infection.

 

Perpetuating factors normally are related to chronic pathological changes of the structure of the ear canal as well as complications within the middle ear.45

 

 

Evaluating level of itch

 

Pruritus level must be evaluated in allergic patients, a visual analogue score published by Hill et al., allows owner to effectively assess pruritus using a scale form 0 to 10 (5). This scale may be used at the rechecks or during the administration of allergen specific immunotherapy.3

 

Favrot criteria.

 

Favrot criteria are useful as a clinical aid in the diagnosis of canine atopic dermatitis (6). Following this criteria in combination with ruling out pruritic skin disease reduce the probabilities of false diagnosis of canine atopic dermatitis. Favrot criteria include:

 

  • Age of onset < 3 years
  • Mostly indoor
  • Corticosteroid responsive pruritus
  • Chronic or recurrent yeasts infections
  • Affected front feet
  • Affected ear pinnae
  • Non affected ear margins
  • Non affected dorsolumbar area

 

Establishing allergic components in the patient.

 

Allergic patient may have an environmental component, food component or flea allergic dermatitis. We must resist temptation to separate allergic diseases in all this major three allowing a patient to be diagnosed as “allergic”. Our diagnostic goal is to identify the allergenic components in the patient, being aeroallergens, food ingredients, flea or insects; separate or altogether in order to create a control plan for each individual (7).alberto 1

 

Patients with non-seasonal pruritus must be suspicious for food allergy, especially if the have gastrointestinal signs present. Questions like number of bowel movements, form of the feces, gases and increase of intestinal noises should be asked to owners. A recent study was able to determine the average number of bowel movements per day as 1 to 3 in 96% of the dogs of the study (8).

 

A correct restrictive diet must be performed in non-seasonal pruritic patients in order to confirm or rule out food allergy. The average length of the food trial is for 6 to 8 weeks (9). During this time, clinician must use hydrolyzed diet, novel protein diet or home cooked restrictive diet with limited ingredients.

 

Hydrolyzed proteins are composed by proteins chemically and physically “broken” in small particles. The smaller the allergen, smaller the capability of the IgE to catch this proteins even if the y are allergic to them. Prescription hydrolyzed diets claim a protein size from 3,500 to 10000 Daltons; novel diets mainly composed by amino acid ingredients claim a size lower than 1000 Daltons. Some studies have evaluated that up to 21% of patients with food allergy may react to hydrolyzed proteins (10).

 

 

The principle of using a novel protein diet is to administer ingredients to which have never be exposed before. The problem with “novel proteins” especially in over the counter pet foods are that the novel ingredients shown are only part of the ingredients contained and common ingredients in pet foods are generally used as additives. The clinician must advise pet owner to read all the ingredients in the dog food in order to avoid previously ingested ingredients. Even tough, another problem is secondary contaminants particles that may be found in “selective ingredients” pet foods as a result of the manufacturing process. A recent study evaluated secondary contamination by PCR and microscopically analysis of several commercial diets used on food trials (11).

 

Home cooked diets with limited ingredients seem, to be the best choice to perform a food trial, however, owner availability to cook for their pets, acceptance by the patient or choose of the correct ingredients are important factors to consider before prescribing this choice.

 

A good, low hydrolyzed prescription diet with small particle size is commonly the best choice to diagnose food allergy in dogs and cats.

 

Pruritus may be controlled the first couple of weeks of the food trials to avoid further injures using shot term pruritic management as short length corticosteroids or oclacitinib to diminish the initial clinical signs. Anti pruritic therapy should be discontinued in order to correctly evaluate the response to the restrictive diet.

 

During the food trial, owner and clinician will observe one of three manifestations: absence, diminish or continuation of pruritus.

 

An absence of pruritus should be continued with a re exposure to the previous ingredients or pet food ingested by the patient, and during the first week, clinical signs must re appear confirming the diagnosis of food allergy.

 

Diminish of pruritus must be addressed as previously stated with a re challenge to pet food, however, in this case, possibility of aeroallergens reaction must be suspected. The patient could be diagnosed as a patient with atopic dermatitis with a food allergy component.

 

Continuation of clinical signs after or during the food trial could lead us in the direction where no food allergy exist, but aero allergens and insect allergen may be the primary allergenic cause in the patient. Re challenge to previous diets is not needed on this case.

 

Allergy testing.

 

Allergy testing is reserved for the elaboration of allergen specific immunotherapy, an effective treatment for hyposensitize patients with environmental allergies. This test may be performed by intradermal application of allergens as well as measuring specific IgE in serum. Allergy testing should not be used with the purpose of diagnosing a patient with canine atopic dermatitis, must be strictly reserved for the elaboration of “allergy vaccines”, that are mixtures of allergens to which the patient is reactive and are applied with increasing concentrations in order to decrease future sensitization.13

 

Establish allergic patient management.

 

A short term, middle and long-term control management for the patient with environmental allergies must be created once we rule out other allergies and pruritic causes (11).

 

Short-term control management of the allergic patient includes:

  • Elimination of secondary bacterial and yeast infections. (identify these by cytology)
  • Short-term control of pruritus with topical or systemic corticosteroids, or oclacitinib administration.
  • Topical therapy with shampoos to control infections or moisturize the skin and coat

 

Middle term control management includes:

 

  • Restoration and improvement of epidermal barrier with essential fatty acids (EFAs) or topical essential oils
  • Prescription diets focused in improving epidermal barrier and diminish pro inflammatory factors
  • Anti pruritic control with Oclacitinib, oral cyclosporine, or corticosteroids (evaluate side effects and monitor the patient)
  • Concomitant use of soft topical steroids like hydrocortisone aceponate (when needed)
  • Topical therapy with moisturizing and epidermal barrier improvement shampoos.

 

Long term control management include:

 

  • Anti pruritic control with Oclacitinib, oral cyclosporine, or corticosteroids (evaluate side effects and monitor the patient)
  • Concomitant use of soft topical steroids like hydrocortisone aceponate (when needed)
  • Topical therapy with moisturizing and epidermal barrier improvement shampoos.
  • Administration of allergen specific immunotherapy based on allergy testing (in vitro or intradermal)
  • Antimicrobial therapy for bacteria and/or yeast (if needed)

 

REFERENCES

 

  1. Hillier, A., & Griffin, C. E. (2001). The ACVD task force on canine atopic dermatitis (I): incidence and prevalence. Veterinary Immunology and Immunopathology, 81(3-4), 147–151.
  2. Mueller RS, Bettenay SV, Shipstone M.. Value of the pinnal-pedal reflex in the diagnosis of canine scabies. Vet Rec. 2001 May 19;148(20):621-3
  3. Griffin, C. E., & DeBoer, D. J. (2001). The ACVD task force on canine atopic dermatitis (XIV): clinical manifestations of canine atopic dermatitis. Veterinary Immunology and Immunopathology, 81(3-4), 255–269.
  4. Saridomichelakis, M. N., Farmaki, R., & al, E. (2007). Aetiology of canine otitis externa: a retrospective study of 100 cases. Veterinary ….
  5. Rybníček, J., Lau-Gillard, P. J., Harvey, R., & Hill, P. B. (2009). Further validation of a pruritus severity scale for use in dogs. Veterinary Dermatology, 20(2), 115–122. Favrot, C., Steffan, J., Seewald, W., & Picco, F. (2010). A prospective study on the clinical features of chronic canine atopic dermatitis and its diagnosis. Veterinary Dermatology, 21(1), 23–31.
  6. Hensel, P., Santoro, D., Favrot, C., Hill, P., & Griffin, C. (2015). Canine atopic dermatitis: detailed guidelines for diagnosis and allergen identification. BMC Veterinary Research, 11(1), 1–13.
  7. Stetina, K. M., Marks, S. L., & Griffin, C. E. (2015). Owner assessment of pruritus and gastrointestinal signs in apparently healthy dogs with no history of cutaneous or noncutaneous disease. Veterinary Dermatology, 26(4), 246–e54.
  8. Olivry, T., Mueller, R. S., & Prélaud, P. (2015). Critically appraised topic on adverse food reactions of companion animals (1): duration of elimination diets. BMC Veterinary Research, 11(1), 1–3
  9. Habil, F. P. G. D. M. V. D., & DVM, S. R. M. (2011). Adverse Food Reactions in Dogs and Cats. Veterinary Clinics of NA: Small Animal Practice, 41(2), 361–379
  10. Ricci, R., Granato, A., Vascellari, M., Boscarato, M., Palagiano, C., Andrighetto, I., et al. (2013). Identification of undeclared sources of animal origin in canine dry foods used in dietary elimination trials. Journal of Animal Physiology and Animal Nutrition, 97, 32–38. Olivry, T., DeBoer, D. J., Favrot, C., Jackson, H. A., Mueller, R. S., Nuttall, T., & Prélaud, P. (2015). Treatment of canine atopic dermatitis: 2015 updated guidelines from the International Committee on Allergic Diseases of Animals (ICADA). BMC Veterinary Research, 11(1), 1–15

LEARN AND TRAVEL with Vets on The Balkans

learn and travelIdea

 

The project intends to assist and support the veterinarians from The Balkans in their desire to upgrade their knowledge and experience in veterinary medicine. They will visit different clinics which are included in the project. The idea is to go directly into practice, to upgrade their own knowledge and experience, to advance their level of practice and generally the veterinary practice on the Balkans.

Goals

 

  1. Rise the level of veterinary service on The Balkans;
  2. Improve health status of the animals and stop transmitting of some diseases;
  3. Improve the financial status of veterinarians by learning different opportunities of management of veterinary clinic and acquiring new skills;
  4. Better understanding of the meaning of the words “hand by hand we all will be better”;
  5. Create contacts and future collaborations.

 

 

Methods to achieve the goals

 

We have agreements with different clinics and they will be involved to provide good environment for education and practice:

 

  1. Central Vet Clinic –  Dr Ranko Georgiev-Sofia, Bulgaria
  2. Nova Veterinary Clinic – Dr Maria Savova-Sofia, Bulgaria
  3. Petcode Veterinary Clinic – Dr Ates Barut-Ankara, Turkey
  4. Regatul Animalelor ( Dermatology Clinic -Rares Capitan – DVM resident ECVD )  – Bucharest, Romania
  5. Vet Derm Therapy – Dr Ana Maria Boncea DVM resident ECVD- Bucharest, Romania
  6. Blue Vets – Dr Constantin Ifteme-Bucharest, Romania
  7. Center Endoscopy and Minimally Invasive Surgery Veterinary- Dr Constantin Ifteme-Bucharest, Romania
  8. Clinica Veterinara Lago Maggiore – Dr Lugi Venco and Dr Luca Formaggini – Italy
  9. Veterinary Clinic Kreszinger – Zagreb, Croatia
  10. Veterinary Clinic More – Sibenik , Croatia
  11.  Dierenartsen praktijk – Dr Ann Criel- Kermt –Belgium
  12. Patisev Veterinary Clinic – Dr Gizem Taktak – Istanbul, Turkey

 

 How can you participate in the project?

 

The vets can submit their applications (they will receive and fill in a questionnaire).

To receive your questionnaire, send an email to gancheva.vet@gmail.com.

 

The vets will receive the agreement from us (Vets on The Balkans) and the clinic chosen by the vet to visit. Depending on the interests of the vet we can recommend a clinic where they can achieve their goals.

 

Financial sources

 

The financial sources will be from donations (vets, clinics, companies). We will cover accommodation and trip expenses. The companies can pay directly for a vet (their client), elected by them.

 

All the money, which come as donations for the project will be transparent and public and easy reachable for every vet.

If you would like to support the project, you can do it! Even with a small amount! Because “HAND BY HAND WE ALL WILL BE BETTER”

 

You can give your support here:

 

 

VETS ON THE BALKANS

 

PIRAEUS BANK – City of Ruse, Bulgaria

 

BG44PIRB 8087 1605 7096 72

 

BIC COD: PIRB BG SF

 

Please write that the money transfer is for “Learn and Travel with Vets on The Balkans”

 

 

 

The project gives opportunities for raising your knowledge in Cardiology ( Bulgaria, Italy ), Dermatology ( Romania,  Turkey) , Orthopedic and Neurology ( Turkey, Croatia and Bulgaria), Endoscopy (Turkey, Romania and Croatia), Exotic animals ( Romania), Surgery ( Turkey, Italy, Belgium, Bulgaria, Romania), Imaging ( Romania, Turkey and Bulgaria) , different management ( Italy, Bulgaria, Romania, Italy , Belgium), Ophthalmology ( Bulgaria) and all standard practices.

 

We would like to express our gratitude to all clinicians who are open to share their experience and especially to CSAVS (Croatian Small Animals Section) and TSAVA who gave us FREE TICKET for their annual congresses for the vet who will visit the country with the project!!! This is very kind of them and we appreciate OUR FRIENDS!

 

THANK YOU ALL!

 

Dr Ates Barut

Dr Lea Keszinger

Dr Ann Criel

Dr Constantin Ifteme

Dr Luigi Venco

Dr Luca Formaggini

Dr Rares Capitan

Dr Ranko Georgiev

Dr Ana Maria Boncea

Dr Radu Boncea

Dr Maria Savova

Dr Emil Ofner

Dr Gizem Taktak12745855_10153614352488768_1773045904046497569_n10449520_331653303690149_6301850326184657855_n11081271_887548304621403_4674371800362832817_n24246_103549239687374_288378_n10632803_386951221474358_809805735081418787_n13876274_1572033829758101_6531483327220244503_n12985514_476693252530917_7663830711320340997_n 1606385_529954783784550_836186800_o11046515_911180198937089_2761924638059587412_n12079558_903035003067421_4071890671212270246_n

 

 

 

 

 

We express our gratitude to our partners Bayer Romaina and Pamas Trading who makes our existence possible.

If you have questions and ideas how to raise our project or something else, please be free to get contact in gancheva.vet@gmail.com!

12814393_1673705086236432_1339900710371625092_n12809768_1673054886301452_3721048230046778423_n

 

 

 

 

Alveolar-pleural fistula, causing spontaneous pneumothorax in a dog- surgical management

vladi prAuthor:

Dr. Vladislav Zlatinov

Central Veterinary Clinic

Chavdar Mutafov str, 25 B, Sofia, Bulgaria

E-mail: zlatinov_vet@yahoo.com

 

Referring vet: Dr. Jordan Jordanov

Introduction

 

Most commonly the pneumothorax in small animals is caused by trauma 1. It could be open or closed; closed traumatic pneumothorax is often the result of blunt trauma (HRS, automobile accidents, etc.). The mechanism includes a chest compressed against the closed glottis, the airway or lung parenchyma can rupture with resultant air leakage.

When there is no evidence of trauma,  air leakage from the lung parenchyma is termed spontaneous pneumothorax. This is relatively rare but potentially lethal condition in small animals. The most common underlying causes are pulmonary bulla, subpleural blebs/emphysema (68% of dogs); neoplasia (11% of dogs); migrating plant seeds; pulmonary abscesses; feline chronic allergic bronchitis; chronic pneumonia; heartworm disease. Siberian Huskies and large chested breeds are overrepresented for the condition2.

In internal pneumothorax, the trachea, bronchi, alveolar ducts could be the source of leakage. The alveolar-pleural fistula (APF) is a communication between the pulmonary parenchyma distal to a segmental bronchus and the pleural space, while a broncho- pleural fistula (BPF) is a communication between a main stem, lobar, or segmental bronchus and the pleural space3.This distinction is important because the treatment for the two types could vary. Indeed in the veterinary literature there are not too many publications, regarding incidence, therapy, etc. of APF.

 

 

Case report

 

Six years old, large (40kg) mix breed dog was presented to us with clinical signs of respiratory distress. The difficult breathing had started suddenly 48 hours ago. The referring veterinarian had done primary diagnostics- chest X -rays and blood work. The radiographs had revealed bilateral pneumothorax; thoracocentesis has been accomplished several times, every time evacuating more than one liter of air. The owner didn’t report any primary trauma. The day before the onset, the dog was treated with parasite prevention drug-Ivermectin 300 ug/kg , s.c.

 

Our clinical examination revealed anxiety, tachypnea- frequent (120/min) shallow breathing, distant breath sounds bilaterally, mild fever- 39.5. The patient was over- all hemodynamically stable- normal mucous membranes, strong femoral pulse.

Emergency care

 

After sedation with Butorphanol + Midazolam (i.v.), thoracocentesis was done at the right 10-th intercostal space. Almost two liters of air were removed.

 

Diagnostics

 

Orthogonal chest radiographs (just after the centesis), revealed residual pneumothorax, left lung lobe collapse (atelectasis), right shifted cardiac silhouette (Fig.1). Pleural fissures were detectable, but no significant pleural effusion was visible; the lung pattern showed mild signs of diffuse alveolo-interstitial pattern, more pronounced in the right hilus area.unnamed

 

A serological Diroffilaria test (Anigen, Bionote, Seul, Korea), done by the referral veterinarian went out positive. Nevertheless, the disease was not confirmed by us- the SNAP 4Dx Test (Idexx comp.) and microfilaria blood smear tests came out negative. Larvo/ovoscopic test (done 6 days later) was negative.

Working algorithm

 

Working algorithm Within the next 8 hours, several thoracocentesis and air evacuations were accomplished, demonstrating the significant air leakage present. The underlying cause was not evident- a spontaneous rupture of a lung lesion (bulla) was supposed. A bronchoscopic or thoracoscopic diagnostic options were not available. A CT study could be used but needed transport to another facility, which was evaluated as too risky. Because of the lack of any signs of lung sealing within 56 hours, an open chest surgical exploration was planned and accomplished.

 

Anesthetic protocol

 

The patient was pre medicated with Acepromazine/ Butorphanol combination- i.m., low range doses. After 10 minutes of hyper oxygenation the patient was induced in anesthesia rapidly (Diazepam/ Propofol) and intubated as fast as possible. The maintenance was achieved by Isoflurane gas (2-3%) and Ketamine drop. Positive end-expiratory pressure (PEEP) of 15 cm H20 ventilation was applied to the patient, using anesthetic ventilator (Midmark Matrix). The hemodynamic parameters- saturation, pulse rate, blood pressure was closely monitored during the whole surgery; no anesthesiological incident was met. The PEEP was adjusted ( up to 25 cm H20), accordingly to the desired lung hyperinflation after chest opening.

 

Surgical protocol

 

A standard ventral median sternotomy approach was used. The sternum was osteotomised (with oscillating saw) in the mid line – from the 3-th to 7-th sternebra; later the approach was extended further caudally , leaving intact the end part of the xiphoid process. Two automatic wound retractors were placed cranially and caudally, achieving excellent approach to all chest structures.

A thorough cavity inspection was accomplished. No free fluid or obvious air leakage was found. Chest walls and heart had a normal surface and structure. The lungs had a normal surface, structure and inflation except one collapsed lobe area.  The pathology was found in the caudal part of the left cranial lung lobe-  atelectasis , with lack of parenchyma inflation. On the dorsal surface there were three small (1 mm) confined lesions areas with serosal  surface defects,filled with granulation tissue (Video 1)

 

A bubble test was accomplished- flooding the chest with warm sterile saline and searching for bubbles during positive-pressure ventilation (up to 40 cm H20). Surprisingly no source of air leakage, including the lesion area, was found.

A second careful  and thorough lung exploration was done, but did not reveal any other areas in question. Finding the visible pathology , we proceeded towards partial lobectomy of the distal collapsed caudal part of the cranial left lobe. One relatively big bronchus and blood vessel were encountered proximally and ligated individually. The resected area was first sutured with  continuous overlapping suture (3-0 PDS). The edge of the incision is over sewn in continuous pattern (4-0 PDS). The sutured sites were tested for leakage again. The lung tissue was separated for histology examination.

Single chest tube was placed before thoracic cavity closure. The thoracotomy was closed routinely, using several full cerclage wires, compressing tightly the osteotomised stenebrae

(Fig.2).vl 5

 

 

Postoperative care and follow up

 

Peri operative analgesia was provided using multimodal approach:

 

NSAID (Meloxicam s.c.) – pre and post op

Transdermal Fentanyl patch 100 μg (applied 4 h pre op),

MLK (Morphine, Lidocaine, Ketamin)  i.v. infusion for 10 hours post op

Local pleural infiltration- 20 ml Levobupivacaine (2,5 mg/ml) in the chest tube every 6 hours.

 

Continuous air suction was not applied but the chest tube was tested and air evacuated every 2 hours.

 

The patient showed fast anesthetic recovery with good pain control after the procedure (comfortable laying in sternal recumbence).

 

The air presence was monitored carefully. After 2 hours of negative finding, an abundant air accumulation started, just as the preoperative status. With the frequent air evacuation, the next 24 h the patient was respiratory stable with occasion onsets of tachypnea. The chest tube was closely examined, and found adequately airtight.

 

Additional diagnostics

 

Significant air leakage (>500 ml/h) was appreciated in the next 24h after the surgery, with no tendency of rate deceleration.  This let us look for a major broncho-pleural fistula with hidden /complex localization. We used an uncommon diagnostic technique- contrast bronchography. After induction in short light anesthesia, the dog was intubated and 3,5 ml Omnipaque (Iohexol 350 mg/ml) were injected through the endotracheal tube, with the head in elevated position. The procedure went uneventfully; the X rays, following 2 minutes of Ambu bag hyperventilation revealed normal bronchial tree, without noticeable pathology(Fig.3).vl 8

Second explorative surgery

 

Considering, that we didn’t adequately addressed the air leakage, and after a fair discussion with the owner we reluctantly decided to go for a second explorative surgery.

 

The same anesthetic protocol was used; we approached the cavity through the recent thoracotomy wound. The lobectomy site was explored, showing perfect sealing and early signs of fibrin formation on the edge. The chest tube intercostal passage looked smooth and nice without soft tissue laceration.

This time, all the lung lobes showed normal inflation and again a frustrating lack of any leakage signs. Special attention was payed on to explore the obscure hilus lung areas. Two saline/bubble test were accomplished without result. At the end (after 30 minutes exploration) an air leakage was demonstrated by an accidental left lung lobe maneuvering, while the chest still filled with saline. We found a single, small (0,5 mm) , barely visible, smooth margins (obviously epithelised) opening on the dorsal surface of the cranial left lung lobe (Fig.4 ). Based on the macroscopic findings we diagnosed alveolar-pleural fistula, having stealthy dynamic characteristics- emissive only in specific lung lobe positions, and dorsal body recumbence not facilitating it (look at the discussion section)

 

A single purse- string  suture (4-0 PDS) was laced around the fistula opening. After the sealing confirmed and final chest lavage the thoracotomy was closed routinely, leaving a chest tube (Fig.5 ).vl 4

 

Follow up and result

 

Immediate cease of the air accumulation was evident after the second surgery (Fig.6). Despite the fast recovery, the dog was closely monitored in clinic for 3 days, afterward the chest tube was removed and the dog discharged for home care.vl 6

The histological report that came later was suggesting not specific granulomatous lung parenchyma changes, with no causative agent (parasites/larva) present in the tested tissue.

 

The dog made full clinical recovery. Its condition was followed 4 years after the thoracotomy surgeries (Fig.7 ).vl 3

 

Discussion:

 

In the presented case report multiple discussions could be initiated. They may regard the possible underlying cause of the pneumothorax, the best diagnostic tools for APF, and the best treatment – conservative vs. surgical, sternal vs. intercostal approach.

In our case we were able to confirm the mechanism of air leakage but we couldn’t reveal the exact primary cause of the lesions. Considering the anamnesis (deteriorating after ivermectin treatment) and the morphology of the lesions- small localized, discreet , we supposed parasitic) migration that had caused alveolar-visceral pleural fistulation. The adult or larva forms of some nematodes may have caused this.

There are numerous evidences that  confirm that D. immitis could cause spontaneous pneumothorax (sometimes lethal) 4,5. There are case reports of a Angiostrongylus vasorum causing massive lung lesion and spontaneous pneumothorax6. Ascaris larvae invasion was reported as a cause of spontaneous pneumothorax in humans7.

Despite we suggest parasitic etiology, it is beyond our knowledge and the scope of the report  to evaluate the morbidity potential of the mentioned or other (Capillaria, Oslerus) parasites. Nevertheless the cause, our retrospective interpretation of the lesions showed these: the fistula canals in the caudal part of the cranial lobe (found at first surgery) had collapsed, causing no serious  air leakage, whereas the cranial fistula (found at the second surgery) was covered with epithelium, preventing it’s successful sealing and creating an air valve. It was interesting that despite its small size the APF was capable of causing serious leakage, with no tendency for healing. Indeed, the small size and the normal local serosal surface around made it difficult to distinguish during both surgeries. Another misleading factor was it’s dorsal localization. With the patient laying in dorsal recumbence, a leakage intermittently blocked by compression of the fistula against the thoracic wall was suggested by us (Fig.8-9 ). This could have been the reason for negative bubble tests- no air leakage, unless lobe manipulation and lifting it from the thoracic wall.Untitled-1

In the presented case, we didn’t had the chance to use advanced imaging diagnostics, so we relied on surgical exploration as diagnostic and vl 9therapeutic option, as recommended in many veterinary sources. We were able to manage the case successfully, but met some difficulties and a revision surgery was needed. It is interesting to suggest how useful could be the advanced imaging tools in the diagnose of APF. Increased accuracy (compared to chest radiography) in finding pathologic lung bullas/ blebs have been proven by studies8.9. One study comparing the accuracy of radiography and CT for bulla and bleb identification in dogs with spontaneous pneumothorax found: radiography to be accurate in 16% of cases and CT to be accurate in 80% of cases. In our case, such circumscribed , air filled structure was missing, so it is questionable if the small air leakage source (APF) could be precisely identified. Possibly, just suggestive signs of gross hypoventilation of the cranial left lung could have been found.

Our suggestion is that a bronchoscopy could also be inconclusive, dealing with a fistulation of small alveolar duct, not accessible for examination from the segmental bronchi. It is interesting if a thoracoscopy study could find such small APF. In a 2003 study,10,11 spontaneous pneumothorax, caused by bullas was successfully diagnosed and treated in three dogs using thoracoscopy,

An argument for a more consistent conservative approach- constant air evacuation system for longer period (>4 days), may be raised. Knowledge  about potential causes of spontaneous pneumotorax is important factor when considering surgical versus nonsurgical management. We based our clinical decision on several reports that show the advantages of the more aggressive surgical  management in canine patients . In one study, recurrence rates and mortality rates for dogs with spontaneous pneumothorax treated surgically (3% and 12%, respectively) were lower than for dogs treated conservatively (50% and 53%, respectively) 1,12.

The feline patients look more prone to conservative management (first choice treatment) of spontaneous pneumothorax, because of prevailing inflammatory ethnologies 13.

It is interesting to mention that in human patients there are publications14,15 for successfully treatment of APF by use of blood patch, synthetic hydrogel and valves, delivered endobronchialy. Watanabe spigots (IBV® valves -Olympus Corp., Japan) are specifically designed for reducing air leaks by means of total occlusion of the affected bronchus. For now, no such interventional option has been reported in the veterinary sources.

The surgical approach that we used -a median sternotomy, may be considered as more aggressive and painful than the alternative- intercostal thoracotomy. The median sternotomy is our preferred choice in such cases because it gives a vast access to all lung lobes and other thoracic structures. There are evidences that in dogs, pain, the degree of cardiopulmonary impairment, and complication rates with between two approaches do not differ 16,17, 18. In humans, median sternotomy causes less postoperative discomfort than intercostal thoracotomy19.

We recognize  that a good pain control is a critical factor , when dealing with thoracotomy patients. Post operatively pain may prevent full thoracic wall excursion, reducing the ventilation and causing hypoxemia20. Pain results in catecholamine release, which contributes to vasoconstriction, decreased tissue perfusion and arrhythmias. A multimodal medical approach was used in the case providing haemodynamic stability of the patient within two open chest surgeries.

Conclusion

 

We would like to stress out the importance of following the medical algorithms in managing such spontaneous pneumothorax cases. In rare cases, the “culprit” / the underlying cause, could not be easily identified even if we know it is there. Still a persistence and systematic approach could be rewarded even in perplexed, frustrating  scenarios

 

References:

 

  1. Puerto DA, Brockman DJ, Lindquist C, et al: Surgical and nonsurgical management of and selected risk factors for spontaneous pneumothorax in dogs: 64 cases (1986– 1999). J Am Vet Med Assoc 220:1670, 2002.