Vets on the Balkans - an online journal for veterinarians from the Balkans

Vaginal tumor in a dog

September 5, 2021

Case history and clinical findings

Dr. Mirela Marinova DVM, EVSSAR member , MVC Bulgaria

Dr. Miroslav Genov DVM, PhD, EVSSAR member, MVC Bulgaria

A 14 kg, 13-year-old female cocker spaniel for truffle hunting was examined for a swelling in the perineal region. As informed by the owner the bitch had given birth once in the past and was in heat two months ago. The swelling appeared one year ago, but had enlarged aggressively the previous month. The dog had been facing difficulty defecating.

Clinical examination revealed palpable little dense masses in the mammary glands. The swelling turned out to be a firm vaginal mass compressing the colon.

CBC and biochemistry profile showed no changes. An ultrasound showed no accumulation of fluid, the ovaries were normal, the bitch was in anoestrus.

Owner was recommended surgical removal of the mass with episiotomy and castration.

The patient was prepared in advance for vaginectomy in case removal of the mass with episiotomy was impossible.

Surgical procedure

Episiotomy was performed for examination of the masses. We started removing them consecutively with an electrosurgical knife. Their location was beneath the mucosa and were removed easily without loss of wall integrity. A part of the vaginal mucosa was hyperplastic so it was also removed. The urethra was unaffected. The vagina was sutured and it’s normal structure was restored.

The second part of the surgery was ovariohysterectomy. No changes in the ovaries and uterine were visualized.

After the castration, careful visual inspection of the uterine stump and the vagina led us to a big mass in the pelvic cavity that compressed the colon. The abdominal cavity was opened caudally to pecten ossis pubis and the uterine stump was pulled cranially. The mass was localised at pars cervicalis. After it’s removal the vaginal wall was sutured.

Post-operative period

The recovery was smooth. Control of the urine bladder was kept and normal defecating restored.

The postoperative edema disappeared in 2 weeks.

Diagnosis

A part of the resected mass was send to laboratory for histopathological diagnosis resulting vaginal polyps- benign non-neoplastic proliferations of well differentiated fibrous tissue, covered by regularly structured hyperplastic epithelium.

Vaginal tumors

Tumors of the female reproductive tract are divided in two categories: arising from the ovaries and those derived from the tubular genitalia.

Genital tract tumours are usually seen in medium-aged (mean age 10 years) non-spayed dogs. Vulvar tumors in dogs are rare- 2,5% of all canine tumors with 70% of them being benign.

https://www.youtube.com/watch?v=SHCML_LI2pw

https://www.youtube.com/watch?v=Dsg-ClVJPpY

Tumors of mesenchymal origin, leiomyomas, fibroleiomyomas and fibromas occur most commonly. Leiomyosarcomas, lipomas, mastocytomas, adenocarcinomas, squamous cell carcinomas occur much less frequently. Transmissible venereal tumors (that spreads during coitus) can also appear in dogs. Transitional cell carcinoma of the urinary tract occasionally extend into the vagina and vestibule. Metastasis to the vagina is extremely rare.

Smooth muscle tumors and polyps of the tubular part of the genital system are common in the bitch. The growth of many of these benign tumours is associated with the ovarian secretion of oestrogen. Therefore, unless the bitch is receiving exogenous oestrogens, it is very unusual to find them in an spayed animal. Leiomyomas appear to be steroid-hormone dependent- around 56% of them have estrogen receptors and 84% express progesterone receptors. This type of tumor is associated with estrogen secreting tumors or ovarian follicular cysts. Spontaneous regression has been observed after castration or treatment with progesterone receptor antagonist.

About 85% of leiomyomas occurring in the reproductive tract in the bitch arise from the vagina, vestibule and vulva. Boxers are predisposed.

Benign vaginal tumours may present as either extraluminal or intraluminal forms. Extraluminal are usually well encapsulated and their growth results in a noticeable perineal swelling. Intraluminal tumours tend to be attached to the wall of the vestibule or vagina. The are often ovoid and firm. Sometimes they can protrude from the vulva. Large intraluminal tumours may become traumatized, oedematous and infected and their appearance may be similar to that of vaginal hyperplasia. Sometimes with the development of the tumour mammary gland tumours, ovarian cysts and cystic endometrial hyperplasia can be seen simultaneously.

Benign tumours can reach 10-12 cm in diameter. When it’s small the consistency is fleshy, but as it develops it becomes firm and hard due to increase in connective tissue ( so called “fibroid”). Small vaginal masses are are asymptomatic unless protruded form the vulva and they can only be discovered by coincidence during vaginal inspection.

Clinical signs include bulging of the perineum, dysuria, stranguria, haematuria, vulvar bleeding and discharge, faecal tenesmus, constipation. Usually there are no changes in the CBC. Radiographs of the caudal abdomen may suggest the presence of vaginal tumor but will not be enough for a definitive diagnosis or it’s location. Endoscopy is an excellent way to visualize the vaginal mucosa and the presence of polyps. Histological examination is considered to be the gold standard in determining the type of the tumor. Surgical resection with ovariohysterectomy ( reduces the risk ot recurrence) provide great outcomes for patients. Digital vaginal and rectal examinations are performed monthly to monitor for tumor recurrence.

References:

Jane M. Dobson and B. Duncan X. Lascelles, BSAVA Manual of Canine and Feline Oncology, Third Edition, 17: 257-259
David E. Noakes, Timothy J. Parkinson, Gary C.W. England, Arthur’s Veterinary Reproduction and Obstetrics, 9^th Edition, 5: 649-651
Robert Klopfleisch, Veterinary oncology, 5: 141-143
Linda G. Shell, DVM, DACVIM, Tanya Gustafson DVM, Vaginal/Vulvar Neoplasia
B. Kand and D.L. Holmberg, Department of veterinary anesthesiology, radiology and surgery, Western College of Veterinary Medicine, Univeristy of Saskatchewan, Case Report: Vaginal leiomyoma in dog
Tuli Dey, Bhajan Chandra Das, Syed Imran, Mohammed B. Bostami, Bibek C. Sutradhar, Sonnet Poddar, University ot Veterinary medicine, Bangladesh, Case report: Surgical Management of Canine Vaginal Leiomyoma of a bitch

Learn ans Travel-Iva Novak, final year veterinary student from the University of Zagreb, Croatia

August 22, 2021

Iva Novak, a final year veterinary student from the University of Zagreb, Croatia share with us her amazing experience:

After living one year in a pandemic, I decided to take one last chance at an Erasmus adventure before graduating this summer. When I came to Padova, I first took a couple of days to explore the beautiful Prato della Valle, Palazzo Bo and the historic center; and also find my way to the clinic. The San Marco veterinary clinic and laboratory is located outside of the city itself, halfway from Padova to Vincenza, another beautiful Italian city. The location makes it available to clients and owners from all over Italy, but also Spain, France, Switzerland and the Balkans. It stretches over 50,000 square meters and 2 floors, with a terrace that gives a wonderful view of the nearby fields.

My first day I was greeted by Dr. Busato who gave me a tour of the clinic, which seemed like a spaceship to me, as I was impressed with magnetic name cards that opened the clinic’s doors! It was nice to put a face to the name of the person I had been messaging with to plan this whole visit, and as expected Dr. Busato was as nice and welcoming in person as she was over email. I am not the best Italian speaker but it turned out that there was no language barrier as everyone at the clinic spoke English and I had no trouble following cases.

To get me started, my first week I was put in the hospitalization ward; where each day one doctor is in charge, but the nurses are the true heart and engine, with over 100 cages, often full, and the nurses still know every patient’s quirks and details. The patients are divided into 6 rooms: for cats, dogs, dogs’ oncology, cats’ oncology, dogs’ infectious and cats’ infectious ward. The intensive care unit is separate and equipped with special beds for patients that can be moved to different areas of the clinic, specialized monitoring devices to provide optimal patient care and diagnostics, CPAP, continuous electrocardiographs, fresh gas and oxygen flow for each patient and round the clock care given by the amazing team lead by Dr. Rocchi. We gave hope and a fighting chance to every animal that walked through the clinic’s door and thanks to doctors Pelizzola, Grossi, Botto and Pallares I practiced my E-FAST skills, ultrasound volemic status assessment, wound management; and there was always good food at morning rounds.

The scale of the clinic is so that if I were to write about each department, this article would turn into a book! San Marco is a tertiary clinic so it provides patients with general medicine and specialist care in neurology, cardiology, nephrology, dermatology, oncology, ophthalmology, orthopaedics, nutrition, and behavior science but one of the most important departments there is radiology. I learned just how big of a part echography can play in disease diagnostics and control check-ups and I also spent one week studying CT diagnostics, which was a whole new world for me. I was lent literature to prepare since CT diagnostics weren’t a part of my studies at the University of Zagreb, and with the help of Dr Negro I was quickly able to follow and recognize pathologies in multiplanar reformatted reconstruction and three-dimensional volume renderings.

As a referral clinic they take in over 6000 patients a year, so cases were abundant but I learned even more during the weekly evening lectures and clinical cases presented almost daily by the clinic’s rotating and specialist interns. The clinic is research oriented, they publish around 30 peer reviewed papers every year and they also provide professional training, traineeships, specialised and rotating internships and residency with evening lectures, seminars and congresses that I have all been attending.

My morning would start in the staff kitchen, where I got to master my coffee-making skills with the instructions given to me by the clinic’s interns, and during lunch, we would exchange pasta recipes. In cardiology, Dr Ledda taught me how to use spectral, flow, and tissue doppler and being one of the doctors that can perform interventional radiology he taught me the theoretical part of it as well. Out of internal medicine, I had the honour of working with Dr Furlanello, Dr Zoia, and Dr Pantaleo. We would receive their own patients, as well as consultations and referrals from other clinics all over Italy.

Since my time there was short compared to the number of procedures they perform at the clinic, out of ophthalmology I was able to only attend one electroretinography on a Tibetan mastiff with SARD syndrome. During surgery week, I observed a TTT with trochleoplasty, nodulectomy with a flap, extrahepatic portocaval shunt closing with fluoroscopic portography and a correction of tibial varus among other procedures. I also helped perform bronchoscopy, rhinoscopy, colonoscopy, gastroscopy with duodenoscopy, and uretroscopy. The endoscopy equipment was also used for intracervical artificial insemination, which was performed by a doctor Ferré.

In the end, one of the things you can’t miss when you first walk into the San Marco clinic is the big swimming pool that can be seen from the waiting room. It is used for physical therapy but I can’t say I didn’t see any of the staff jumps in just before it is supposed to be emptied. At physical therapy, they explained to me the history and progress of every patient and taught me how to use laser therapy in theory and practice along with applied hydrotherapy in the pool or the underwater treadmill.

Now, after 3 months, my adventure is coming to an end, I plan on visiting all the beautiful places in Veneto and surrounding regions I still haven’t seen, like Bologna, Verona and Milano.

I embarked on an Erasmus in the middle of the pandemic but I was lucky to be welcomed into an amazingly organized clinic, following the rules and measurements put in place, my Erasmus experience was barely affected by the pandemic. I am thrilled to have had this opportunity to meet amazing people who work in the same field as me. I can recommend San Marco Vet Clinic to colleagues that want either basic training or to further their skills with specialist grade education. Thank You to everyone who shared their knowledge with me. I will treasure it for a lifetime.

Canine juvenile cellulitis – a case misdiagnosed as meloxicam allergy

August 16, 2021

Authors:

Tsvetan Velev¹, Anna Valerieva², Plamena Novakova², Elitsa Valerieva³, Elena Petkova², Tsvetelina Lazarova¹, Maria Staevska², Miroslav Todorov¹

Affiliations:

¹ Veterinary clinic “Blue Cross”, Pancharevo, Sofia, Bulgaria; ² Department of Allergology, University Hospital “Alexandrovska”, Medical University of Sofia, Bulgaria; ³ Dr. Shterev Hospital, Sofia, Bulgaria;

Abstract

Herein, we report a rare case of canine juvenile cellulitis misinterpreted as meloxicam allergy. Early diagnosis and proper treatment of the condition is associated with a very good prognosis. It is recommended that therapy should be aggressive and initiated as soon as diagnosis is made in order to avoid scarring, secondary infections and to maintain a favorable prognosis. Additional treatment includes topical medications (eg. antimycotics, antibiotics and steroids) along with antiseptic dressings. Awareness of this condition must be improved as the severity of juvenile cellulitis may lead to euthanasia, therefore it is of vital importance that the disease is considered and explored early, and proper treatment is initiated promptly

Key words: juvenile cellulitis, puppy strangles, canine drug allergy, misdiagnosis, autoimmune cellulitis, sterile granulomatous dermatitis, juvenile pyoderma

Introduction

Juvenile cellulitis (also known as juvenile sterile granulomatous dermatitis and lymphadenitis, juvenile pyoderma or puppy strangles) is a rare sterile granulomatous disorder that commonly affects the face, pinnae and submandibular lymph nodes of young puppies between 3 weeks and 8 months old (1). Clinical signs of juvenile cellulitis include fever, lymphadenopathy as well as bilaterally symmetric, pruritic lesions in the periocular areas, face, muzzle, pinnae and inguinal regions. Symptoms progress to crusting and alopecia. Lesions typically form fistulae that drain. A typical feature which also gave rise to the term “puppy strangles”, is submandibular lymphadenopathy. Apart from all these findings, affected dogs are usually active and in good general health (2,3).

Figure 1. Bilateral symmetric, pruritic granulomatous lesions of the muzzle and the periocular areas.

Case-presentation

A 14-week-old miniature Spitz-Pomeranian puppy (regularly vaccinated) spontaneously presented with left hind limb lameness and pain. A hypothesis of possible trauma resulted in intramuscular meloxicam application in two consecutive days with no clinical benefit. Dermatological symptoms occurred after 48 hours and were misinterpreted as meloxicam allergy: bilateral symmetric, pruritic lesions in the periocular areas, face, muzzle, pinnae and inguinal region. This lead to a prescription of antihistamine and low-dose corticosteroid treatment.

Thereafter, the puppy presented also with fever and mandibular lymphadenopathy. Dermatological symptoms progressed to crusting and alopecia, some pustules formed bloody abscesses and drained. Symptoms continued to worsen requiring to rule out various infectious diseases: canine distemper, leishmaniasis, anaplasmosis, babesiasis and toxoplasmosis, all of which resulted negative.

Blood tests were within reference ranges and non-conclusive of an infectious agent. Clinical presentation suggested a diagnosis of autoimmune juvenile cellulitis and high-dose systemic corticosteroid and antibiotic therapy was initiated with clear benefit in less than 12 hours: prednisolone 2 mg/kg + trimethoprim/sulfamethoxazole, together with ocal antiseptic care. Therapy was tapered in 35 days with no signs of a relapse. At the final check, the puppy is 17 months-old with normal development and in good general health.

Figure 2. Bloody abscess on the back (spontaneously drained within few days)

Discussion

The cause and pathogenesis of juvenile cellulitis are not yet fully understood. It was suggested that it is a systemic condition with primary lymphadenopathy resulting in secondary dermatological lesions with some extent of immune dysfunction as well as hereditary components (4). Inflammation in juvenile cellulites is pyogranulomatous with no culprit microorganisms. Cytological findings reveal a nonbacterial aetiology of the disease (5). Analysis of joint fluid often shows signs of sterile suppurative arthritis. Examination of aspirates of affected lymph nodes, pustules, abscesses and joint fluid rarely show any sign of bacterial growth. Biopsy of lesions usually demonstrate discrete or confluent granulomas and pyogranulomas consisting of clusters of large epithelioid macrophages with variably sized cores of neutrophils (6). It was also suggested that since juvenile cellulitis usually occurs at the age when dogs usually receive their first vaccinations with modified-live virus vaccines, there could be a possible pathogenic link between infection with vaccine or other viruses and the evolution of this disease. Data on this association is, however, insufficient. Definitive diagnosis is based on cytological and histopathological analysis as well as on typical findings on complete blood cell count (leucocytosis, neutrophilia, and normocytic-normochromic anaemia) (6).

Juvenile cellulitis is responsive to high-dose corticosteroids which are often prescribed along with antibiotics due to the risk of secondary bacterial infection (5). Rapid and aggressive therapy is recommended in order to maintain a favourable prognosis, to avoid scarring, and to reduce secondary infections (7). The major differential diagnosis includes: canine distemper, demodicosis, bacterial pyoderma, dermatophytosis or an adverse drug reaction, as in the case presented here. However, sterile pus on cytology and responsiveness to corticosteroid treatment differentiate infectious or drug-related causes from juvenile cellulitis. Since juvenile cellulitis is a relatively rare condition, it doesn’t usually come as the first diagnosis in mind and other more common conditions are considered (2). However, as the severity of juvenile cellulitis may lead to euthanasia, it is of vital importance that the disease is considered and explored early, and proper treatment is initiated (8). Juvenile cellulitis is very responsive to high-dose corticosteroids, usually prescribed along with (5). It is recommended that therapy should be aggressive and initiated as soon as diagnosis is made in order to avoid scarring, secondary infections and to maintain a favourable prognosis. Additional treatment includes topical therapy (e.g. terbinafine, oflaxacin, ornidazole and clobestal) along with antiseptic dressings (7).

Figure 4. Dermatological changes of the penile skin.

Conclusion

We report a rare case of canine juvenile cellulitis misinterpreted as meloxicam allergy. If diagnosed early and treated properly the condition is associated with a very good prognosis. It is recommended that therapy should be aggressive and initiated as soon as diagnosis is made in order to avoid scarring, secondary infections and to maintain a favourable prognosis. Additional treatment includes topical medications (e.g. antimycotics, antibiotics and steroids) along with antiseptic dressings. Juvenile cellulitis has a very good prognosis if diagnosed early and treated properly. Complete recovery is typical with a low chance of recurrence (9). Dogs’ condition usually improves markedly by the 14^th day after treatment start. Symptoms are reported to resolve completely within the fourth week (7).

Awareness of this condition must be improved as the severity of juvenile cellulitis may lead to euthanasia, therefore it is of vital importance that the disease is considered and explored early, and proper treatment is initiated promptly.

References:

Kumar AA, Pillai UN, Aipe AA. Clinical management of juvenile cellulitis in a dachshund pup. Intas Polivet 2013; 14:234–235.
Hutchings SM. Juvenile cellulitis in a puppy. Can Vet J 2003;44: 418–49.
Scott DW, Miller WT, Griffin CE. Small Animal Dermatology, 6 ed. Toronto: WB Saunders, 2001:1163–1167.
Dubey P, Sarkar S. Therapeutic management of juvenile cellulitis in Labrador pup. Intas Polivet. 2013; 14:232- 233.
Bassett RJ, Burton GG, Robson DC. Juvenile cellulitis in an 8-month-old dog. Aust Vet J 2005; 83:85.
Reimann KA, Evans MG, Chalifoux LV, et al. Clinicopathologic characterization of canine juvenile cellulitis. Vet Pathol 1989; 26:499–504
Martens S. Juvenile cellulitis in a 7-week-old golden retriever dog. Can Vet J 2016;57: 202–203
Mason IS, Jones J. Juvenile cellulitis in Gordon setters. Vet Rec 1989; 124:642.
Jyothi J, Preethi K, Sathish K. Therapeutic management of juvenile cellulitis in a Labrador retriever puppy. The Pharma Innovation Journal 2017; 6(11): 840-842

HYPERPHOPSPHATEMIA: DIET AND PHOSPHATE BINDERS

July 7, 2021

Serum and plasma phosphorus levels in blood mainly depends on intestinal uptake and urine excretion.

Kidneys have a key role in maintaining serum phosphorus levels, as they can either increase or reduce the quantity excreted with urines. In case of a dog or a cat fed with a high-phosphorus diet, kidneys promote its excretion and the opposite happens with a low-phosphate diet.

In cats and dogs affected by chronic kidney disease, also in the early stages, it’s difficult for the kidney to maintain the phosphate balance because as the kidney function declines, patients tend to phosphorus accumulation: this is called hyperphosphatemia.

In both dogs and cats with renal disease, hyperphosphatemia is mainly caused from a diminished phosphorus excretion (phosphates) and, to a lesser extent, it is consequence of a high acidity of blood (metabolic acidosis).

Hyperphosphatemia is often accompanied to hypocalcemia (low calcium levels in the blood serum), which leads to the increase of parathyroid hormon (PTH) as an attempt to correct calcium concentration in serum.

If hyperphosphatemia is not treated, PTH can be excessively secreted leading to renal secondary hyperparathyroidism, responsible for bone demineralization, renal interstitial and soft tissue mineralization.

Studies in dogs affected by chronic kidney disease have shown the efficacy of a low-phosphate diet (0.4% phosphorus on dry matter) in slowing the progression of renal damage and reducing calcium deposition in the kidney.

Patients in IRIS stage 2, 3 e 4 can show hyperphosphatemia that can be diagnosed testing phosphorus levels in blood and correlating results to the patient’s IRIS stage. In stage 2, dogs and cats are hyperphosphatemic with serum phosphorus above 4.6 mg/dL, in stage 3 with a phosporus level above 5 mg/dL and, finally, patients in stage 4 in case of phosphorus above 6,0 mg/dL.

First therapeutic approach in case of hyperphosphatemia of renal origin is administering a renal diet, with a low-phosphate level. It is recommended to check serum phosphorus after 2-4 weeks: diet is efficacious if serum phosphorus is below 4.6 mg/dL in IRIS stage 2, 5.0 mg/dL in stage 3 and below 6.0 mg/dL in stage 4. In case the diet alone is not working, it will be necessary to introduce phosphate binders.

IRIS stage	Phosphorus(mg/dL)	Therapy
1		No
	>4.6	Diet ± Binders
3	>5.0	Diet ± Binders
4	>6.0	Diet ± Binders

Phosphorus-binding agents should be given together with meals or within 2 hours of feeding to maximize their binding of dietary phosphorus. Commonly employed oral phosphorus binders include aluminum hydroxide, calcium carbonate, and calcium acetate. The starting dosage of these phosphorus binders is approximately 60-90 mg/kg/day, usually divided twice, and the dosage should be adjusted by periodic evaluation of the serum phosphorus concentration. Calcium salts may be superior to other intestinal phosphate binders if ionized calcium is moderately to severely decreased, which is common in the later stages of the chronic kidney disease. Animals should be monitored for development of hypercalcemia whenever phosphorus binders containing calcium are used, especially if calcitriol is being administered concurrently.

Pharmacross NormaPhos® PLUS contains calcium carbonate and chitosamine, with Vit.C and folic acid. As a phosphate binding agent, calcium carbonate is considered safe for long term use while chitosamine is a naturally occurring substance that enhances phosphate binding of calcium carbonate and binds uremic toxins, reducing their absorption in the bloodstream. Finally, Vit.C shows antioxidant properties and the adequate content of folic acid supports the red blood cell function.

Dietetic approach to Chronic Kidney Disease

May 17, 2021

A correct dietetic approach is the key of the therapeutic management of either dogs and cats affected by CKD.

Renal diets have some characteristics:

controlled protein level, with proteins of high quality
low phosphorus & sodium
alkalizing agents to control metabolic acidosis often associated to CKD
high content of Vit.B complex
high content in fibers
polyunsatured Omega-3 fatty acids (PUFA) and antioxidants

It is wrong to consider a renal diet a “low protein diet” as there are still many diets with a lower content in proteins, addressed to other diseases, that are not good to be administered to patients affected by CKD.

Some renal diets underwent clinical trials in order to establish their efficacy in slowing the progression of renal damage or reducing the risk of mortality because of uremic crisis in patients affected from renal failure.

Protein content

There is no consensus about the ideal protein content of renal diets for dogs and cats, although it is accepted clinical signs of uremia improve after a renal diet is administered to patients in IRIS stage 3 & 4. For IRIS stage 1 patients there is no consensus about the utility of a renal diet, but it can be introduced to treat other conditions such as proteinuria. The theoretical utility of a low protein diet in slowing the progression of renal damage in IRIS 2 dogs has not been demonstrated yet and is, therefore, anecdotally applied based on studies carried out in other species.

Clinical trials of efficacy

The efficacy of a renal diet in reducing both uremic crisis and mortality of dogs in IRIS stage 3 has been demonstrated in a randomized controlled clinical trial (RCCT). Dogs feeding a renal diet reduced their risk to develop uremic crisis of 75% as well as of 66% for the risk of renal related mortality, compared to dogs fed with a maintenance diet. In the same study, dogs feeding a renal diet showed better quality of life too.

In another trial, cats with serum creatinine between 2.0 and 4.5 mg/dL were randomized into two groups, one feeding a renal diet and the other feeding a maintenance one; the renal diet reduced the risk of developing uremic crisis and death for renal causes.

Furthermore, a clinical trial studied the difference in survival times of cats feeding a renal diet compared to ones eating a maintenance one. Also in this case, there was a significant difference in survival time between the groups: a median of 633 days for cats fed with a renal diet and 264 for those eating a maintenance one.

Diet change

It takes its time to make a patient accept a new diet. Passing to a new diet too fast as well as a force-feeding are all reasons potentially leading a patient to food aversion. Changing a diet too fast can also cause diarrhea, subsequent dehydration and worsening of renal function. The new diet has to be introduced in growing percentage compared to the old one, subdividing the period in 4 phases. Cats, and dogs with selective appetite, will be changing their diet in 4 weeks, while easier patients will be doing it in 2 weeks.

1st period	25% renal diet + 75% current diet
2nd period	50% renal diet + 50% current diet
3rd period	75% renal diet + 25% current diet
4th period	100% renal diet

Therapeutic suggestions and evidence based medicine

Clinical trials demonstrated the efficacy of renal diet in both improving quality of life and survival time, other than reducing the risk of uremic crisis in dogs in IRIS stages 3&4 and cats in stages 2, 3&4. The real utility of a renal diet for dogs in IRIS stage 2 has not been demonstrated yet, although hyperphosphatemic patients may take advantage of a low phosphorus diet. Regardless the IRIS stage, the renal diet should be used in both proteinuric dogs and cats; its efficacy in reducing serum creatinine and urea is evaluated in 4 weeks.

Omega 3 fatty acids are widely used in both dogs and cats affected from chronic kidney disease (CKD). In dogs with proteinuric renal disease, clinical trials demonstrated the efficacy of Omega3 in reducing the protein loss and slowing the progression of renal disease and glomerular damage particularly if administered in association with antioxidants. In cats, no clinical trials evaluating the efficacy of Omega3 in slowing the progression of renal disease is available, although a retrospective study evaluating survival times of cats feeding different diets have showed a longer life-span in those cats eating the greater content of Omega3 fatty acids.

No data is available about the efficacy of Omega3 administered not in association to a renal diet. Both EPA and DHA are useful in course of CKD, even though diet should be supplemented with fish oils mainly represented from EPA and a fewer amount of DHA, at high concentration in EPA and low DHA.

On a side note, it has to be stressed Omega3 deriving from vegetal oils contain ALA, and are converted to a minimal part in EPA and DHA in canines, while cats are not able to convert ALA at all thus resulting in a lack of efficacy in case of CKD.

Content of EPA to be administered to renal patients is 80 mg/kg daily if associated to a renal diet. Pharmacross kcMEGA3, due to its high content of omega 3 fatty acids and the optimal EPA:DHA ratio meets the EPA content requirements for the health of the kidneys.

New ‘European Stream’ at 2021 Virtual VMG-SPVS Congress

May 8, 2021

Thursday 13-Friday 14 May 2021

Veterinary professionals around the world with an interest in business, leadership and management are invited to join this year’s VMG-SPVS Congress, which will provide inspiration and the latest insights and learning from speakers from the UK, North America and Europe. New this year is a stream of lectures specifically for European veterinary professionals and chaired by Torill Mosent, Vice Chair of the Federation of Veterinarians of Europe and President of the Norwegian Veterinary Association.

The largest non-clinical veterinary conference in Europe, VMG-SPVS Congress offers state-of-the-art learning and development in all aspects of veterinary business, including financial planning, business strategy, HR and people management, marketing and sustainability. Speakers this year include:

28/11/2019
A link in the chain: Tackling mental health, poverty and loneliness through pet ownership
All Rights Reserved – Helen Yates- T: +44 (0)7790805960
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US coach Katherine Eitel Belt, who will explore how the development of ‘courageous’, unscripted conversations with clients, colleagues and audiences can achieve extraordinary results.
Canadian social worker, Professor Angie Arora who will discuss ‘Veterinary social work – a new paradigm’. Angie was principal investigator in a research study to develop guidelines for veterinary teams to better support clients through their pets’ end of life.
David Giraldi, Managing Director of Vet Partners, Italy, who will discuss ‘Practice Consolidation: What Europe can learn from a mature veterinary market’.

All live sessions will feature a speaker Q&A and the opportunity to participate in polls. The virtual congress platform also offers delegates the opportunity to engage with other attendees and to browse the large online exhibition.

The full programme is available here with all lectures available to delegates for three months following congress so they can watch them at a convenient time.

Commenting, VMG President Rich Casey, said: “As VMG-SPVS Congress is virtual this year, it offers a fantastic opportunity for delegates to join us from Europe – or indeed – around the world, for two days of exciting, affordable and highly engaging learning.”

Anna Judson, SPVS President, said: “We are particularly excited to host our new ‘European stream’, this year. The profession on the continent faces some specific challenges and we have brought together experts from across Europe to discuss them and offer potential strategies and solutions.”

Group tickets start at just GBP100 for access to the whole event – with discounts available for single ticket purchase for those who are VMG or SPVS members.

Click here to register.

General remarks on Chronic Kidney Disease (CKD)

April 18, 2021

Treatment of CKD aims at:

Improving both clinical condition and quality of life
Prolonging survival time
Slowing the progression of renal disease

Once chronic kidney disease has been diagnosed, it is recommended:

Stop any drugs with certain or potential nephrotoxicity;
Identify and treat any concurrent disease influencing renal function and determining renal damage. In some patients, other pathologic conditions (such as endocrinopathies) can make difficult either staging renal disease and setting an adequate therapy;
Investigate all causes leading to renal damage and, if possible, treat it. Sometimes, a renal biopsy can be useful to evaluate histologic lesions; in case of proteinuria, results of renal biopsy can provide a specific diagnosis and therapy;
To apply a conservative approach of clinical conditions associated to kidney failure such as metabolic, acid-base and electrolytic imbalances. Therapy is addressed to correct hydration and mineral disorders, acid-base alterations and nutritional impairments. Patients benefit from symptomatic treatment improving their quality of life although azotemia is not significantly modified as this is undoubtedly just one of the factors contributing to the clinical picture of renal patients.

As general recommendations, clinically stable dogs and cats affected from CKD should undergo a clinical examination and laboratory evaluations based on their IRIS stage (www.iris-kidney.com)

every 12 months in IRIS stage 1
every 6 months in IRIS stage 2
every 4 months in IRIS stage 3
every 6-8 weeks in IRIS stage 4

Clinical Evaluation– Other than general and particular clinical examination, a special attention goes to the nutritional condition of the patient, determined by body weight, Body Condition and Muscle Condition Score (available both for dogs and cats at WSAVA). Nutritional status of patients affected by CKD is related to risk of developing uremic crisis and mortality: bad nutritional condition is associated to higher risk of uremic crisis and mortality for renal related causes. Blood pressure is determined too and hypertensive patients are put under treatment.

Laboratory exams– Once CKD has been diagnosed, Veterinarian proceeds to request the laboratory exams useful to identify concurrent pathologies known to determine renal damage or the progression of kidney disease. After the initial evaluation of a complete blood count, biochemistry and urinalysis (included UPC) the Veterinarian will be requesting further exams based on patient’s laboratory results and clinical history such as exams for infectious disease, endocrinopathies, ect.

Below are IRIS stages and most common disorders by stage (modified from Polzin, 2006 and 2019)

Clinical signs	IRIS stage
Polyuria/Polydipsia	1-4
Proteinuria	1-4
Hypertension	1-4*
Urinary infection	1-4
Hyperphosphatemia	2-4
Hypopotassemia	3-4
Anemia	3-4
Metabolic Acidosis	3-4
Anorexia and weight loss	3-4
Vomit	3-4
Dehydration	3-4

*although it is possible to identify hypertensive patients in any stage of the disease, the prevalence of hypertension increases with increasing of IRIS staging

Idiopathic Renal Hematuria in a mongrel dog

April 4, 2021

(case report)

Dr. Plamen M. Kirov, DVM, MVSc, MSc

Timisoara -Romania, and Sofia-Bulgaria

Introduction

Hematuria describes a condition in which is observed presence of blood in the urine. It could be a result of diseases of the urinary tract – kidney, ureter, urinary bladder, urethra; or by diseases of the genital tract – prostate, penis, prepuce, uterus, vagina, vestibule. It can be classified as: macroscopic (visible to the naked eye), or microscopic (increased number of RBC in the urine, observed during microscopic examination). In general, hematuria can be a result of multiple reasons, as follows [1]:

Urinary tract origin
- Trauma
- Urolithiasis
- Neoplasia
- Inflammations (UTI, etc.)
- Parasites (Dioctophyma renale)
- Coagulopathy (Warfarin intoxications, etc.)
- Renal infarction
- Renal pelvic hematoma
- Vascular malformations
- Kidney polycystic disease

Genital tract origin
- Trauma, Neoplastic or Inflammatory diseases of the genital tract
- Estrus
- Subinvolution of placental sites

For Idiopathic Renal Hematuria, we speak when the origin of RBC in the urine cannot be associated with any of the above-enumerated reasons and is of a renal origin. It is a very rare condition, which occurs in middle and big-sized young dogs (younger than 5 years of age), occasionally has been observed in older dogs and cats. Microscopic IRH is found by incidence during urine microscopic exams when macroscopic one is observed by the owners and described as unusual darker coloration of the urine. The condition is mostly unilateral and can be periodic – with a period of no bleeding. Since there is a release of RBC into the urine, anemia can be present in ranges from none to severe. Further, we will take a look and discuss the available treatment options.

Clinical case

The dog was brought to me by his owner, who observed “Cola-like” coloration of the urine in the last 2-3 days. According to the owner’s description, there are no changes of the dog’s behavior and, according to him, the micturition is normal and does not cause discomfort.

The patient:

3-year-old male mongrel dog
25 kg BW, normal body score
Neutered when he was 8 months of age
Vaccinations up to date and according to the protocol
Living indoors
No data for traumas
No medications or treatments in the last 6 months

Physical examination

During the physical examination, no abnormalities were observed, body temperature, heart and respiratory rate, and blood pressure were in the normal ranges. No any tegument abnormalities or signs of traumas. Dog temperament was relaxed and friendly.

Clinical diagnostic tests

The CBC was normal, with an RBC count near the left border reference value. Tests for Babesiosis and Lyme disease were negative. A sterile probe of urine was collected by US-guided cystocentesis and examined. Urine-specific gravity was slightly elevated, presence of erythrocyte was confirmed by microscopic examination, microbiological culture was negative. Pigmenturia was excluded after centrifugation of the urine sample, which resulted in a clear separation between RBC (collected at the bottom of the test tube) and urine (supernatant).

The performed x-ray did not reveal any abnormalities (uroliths, tumors). The ultrasound examination did not result in any abnormalities in the urogenital tract – renal parenchyma was with normal structure.

Idiopathic Renal Hematuria was diagnosed by exclusion as a result of performed test procedures and obtained results.

Additional information about the diagnostic approaches for hematuria in dogs and cats can be found in [2]

Treatment options

For treating Idiopathic Renal Hematuria we have few options available, we could differentiate as:

Invasive. Surgical cauterization of both ureters before the urinary bladder, and observing which kidney is the bleeding one, sclerotization of the kidney with povidone-iodine and silver nitrate [3][4] [5]. This method can be used and for bilateral hematuria. For cases with unilateral bleeding leading to severe anemia, ureteronephrectomy is recommended [1]

Since the dog doesn’t present anemia and invasive methods are more complex for performance and maintenance, I have directed my decision towards a non-invasive treatment option.

Non-invasive. It was described that IRH results from elevated blood pressure inside the glomerular arterioles leading to their higher permeability for RBC. This was observed by multiple studies and reports and the effect of ACE2 inhibitors, especially Benazepril, over the arterioles in the renal glomerulus was demonstrated [6] [7] [8]. In addition, during my studies in FMV-Timisoara, I had the opportunity to observe the treatment of a hunting dog with IRH, using Benazepril with good results (Dr. Doru Morar, FMV-Timisoara).

The dog was treated with Benazepril in dose 0.40mg/kg per os every 24h. In the following days was observed visible reduction of the hematuria – by the owner’s account, urine coloration became normal. Repeated urinalysis revealed the persistent microscopic presence of RBC with a tendency of reduction during the time. Blood pressure was normal and without indications for hypotension during treatment.

Conclusion

Dogs diagnosed with IRH with absent to mild anemia can profit from treatment plan with ACE2 inhibitors – surgical methods are not widely available, are expensive, require hospitalization of the animals, and nephrectomy deteriorates the quality of life for young animals (in cases the IRH becomes bilateral this can lead to a negative outcome for the patient).

Olympic runner leads virtual run at BSAVA Congress

March 19, 2021

Olympic Athlete Laura Muir is helping host a virtual run at BSAVA Virtual Congress (25-27 March 2021) this year, to highlight the physical and mental health benefits of being active. She has made three inspirational videos to encourage delegates to step out for wellbeing.

As well as being a qualified vet, having studied at the University of Glasgow, Laura Muir is the British record holder over the 1500m, a five-time European Champion and is aiming to claim her first Olympic medal at the Tokyo Olympics this summer. She will be encouraging Congress delegates to put their best running feet forward during the three days of Congress.

Laura has made three illuminating videos to show how she has successfully balanced running with her veterinary studies, revealing the low points as well as the high points and how the key is to focus on the positives. In the videos Laura is interviewed by vet and runner Brian Faulkner who achieved the extraordinary feat of running 31 marathons in 31 days. Brian will also be speaking at Congress in the Lessons from Lockdown session on the Saturday.

“There are so many things in life you can’t control,” said Laura. “My own philosophy that keeps me going is ‘do the best that you can do’. For students it’s about remembering all the hard work they’ve put in over the years. To get to where they are in vet school, is a huge achievement in itself. For practitioners who perhaps have had a bad day, taking a moment to remember just how many animals they’ve helped might just keep that negative experience in context.”

Brian Faulkner agrees; drawing on his coaching experience, he refers to something he affectionately calls ‘bitch spay-ophobia’. When students and colleagues become fearful that they may cause more harm than good he reminds them of the bigger picture and that the long-term benefits of performing such procedures are the very reason why many wanted to become vets in the first place.

Participants can support each other by posting details of their run or walk on the Congress platform in the Health and Wellbeing chat room. There are no set times or distance, and delegates are encouraged to take part at a pace, time and location that suits them. Prizes will be awarded for the best selfie taken and posted on Twitter or Instagram tagged #BSAVAVirtualRun .

For extra motivation runners will be able to join the BSAVA running community via the Health and Wellbeing chat room where they can pose questions for Laura and other runners and can share their own experiences and achievements. Attendees can listen to the three motivating videos from Laura at the Health and Wellbeing stand in the exhibition, in which she speaks about Laura the athlete, Laura the vet and Laura the person.

“Whether you are a seasoned runner or have never broken out of a walk we are encouraging everyone to participate,” said BSAVA President Professor Ian Ramsey. “Becoming more active is beneficial to health and wellbeing in so many ways and we are hoping to inspire delegates to lace up their trainers, clock up some miles and feel the difference.”

It’s free to join the BSAVA Virtual Run and you can sign up here.

BSAVA Run is part of a motivating range of wellbeing sessions at Congress this year: Keynote speakers Dr Ranj and Jenny Campbell drawing on their own experiences to emphasise the importance of wellbeing. In addition, delegates can exercise their bodies as well as their minds with yoga and some restorative meditation practices.

To register now visit https://www.bsavaevents.com/bsavacongress2021/en/page/home

For information on how to become a BSAVA member visit https://www.bsava.com/Membership/Member-categories

Suture material reactions: fistulas and granulomas. Review of several clinical cases

March 17, 2021

Dr Tetiana Khramova

Veterinary Surgeon at Khramova STS Soft tissue surgery

Kyiev, Ukraine

Complications on unabsorbable suture materials are not widespead in the countries where absorbable suture material or tissue sealing with electrocautery or Ligasure devices are used. But it’s still seen as a consequence of using unabsorbable multifilament suture material. It is considered, that such reactions arise because of lack of sterility during the surgery, and bacteria forming biofilms on the sutures as a result. As a reaction from the body granulomas form around the sutures and lately they might cause formation of fistulas. The most common surgeries when we can see such complications are bitch spays.

Periods of time, when fistula(s) form can be quite different. From my personal experience it can happen a cuople of weeks after the surgery, but it also happens as late as several years after spaying. The longest period in my practice was 10 years after the surgery.

The clinical appearance is usually typical: owners notice fistula(s) on the abdomen or lateral parts of the pet with exudate or pus. Rarely it can be just a painful skin inflammation on the flank without actually a fistula there. A lot of dogs demonstrate unwillingness to run and jump without any obvious lameness. Another clinical sign can be pollakiuria in the cases when granuloma forms around the uterus stump.

The tentative diagnosis can be made via clinical appearance. But in all the cases it’s mandatory to perform an ultrasound of the abdomen in order to check all the possible granulomas, that can be asymptomatic. The areas of interest during the ultrasound are caudal poles of the kidneys and uterus stump. It’s quite important to check whether the ureters are involved in the granulomas, as it makes the case much more complicated. CT can be much more useful in checking the organ involvement and planning the surgery.

The СBСs are usually unremarcable or with signs of inflammation. In cases where granulomas have formed around the ureters the patient can show signs of azotemia (post-renal) and we will see high urea and creatinine in biochemistry panel.

The only possible option to treat the patient is surgical removal of the granulomas with the suture material inside or just the suture material from the ventral body wall. The therapeutic approach: using antimicrobials, flushing and draining the fistulas can help for some period of time, but then the problem will arise again.

The surgical approach to such cases is always the same: remove all the sutures from the body wall (often with a part of it in case of severe inflammation and thickening) and remove all the sutures and granulomas from the abdomen via middle-line laparotomy. Nevertheless, a lot of such surgeries are quite complicated because granulomas tend to be firmly connected with kidneys and it’s mandatory to remove them without injury of the kidneys. Another problem can be to free the ureter from the granuloma without breaking it or sometimes you have to reimplant them to the bladder or partly resect. It can be quite tricky to remove the granuloma from the uterus stump as they tend to be firmly connected with the dorsal part of the bladder. Sometimes other organs can be involved like omentum and intestines that leads to partial resection.

In severe cases you can observe hydronephrosis because of the mechanical compression of the ureter, and in such cases the kidney must be removed.

After removing granulomas it’s important to check whether all the suture material has been removed, and to flush and suture the peritoneum. The actual absesses around the sutures are quite rare.

After closing the abdomen don’t forget to check and flush and maybe drain if nessesary all the fistulas. If you have removed all the implants, the fistulas will resolve in about a week.

The prognisis in such cases depends on how much all the other organs (kidneys, ureters, bladder) are involved in granulomas, so it can vary from excellent to grave.