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!

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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.

 

Dermatology – Part 1

svetlina

Dr Svetlina Alexandrova DVM, Member of ESVD

Light Vet Clinic, Bulgaria

 

 

1ST THING TO DO IS SKIN SCRAPING!!!

 

derma 14

Slide, mineral oil (lactophenol, glycerin, liquid paraffin), blunted scalpel blade and coverslip

1ST THING TO DO IS SKIN SCRAPING!!!

 

 

 

 

 

 

1.SARCOPTES SCABEI VAR. CANIS    

 

               Even if you don`t see it, treat it!

sarc

SARCOPTES SCABEI VAR. CANIS

sarc2

SARCOPTES SCABEI VAR. CANIS

Some treatment options:

Selamectin spot on 3 x every 2 weeks;

Moxidectin spot on 3 x every 2 weeks;

Ivermectin 0,2-0,4 mg/kg s.c. 4 injections every 7 days (not licensed for this use, heartworms test, MDR1 gene mutations);

Fipronil spray 3 mg/kg at 14-day intervals

 

 

2.DEMODEX SPP

 

 

Important note for all parasites search: closed diaphragm of the microscope and less light; scan the entire slide using 10X objectivederma

demo

DEMODEX SPP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.NEOTROMBICULA AUTUMNALIS (skin scrapings)

 

Clinical signs late summer and fall.

Some treatment options:

Fipronil spray

Parasiticidal dips

derma5

NEOTROMBICULA AUTUMNALIS

derma6

NEOTROMBICULA AUTUMNALIS

 

 

 

 

 

 

 

 

4. CHEYLETIELLA SPP. (skin scrapings, tape strip test)

 

Some treatment options:

Selamectin spot on every 14- to 30-day intervals

Ivermectin 0,2-0,3 mg/kg sc 2 injections at 14-day intervals

Fipronil spray

derma9

CHEYLETIELLA SPP.

derma10

CHEYLETIELLA SPP.

 

 

 

 

 

 

 

 

 

 

 

5.TRICHODECTES CANIS (coat brushing)

 

Some treatment options:

Selamectin spot on every 14- to 30-day intervals

Ivermectin 0,2-0,3 mg/kg sc 2 injections at 14-day intervals

Fipronil spray

derma11

TRICHODECTES CANIS

derma 12

TRICHODECTES CANIS

 

 

 

 

 

 

 

 

 

 

 

6.DERMATOPHYTOSIS  (tape strip test, wood lamp, fungal culture)

 

Some treatment options:

Topical therapy: enilconazole rinses, miconazole…

Systemic therapy: itraconazole, ketoconazole

derma13

DERMATOPHYTOSIS

derma 3

DERMATOPHYTOSIS

Patent Ductus Arteriosus in adult dog

 

13549281_10207110414020766_1752592814_o

Todor Kalinov, DVM, Zaravet veterinary clinic

Todor Kalinov, DVM, Zaravet veterinary clinic, city of Plovdiv, Bulgaria, e-mail drkalinov80@gmiail.com

INTRODUCTION

 

2

Fig 2

1

Fig 1

Patent Ductus Arteriosus(PDA) is one of the most frequently encountered congenital heart disease in dogs , ranging in prevalence from about 25 to 32 % from reported malformations 1 , and lest frequently in cats – about 11 % .  The ductus arteriosus is normal foetal structure  that  shunts blood from  pulmonary artery to aorta 2. Before the birth , it divers approximately 80 to 90 % of the right ventricular output back to the left side of the circulation. After parturition and the onset of breathing , pulmonary vascular resistance falls, flow in the ductus reverses , and the resulting rise in arterial oxygen tension inhibits local prostaglandin release causing constriction of the vascular smooth muscle within the vessel wall and functional closure of  the ductus arteriosus3.

4

Fig 4

3

Fig 3

6

Fig 6

7

Fig 7

5

Fig 5

8

Fig 8

The ductal wall usually contains a loose branching pattern of circumferential smooth muscle in normal pups. The increasing genetic liability to PDA represents extension of the noncontractile wall structure of the aorta to an increasing segment of the ductus arteriosus, progressively impairing its capacity to undergo physiologic closure1.

In typical cases because of the lower pressure in pulmonary circulation there is continuous flow thru the ductus arteriosus from aorta to pulmonary artery. Clinical impact from this is volume overload of the structures in the shunt pathway : the main pulmonary artery, lungs, left atrium, left ventricle, and back to the ascending aorta up to the level of the ductus4. In that shunt direction the dogs show signs of left-sided congestive heart failure – exercise intolerance, coughing, eventually pulmonary edema. In rare instances when the ductus still wide after birth, the flow is really enormous and this leads to increase in pulmonary vascular resistance and change in direction of the shunt, so-called Eisenmengers physiology and reversed PDA . This pattern of pulmonary hypertension and reversed (right to left) shunting usually develops within the first few weeks of life3. Clinical signs in reversed PDA are shortness of breath, differential cyanosis – pink mucous membranes in cranial part of the body and cyanosis in caudal membranes, polycythemia , pelvic limb weakness, collapse, and seizures. The changes in pulmonary vasculature are irreversible and closure of the PDA is not suggested.

Many dogs with left to right PDA do not show any clinical signs, but if left heart failure has developed in first year of life, up to 65 % would die if left untreated. In most of the dogs clinical signs are apparent before the third year of age. The appearance of signs in older dogs is unusual2.

 

CASE PRESENTATION

 

Buky was 7 years old springer spaniel admitted in our clinic with severe respiratory distress. He had history of heart murmur noted on routine examination , several episodes with increasing respiratory rate, and one presyncopal event with rear limb weakness. All clinical signs were apparent past several months.

The dog breathed with open mouth, mucus membranes were cyanotic , respiration rate increased, and on auscultation we have founded continued heart murmur, and crackles on the both side of the thorax. On the X-ray there was severe generalized cardiomegaly, pulmonary overcirculation with dilation if the pulmonary arteries and veins, interstitial to alveolar lung pattern (Figure 1 – L/L projection, Figure 2 – D/V projection). We have applied initial therapy for congestive heart failure with:

Furozemide – 4mg/kg/hour i.v.

Pimobendan – 0.25mg/kg p.os.

Enalapri – 0.5mg/kg p.os.

Sodium nitroprusside – i.v.  constant rate infusion

Oxygen – via mask .

After several hours there was a reduction in respiratory rate, and efforts and an ECG and echocardiography were made.

ECG findings :

Sinus tachycardia – 163 bpm

Wide and tall P wave – suggestive of left atrium enlargement

Tall R wave – suggestive of left ventricular enlargement (Figure 8)

Atrial premature complexes (Figure 3)

Ventricular  premature complexes(VPC) with origin in left ventricle (Figure 4)

Fusion beats – intermediate morphology between normal complexes and VPC (Figures 5, 6, 7).

 

ECHOCARDIOGRAPHY

 

9

Fig 9

11 (1)

Fig 11

10

Fig 10

12

Fig 12

We have made echocardiography at left and right lateral recumbency of the patient with all parasternal  views according to accepted standards. From the exam we have found severe left heart volume overloud with eccentric hypertrophy of the left ventricle. Left atrium was dilated with rightward excursion of the atrial septum. Left ventricle was dilated with thin free wall and interventricular septum, dooming of the septum to the right ventricle, and reduced systolic motion of the free wall and the septum (video 1).

 

 

 

Left atrium and aorta  was measured on right parasternal short axis view at the heart base and the ratio LA/AO was estimated with results showing at Figure 11. Normal LA/AO ratio have to be < 1,6. Main pulmonary artery was dilated compared to aortic root (video 2)

 

, and blowing of the pulmonary valve was noted (Figure 12).

14

Fig 14

13

Fig 13

15

Fig 15

16

Fig 16

On Color Doppler exam there was mild mitral regurgitation with central jet , probably because the dilation of the mitral annulus (Figure 13), and in pulmonary artery was noted typical for PDA continuous flow (video 3).

 

 

With  CW Doppler the aortic flow velocity was measured 2,19 m/s , with normal speed les then 2.0 m/s. In pulmonary artery CW Doppler show typical continuous bidirectional flow (Figure 14).

On the  basis of this findings the dog was diagnosed with Patent Ductus Arteriousus with left to right shunt. Because of the dramatic structural and functional changes in heart, the already developed left heart failure and increased anesthetic risks the owners refused surgical ligation of the ductus. At the time of the diagnosis in our country we did not have the chance for transcatheter coil embolisation. So the only opportunity was to treat congestive heart failure with medications. We have prescribed :

Pimobendan – 0.25 mg/kg/12 h. p.os

Enalapril – 0.5 mg/kg/12 h. p.os

Furozemid – 1.0 mg/kg/12 h. p.os

Spironolacton  – 1.0 mg/kg/12 h. p.os

Supplements with L carnitine, taurine, and coenzyme q10.

The dog was very well after the beginning of the therapy and had only exercise intolerance. After about 1 year he had improvement in some echocardiographyc parameters of systolic function – normal fractional shortening, normal pre ejection period, normal ejection time, but the left atrium was bigger then year ago (Figures 15, 16, 17).

 

 

 

Video 4 – right parasternal  four and five chamber view year after diagnosis ,

 

 

 

 

 

 

video 5 – modified left parasternal short axis view of heart base with color Doppler of the pulmonary artery showing continuous flow with small turbulent jet in opposite direction.

COMMENTS

 

The treatments for Patent Ductus Arteriosus are surgical ligation or transcatheter device closure. Because of the technical factors and price in our country no one does make device closure but in many clinics surgical procedure can be done with great success. In this case the owners decline surgery, but mine opinion is also that the dog was not appropriate candidate for operation. Despite the fact that in most cases there is dramatic improvement in clinical status and cardiac function after surgical closure, the age ,the already developed  heart failure, and concurrent heart disease, affect negatively survival period after PDA closure5. In adult dogs one of the major surgical complications is haemorrhage due to ductus friability2. Mitral valve endocardiosis is also an important factor affecting the survival period. On video 1 and 4 we can see the slight thickening and prolapsed mitral valve leaflets, so I supposed that the dog had degeneration of the mitral valve. Conduction instability of the heart is another reason for anesthetic complications. Actually the dog has died suddenly during routine walk without any other signs, about two years after the diagnosis,  so malignant arrhythmia can be the reason. Despite this facts in most of the literature, the authors suggest closure of the PDA, even in adult dogs, only important contraindication for not closing is right to left shunt.

CONCLUSION

It is not known why some animals with PDA do not show any signs until adulthood. One of the reasons could be the small diameter of the ductus. In human medicine the maintenance of normal pulmonary vascular resistance is important factor for survival of the older patients2. It is certain that the adult dogs with congenital heart diseases are more then we expect, and always  when we examine adult animal for some heart disease, we have to think not only for degenerative valve disease and cardiomyopathies but also for congenital and inherited problems. And of course rare things do happen everyday.

 

 

 

LUIGI VENCO, DVM , SCPA, Dipl EVPC, Pavia, Italy

gigi vbLUIGI VENCO, DVM , SCPA, Dipl EVPC, Pavia, Italy

Graduated in Veterinary Medicine  in 1987 from the University of Milan, after that obtained  the Specialization in Small Animal Practice  and in Veterinary  cardiology . Stayed for study, research and teaching, for several months, at University Veterinary Schools in  U.S.A  (Athens GA, Davis, CA, Philadelphia, PA, Ft Collins CO) and in Japan (Gifu) and was invited speaker  in over 100 courses and conferences in Italy, USA, Japan, Cuba, Croatia , Serbia, Bulgaria, Slovenia, Spain, Poland, Romania, Czech republic. He is author and co-author of more than 40 publications in “peer-reviewed international journals “, 2 books on Heartworm disease 3 on CVBD  on one about Veterinary Cardiology. Collaborates in research projects with the University of Milan, Parma, Zagreb and Salamanca. He is member of the American Heartworm Society,  Feline Heartworm International Council,  SOIPA, ESSCAP and WAAP, and is vice President of the European Dirofilaria Society. He is an  EVPC (European College of Veterinary Parasitology) diplomate. He deals with Parasitology, Cardiology and Cardiac Surgery both in  Italian Veterinary Hospitals (Clinica Veterinaria Lago Maggiore, Ospedale veterinario Città di Pavia, Ospedale veterinario Poggio Piccolo, Istituto Veterinario di Novara) and abroad (Spain and Hungary)

 

Who is Luigi Venco?

 

He is a 27 year old vet with 28 years of experience.

Lucky enough to start working when veterinary medicine started to catch up with the human one.

Lucky of having had great teachers in Italy and around the world and being  grateful to them. Lucky of having had the opportunity to work in many countries. Lucky to have found true friends and wonderful colleagues anywhere. Lucky to still have a lot of enthusiasm in his work and to have the strength to be happy for a life saved and grieve for a lost one.

Just lucky13403164_1605949529716424_8575905289380343021_o

 

We know you work with many vets from the Balkans. People say we are different. What do you think?

 

Absolutely different. Full of enthusiasm and with great sense of friendship and collaboration. As young boys in love with what they do.

 

 

Tell us more about your daily work and your problems( as well your solutions)  ?

 

The every day  work of is full of joy for the victories and sorrows for defeated. It collides with little or too much love for animals. With the economic problems of the owners. With what we would like and we can not. It ‘s a battle to fight with your heart and your mind. The solution, at the end of a tiring and stressful day, is to be able to sleep thinking: “I do not know if I was perfect. But I did the best I could. Tomorrow anyway  I will do better”12038965_1504257143218997_269021453342248416_o

 

Can you share with us your “golden rules” for better practice?

 

– Be critical of yourself, not of others, you can do  better always

– Not justify your mistakes but learn from them

– Do not be afraid to teach everyone and be humble to learn from everyone

– Never think you’re the best, always think that you will become

– You are taking care of a life, not a number or a name. Always look in their eyes and listen to what they say

– Nothing is useless. Also visit a healthy dog. Only by knowing what is normal you will be able to understand what is not normal

–  Never stop studying and to update you.  Veterinary medicine runs in a hurry

 

What do you think about the level of vet medicine on the Balkans( you receive so many vets, who come to learn from you) ?

 

I believe that the level of veterinary medicine in the Balkans is growing every day. As in Italy a few years ago. And it runs very fast. Thank you for transmitting us this feeling

 

What do you think about vet online journal Vets on The Balkans?

 

It ‘s a wonderful Journal.  Open source. Clinical cases and tips useful for the reader. Not just a display of vanity for the authors. Congratulations to the editors for strong expended effort

Surgical extraction of adult D. immitis filariae from the pulmonary arteries of a patient with stage III heartworm disease

ranko

Dr Ranko Georgiev

Ranko Georgiev1, Hristina Shukerova2, Nadezhda Petrova3(anesthetist)

1,2,3 DVM, Central Veterinary Clinic, Sofia, Bulgaria; 2016

 

Introduction:

 

An “exotic” diagnosis for Bulgaria just 5 years ago, Heartworm Disease (HWD) is a parasitic infestation that we nowadays see regularly in our small animal practice. Due to climate change and spreading of intermediate vectors, ever more dogs are getting affected. Other major contributing factors are the infrequency of preventive measures in the country and the high number of undiagnosed and subclinical patients, leading to a reservoir of hosts in the general canine population.

The aim of this article is to report a case where the heavy worm burden of the patient warranted surgical extraction prior to adulticide therapy.carcar3

 

Case presentation:

 

Rem is a 25kg, 10 years old MC mix breed dog admitted because of ascites and exercise intolerance during the past few weeks. Most prominent of the clinical signs was the severely distended, fluid-filled abdomen – assessed as modified transudate on abdominocenthesis (more than 4 liters were drained because of the labored breathing).

Thoracic X-rays revealed right-sided cardiomegaly and severely distended tortuous and blunt-ended pulmonary arteries. On echocardiography, right heart pathology was mainly observed – including a distended right atrium and ventricle, dilated pulmonary artery and evidence of pulmonary hypertension, as well as many tubular echoic structures in the lumen of the main pulmonary artery, typically identified as adult parasites.car1

Serology was positive for D. immitis (IDEXX 4D snap test) and the dog was classified as stage III HWD.

Because of the high worm burden and ascites, the possibility of interventional removal of the worms, before the adulticide treatment, was suggested to the owner, who gave his informed consent.

The patient was scheduled for surgery several days after hospitalization and treatment of right congestive heart failure and pulmonary hypertension using the following therapeutic protocol:

Torasemide: 0.2mg/kg/12h, IV and PO

Sildenafil: 2mg/kg/12h, PO

Ivermectin: 6ug/kg monthly, subcutaneously

Surgical extraction of worms was routinely performed using the right jugular vein approach. The area was scrubbed aseptically and a small skin incision was made over it. The vein was dissected free from the surrounding tissue and ligated proximally. A small transverse cut in its wall was made, through which a forceps was advanced into the heart under fluoroscopic control.

Video:   http://dox.bg/files/dw?a=f058367161

 

An Ishihara Flexible Alligator Forceps (Fujinon TypeL FK-480L) was used, which is a vet instrument designed in Japan, especially for Dirofilaria extraction.car2

The anesthetic protocol we used was typical for this procedure; in particular premedication with Atropine, Butorphanol and Midazolam; induction with Etomidate; and finally Isoflurane maintenance.

After nearly 20 attempts, we extracted 25 adult worms. The overall fluoroscopic time of the procedure was less than 5 minutes. The recovery of the patient was uneventful and a day later we started the adulticide protocol for HWD treatment, as recommended by the American Heart Worm Association.car4car5

 

Comments:

 

In all cases with stage III or IV HWD it is advisable to discuss the possibility of surgical extraction of some of the worms as a pre-adulticide step. This will lower the risk of fatal pulmonary thromboembolism after the injection of Immiticide and will likely improve the symptoms of existing pulmonary hypertension.

It should be noted that if a different extraction device is used (endoscopic loops and baskets, rigid or semi-rigid alligator forceps, different types of graspers, etc.), the success rate of the procedure is much lower, at least in our experience. The Ishihara forceps could be actively maneuvered into the RVOT, hence providing faster and easier access to the PA.car6

 

Conclusions:

 

Surgical extraction of a heavy worm burden is possible and clinically important before adulticide treatment, in patients with end-stage HWD.

Rem, the dog of our study, successfully completed the treatment protocol for HWD without any evidence of pulmonary thromboembolism; meanwhile the symptoms of RCHF have slowly abated.

Gastrointestinal linear foreign body

1 year old, Samoyed, F

 

History: vomiting, lack of appetite

 

pic 1

pic 1

pic 2

pic 2

Findings: On plain radiographs there is a plicated appearance of some of the small intestinal loops on the middle side of the abdomen. The content of this intestinal loops it’s mixt gas-fluid, with variably sized and shaped gas bubbles.

pic 3

pic 3

pic 4

pic 4

Fallowing contrast medium administration: Delayed gastric emptying time. The bunched and plicated pattern it’s  highlighted affectind the duodenum and the jejunum.

 

Conclusion: Gastrointestinal linear foreign body

TTA cases , Dr Goran Tomisic from Belgrade, Serbia

big dog 3

Neapolitan mastiff

big dog 1

Neapolitan mastiff

In our experience most of the patients with TTA surgery are large breed dogs between 25-45kg. We heve  had experienced to work with gient dog (70kg  Neapolitan mastiff)big dog 2 and very small dog (6kg Poodle). 12966364_10209325595520597_1193906793_nFurthermore, the expectations before surgery were that the bigger dog will be a problem for setting the implants, but after both surgeries we were surprised how difficult was to set all implants into the smaller dog. Making the plane of  TTA surgery for small dog our biggest concern before the surgery of poodle was how we would cut the bone, but that part was easiest of the surgery.12966314_10209325898568173_2006959456_n12935231_10209325902128262_1630163835_n Placing the cage and screws was the real challenge. 12939598_10209325908008409_1471598489_n12966391_10209325905128337_1038654349_nThe toughest job was insert the fork into the TTA plate that took most of  the time of surgery. Overall, TTA would be the first chouse for ACL rupture in dogs.

Farmina Vet Life Struvite, Struvite Management and Oxalate

3_strWHAT IS CALCULOSIS

Calculosis is more and more
common among pets, it is
the presence of crystalline
aggregates in the urinary tract.

Uroliths, or calculi, may be small and fine and
resembles sand or coarser and defined, to look like
real stones, with varying dimensions.

WHAT CAUSES IT

In general, the predisposing
factors in urolith formation are
genetics, metabolic disorders or feeding the wrong
diet. Low urine turnover, leading to high concentration11
of salts and a non-physiological pH level, results in urolith formation. Dogs or cats which drink little tend
to generate more concentrated urine, favouring crystal
formation. Bacterial infection can also change urinary
pH resulting in crystal formation2_str

How to intervene

In more serious cases the urinary tract can be
obstructed and surgery is therefore necessary; with
an early diagnosis one can intervene with a targeted diet, in order to eliminate and/or prevent the formation
of uroliths.3_str(1)

Farmina OFFERS THE RIGHT SOLUTION

Farmina Vet Life Natural Struvite is the ideal food for the
dietary treatment of struvite uroliths. With just 2/3 months
treatment the struvite uroliths will dissolve.
After treatment with Farmina Vet Life Struvite it is possible
to continue the treatment Farmina Vet Life Natural Struvite
Management, the ideal food for the prevention of the recurrence of
struvite uroliths and idiopathic cystitis.
Farmina Vet Life Natural Canine Oxalate formula is the ideal
food for the prevention of oxalate, urate and cystine uroliths.