Multimodal treatment approach to canine oral malignant melanoma: a clinical case

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Dr Ana Nemec

Ana Nemec, DVM, PhD, Dipl. AVDC, Dipl. EVDC; Ana Rejec, DVM, PhD, Resident, Veterinary dentistry

 

Animal Hospital Postojna, Cesta v Staro vas 20, 6230 Postojna, Slovenia

 

Case history and clinical signs

Fig. 1

Figure 1: Amelanotic malignant melanoma affecting right rostral maxilla in a 4-year-old female German shepherd at presentation.

A 4-year-old 30-kg female spayed German shepherd was presented due to rapidly growing rostral maxillary mass. At presentation, the proliferative mass, located around right maxillary third incisor and canine tooth was ulcerated and bleeding (Fig. 1). The patient was otherwise healthy with physical exam findings, CBC and biochemistry all within normal limits. Staging options were discussed and the client elected computed tomography (CT) of the head and neck as well as chest CT together with biopsy of the lesion and an abdominal ultrasound.

 

Imaging and histopathology findings

Fig. 2

Figure 2: A CT image taken at the level of maxillary canine teeth at presentation. Note an invasive lesion occupying majority of the right nasal cavity and crossing the midline

Pre- and post-contrast CT images revealed an invasive lesion, located primarily around the maxillary canine tooth and extending from the right maxillary second  incisor tooth to the mesial root of the right maxillary second premolar tooth, occupying majority of the right nasal cavity and crossing the midline (Fig. 2). CT of the neck and chest revealed no metastatic disease to the regional lymph nodes and lungs, and abdominal ultrasound was also within normal limits.

Histopathology of the lesion revealed spindle-cell neoplasm, with differential diagnoses being fibrosarcoma or spindle-cell amelanotic melanoma, and further immunohistochemistry using Melan A and PNL-2 antibodies was performed and was suggestive of amelanotic melanoma.

A stage III (with no detectable metastasis based on the diagnostics performed) amelanotic melanoma was diagnosed.

 

Treatment and follow-up

Fig. 3

Figure 3: With the dog under general anaesthesia in dorsal recumbency an incision is planned to remove the tumor with narrow margins (“debulking surgery”).

Fig. 4

Figure 4: Once the right rostral maxilla and left incisive bone are en-block removed together with the tumor, hemostasis is achieved by ligation of major palatine arteries. Note macroscopically-visible tumor remnants in the right nasal cavity.

Fig. 5

Figure 5: Immediate post-operative photograph of the 4 years old dog with OMM.

Due to an extensive involvement of the nasal cavity, wide resection was impossible to achieve without significantly impairing the cosmetic appearance and function of the animal, and the client elected palliative-intent extended unilateral rostral maxillectomy to reduce tumor burden (Figs. 3-5), followed by a course of adjuvant hypo-fractionated radiotherapy of the surgical area (6 x 6 Gy twice weekly) 3 weeks after the surgery (Figs. 6-9).

 

 

 

 

 

 

 

 

 

 

Fig. 6

Figure 6: Three weeks post surgery the mucosal flaps have healed and any remaining sutures are removed to minimize irritation and inflammation before radiation therapy is initiated

Fig. 7a

Figures 7: Radiotherapy is performed 3 weeks after surgical resection of amelanotic malignant melanoma with the dog under general anesthesia. Note a lead plate positioned in the mouth to prevent irradiation (exit dose) of the healthy mandibles. A bolus is used on the maxilla to achieve optimal dose distribution in the irradiation field.

Fig. 8

Figure 8: Radiation therapy technologist adjusting the patient and equipment to correctly apply the radiation treatment plan.

Fig. 9

Figure 9: Acute side affects of radiotherapy (radiomucosititis) 2 weeks after completion of radiotherapy, which diminished with supportive antibiotic, local antiseptic and anti-inflammatory treatment.

Melanoma vaccine treatment (4-dose, biweekly protocol, then boosters in 6-month intervals) was added to the treatment protocol as an immunotherapy approach to multimodal treatment approach. At all re-checks, the patient was clinically healthy and the most recent re-check head and neck and chest CT revealed no metastases 5 years after the diagnosis (Fig. 10). Fig. 7b

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Discussion

Fig. 10b

Figure 10: 5-year follow up – no clinical nor CT evidence of local tumor recurrence

Malignant melanoma (OMM) is the most common nonodontogenic oral tumour in dogs. Clinical signs may vary greatly; the tumour is not necessarily pigmented (black). Histopathological diagnostics may be complicated as a tumour may present as amelanotic variant and/or as epithelioid-cell OMM, spindle-cell OMM or mixed-cell OMM. Therefore, immunohistochemistry is often needed to determine the diagnosis. OMM is locally invasive, with 50% of tumours being associated with surrounding bone invasion. Metastases are also common: in 74% of cases, OMM metastasise in regional lymph nodes and in up to 92% of cases in the lungs.

Hence, before any treatment is attempted, a patient with an OMM needs to be properly staged. To evaluate local disease, tumor location is noted and the lesion measured. Diagnostic imaging of the local lesion should include pre- and post-contrast CT of the head, as skull radiographs and/or intraoral dental radiographs will underestimate the extent of the lesion and especially invasion of maxillary tumor into adjacent structures. Magnetic resonance imaging (MRI) can also be considered and PET/CT is becoming available in veterinary medicine as well.

Evaluation of regional lymph nodes may be challenging. Although palpation of the mandibular lymph nodes should be routinely performed, it needs to be realized, that 40% of palpably normal lymph nodes contain metastases. Fine needle aspiration of the regional lymph nodes may be helpful, but reaching the main draining center of the head – retropharyngeal lymph nodes – requires ultrasound-guided approach. Also, it has recently been described, that consensus between cytology and histopathology for staging of lymph nodes in patients with melanocytic neoplasms is poor, and negative result does not rule out metastases. Evaluation of size and contrast-enhancement pattern on post-contrast CT images can be very helpful in evaluating regional lymph nodes for metastases, and PET/CT is also very promising. Excisional biopsy of the lymph nodes is debatable, as complete staging requires removal of all lymph nodes of the head and neck. Excisional biopsy of the sentinel lymph node – technique which is well developed in human medicine – is the goal and determination of the sentinel node will hopefully become easier with advanced imaging techniques.

Staging is completed with evaluation of distant organs for possible metastatic disease, where chest CT is much more sensitive to diagnose pulmonary metastases compared to thoracic radiographs. Full body CT may be recommended, if involvement of abdominal organs is suspected, which is rare in cases of canine OMM, and abdominal ultrasound is usually performed.

Once the stage of the OMM is determined, the treatment approach(es) and prognosis can be discussed with the client. It is worth mentioning here, that scientific data on treatment outcomes for specific stage OMM, especially when several treatment approaches are combined, are scarce. Hence, proper communication with the client is extremely important to present as much as possible information and keep realistic expectations. Generally, prognosis for animals, especially if the tumour arises from dentate areas, is guarded due to early and common metastases. Dogs with small OMM (smaller than 2 cm in diameter, stage I) located rostrally and those without metastases, have the best prognosis. With radical tumour resection (tumour with associated 1 cm of healthy tissues as determined by CT) median survival time was reported to be 723 days and related to tumor stage. It has also been reported, that even incomplete tumour resection (dirty margins) increases survival time. When complete resection cannot be achieved (as was expected in the presented case), or the client declines surgical treatment, or when surgery has resulted in incomplete removal of the tumor, or when regional metastases are present, other treatment options exist, although some studies questioned the benefits of adjuvant therapies. When recommending an adjuvant treatment, most commonly suggested is radiation therapy, which can also be the sole treatment for OMM (local and regional disease). The outcome of radiation therapy depends, as with surgery, on the stage of the tumor as well as on the radiation protocol; most commonly hypo-fractionated radiation protocols are recommended and, when used as a sole treatment of OMM, can result in median survival times a bit shorter than those achieved with surgical treatment. Acute side effects, such as radiomucositis are common, expected and usually resolve with supportive treatment, while late life-threatening side effects, such as osteoradionecrosis or secondary tumors, are rare, but need to be discussed with the client in advance, especially when long-term survival of irradiated patients is expected.

OMM is considered poorly responsive to chemotherapy, but is a highly immunogenic tumor. Although the exact immune mechanisms are not completely understood and are likely individually-specific, several immunotherapy and/or gene-electrotransfer therapy approaches have been suggested for canine OMM patients. Most (clinical) research has been performed on a canine melanoma vaccine (xenogeneic plasmid DNA with a cDNA insert encoding human tyrosinase), which has been shown to be safe, but data on its’ efficacy are conflicting. Although it remains unclear, what (if any) role melanoma vaccine and other treatments played in the prevention of metastatic disease in the case described in this report, it is important to realize, that the outcome of canine OMM treatment may not neccessary be poor. In addition, new multimodal approaches are being developed to treat canine OMM and are changing this disease with historically poor outocme into a chronic disease, at least in selected cases.Fig. 10a

 

Clinical study at Animal Hospital Postojna

At Animal Hospital Postojna we recently began a study titled “Evaluation of immune system response to hypo-fractionated radiotherapy in canine non-operable oral, cutaneous or digital melanoma’ together with the Oncovet Clinical Research Centre in France. The study aims to evaluate immune system response to hypo-fractionated radiotherapy in canine non-operable oral, cutaneous, or digital melanoma and to assess the ability of this therapy to improve the response to immunotherapy in combined treatment. With the client’s agreement, we include dogs (males and females) with malignant melanoma when the tumour cannot be surgically removed, either due to its localisation preventing the recommended wide excision, or the client’s refusal to approve such a procedure. In that case, hypo-fractionated radiotherapy remains the preferred treatment. If you or anyone you know are interested in participating in the study and would like to know more about the study protocol and obligations, risks and potential constraints as well as benefits that we offer if you decide to participate, please, contact us at info@ahp.si

 

 

Brachycephalics-Anaesthesia and Intensive Care particularities

 

10455370_1662135347386201_2573188422215976094_nDr Ruxandra Costea, PhD

Bucharest, Romania

 

 

Brachycephalics are patients that are prone to the increase in the superior airways’ resistance, with the decrease of the airflow at the level of the nose or mouth, which implies higher risks and complications associated with anaesthesia.

The acute obstruction of the superior airways can manifest itself consequently to the overheating syndrome (excessive heat, excessive humidity, after physical effort, hyperthermia), post-detubation or as the worsening of a chronic obstruction.Presentation5

The overheating syndrome is represented by the the body’s incapacity to dissipate the accumulated heat and can manifest clinically through hyperthermia (> 41° C), dysfunctions of the central nervous system, the activation of the inflammatory mechanisms, hemostasis disorders and initiation of the systemic inflammatory response syndrome (SIRS). The physiopathological cascade can evolve through multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), disseminated intravascular coagulation (DIC).

The risk factors for the triggering of the overheating syndrome are represented by any anterior episodes, obesity, breed (brachycephalics, Golden Retriever, Labrador), elevated ambiental temperatures and humidity,  poor acclimatization, low resistance to physical effort.29425659_10211461064425220_967441903115042816_o

Hyperthermia can generate cerebral hypoperfusion, neuronal necrosis, vascular lesions, cerebral edema, haemorrhages, multifocal vascular thromboses. The clinical signs can be spontaneous haemorrhages (petechiae, hematemesis, hematochezia).DIC can appear anytime during the first 24 hours after the incident (close monitoring). Hyperthermia can trigger oxidative stress mechanisms, which can act at gastrointestinal level through intestinal ischemia, cytoskeleton relaxation, increase in intestinal permeability and finally, bacterial translocation. Temperature control is essential for the limitation of clinical manifestations (tachypnea, tachycardia, vasodilation, massive haemorrhagic diarrhea and hematemesis coagulopathies, miocardial hypoperfusion, lactic acidosis, electrolitic disturbances, cardiac arrhythmias, stupor, convulsions, exitus). The patient will have to be cooled simultaneously with the administration of  fluids for the control of tissular perfusion and hydroelectrolytic disorders. Crystalloid isotonic fluids will be administered, supplementing, if needed, with colloid boluses, depending on the hydration state, cardiovascular potential and the electrolytic status of the patient. The therapy will continue without interruptions until the patient is stable. In severe cases, it is necessary to start the antimicrobial therapy for restricting the endotoxemia and preventing sepsis ( broad-spectrum antibiotics). The therapy will be completed with gastrointestinal protectors, H2 antagonists (famotidine) and proton pump inhibitors (pantoprazole). Continuous monitoring throughout the therapy is mandatory, because the patients need re-evaluation and consequent adaptation of the therapy.

The key points in the therapeutical management of the overheating syndrome are:

  • Oxygen supplementation
  • Sedation, general anaesthesia
  • Temperature control
  • Control of the tissular perfusion and of the acid-base and hydroelectrolytic disorders
  • Correction of homeostasis disorders
  • Maintenance of the renal function
  • Blood glucose monitoring
  • Antimicrobial therapyPurpose:  Presentation4 

    Oxygen supplementation is necessary when the patient first shows up ( starting with the triage phase) in the case of acute respiratory distress syndrome (ARDS), noncardiogenic pulmonary edema or laryngeal edema. Brachycephalics in thermal shock exhibit compensatory hyperventilation or can’t oxygenate themselves enough, consequently to respiratory insufficiency, with high respiratory effort, hyperthermia, muscular exhaustion and, finally, respiratory arrest! The immediate control of hypoxemia initially requires oxygenation through noninvasive methods, followed, if needed, by additional invasive procedures (general anaesthesia with endotracheal intubation, nasal oxygenation catheter, tracheal catheter, tracheotomy/ tracheostomy). High air flow devices can be used for oxygenation (>15l /min.)- oxygen tent/cage, AMBU-bag or low flow devices(<6l/min.)-mask, nasal oxygenation tube, endotracheal probe, tracheal catheter.29388957_10211461064265216_3957696742744391680_n 29425012_10211461064385219_3239167496015577088_n

    Assisted ventilation is recommended either in case of hypercapnia (PaC O2 >60 mmHg) or severe hypoxemia (PaC O2 <80 mmHg or SpO2 <90%) with persistent cyanosis despite having oxygenation levels reaching 100%.Possible complications regarding mechanic ventilation are correlated to the accidental disconnection of the patient, device failures, barotrauma, atelectasis or oxygen toxicity.

    Brachycephalics are NOT the best candidates for „a simple sedation”, requiring, in most cases, general anaesthesia protocols. Given the fact that all anaesthetics affect the respiratory function through central depression or through muscle relaxation, a continuous monitoring is necessary, from premedication to the patient waking up from anaesthesia.Presentation1

    Preanaesthetic evaluation will be cautiosly approached, in order to reduce the perioperative mortality, by tracing and evaluating the risks and by adjusting the perioperative protocols. The patients will be premedicated in order to reduce stress, anxiety, agitation, this also leading to a decrease of the doses that are necessary for maintenance. For critical patients, premedication can be excluded, but analgesia must be maintained! A minimal contention is recommended, without a muzzle! For brachycephalics, preoperative preoxygenation is mandatory. For induction, the lowest propofol doses will be slowly administered intravenously. (1.0 mg/kg slowly injected intravenously for the first 15 seconds, then another 1.5-2 mg/kg until reaching the desired effect). The administration of propofol in rapid bolus causes apnea, bradycardia, hypotension and respiratory depression. Propofol reduces the cerebral metabolism, the cerebral blood flow and the intracranial pressure, also alleviating the effects of the hypoxic lesions, and inhibiting lipid peroxidation, having an antioxidative action.

    The endotracheal intubation of the brachycephalics must be done with care. It is hard to anticipate the dimension of the trachea by the size of the patients, because they often  have hypoplastic tracheas. Anaesthesia is maintained gaseously, ensuring the efficient ventilation of the patient.  For avoiding regurgitation, the patients will be positioned slighly forward, with the anterior extremity lifted at . Inhalation anaesthesia protocols can be carried out, if needed, at the same time with the administration of opioids (bolus or CRI) or with locoregional anaesthesia techniques (blockages, infiltrations, epidural etc.).29496194_10211461064545223_8396511414134505472_n

    Secondary effects can appear at high doses of opioids (dysphoria, bradycardia, respiratory depression). For ensuring the polymodal analgesia, opioids, NSAIDs and local anaesthetics can be administred.

    Managing the hemostasis disturbances implies the stabilization of the coagulation system, the administration of fresh frozen plasma or anticoagulants, for preventing thromboses.

     

    Maintaining the renal function is possible in the case of patients suffering from thermal shock through maintaining the perfusion and oxygenation of the kidney. Hypovolemia and dehydration will determine the arterial tension and the cardiac output to lower, leading to the decrease of the renal perfusion ( renal ischemia). Lowering the oxygenation at renal level will favor the triggering of acute renal insufficiency. Consequent rhabdomyolysis and myoglobulinemia will damage the kidney even more. If the urine output is low (<1ml/kg/h) even after fluidotherapy, furosemide and/or mannitol can be administered. Mannitol (osmotic diuretic) will reduce the water content of the neuronal cells, will increase the reanl perfusion and diuresis. Furosemide can be administered at 15 minutes after the administration of mannitol. An option for hyperhydration, uremia or different electrolytic imbalances is represented by hemodialysis.

     

    Monitoring the glycemia is very important for critical patients, because the ones that are hypoglycemic have a hard time compensating!

     

    A particular situation is represented by the acute obstruction of the superior airways after detubation. The muscles of the superior airways, which are relaxed post anaesthesia, can favor the appearance of acute obstructions at brachycephalic breeds, together with the inflammation of the larynx and the pharynx, especially after the specific correctional surgical procedures. That is the reason why it is recommended to postpone these patients’ extubation for as long as possible after anaesthesia and to supplement their oxygenation through noninvasive methods (nasal oxygenation probes, prongs, oxygen cage), until they have completely recovered from it. Since the risk of complications is high, it is good to be prepared for a possible reintubation or even for invasive oxygenation methods (trecheotomy, trecheostomy).

     

FELINE LYMPHOPLASMACYTIC GINGIVITIS STOMATITIS COMPLEX

index

Dr Adriana Moise

CASE PRESENTATION

  1. MOISE ADRIANA

TAZY-VET, BUCHAREST

 

SIGNALMENT AND HISTORY

  • FEMALE CAT , 2 YEARS OLD WAS PRESENTED FOR A CLINICAL EXAMINATION WITH HYPERSALIVATION , HALITOSIS, LACK OF APPETITE FOR PROCESSED DRY FOOD

CLINICAL FINDINGS

-THE CAT HAD NORMOTHERMIA AND A NORMAL BODY WEIGHT

-AT PHYSICAL EXAMINATION SHE PRESENTED ULCERATIVE LESIONS IN ORAL CAVITY, LOCALISED ON GINGIVAL MUCOSA, INFLAMATION ON PALATOGLOSSAL FOLDS AND PHARYNGEAL WALLS

-EDEMA WAS PRESENTED AND LOCAL LYMPHNODES WERE REACTIVE TOO

der2

photo 1

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photo 2

LESIONS WERE PRESENTED BILATERAL ( photo 1,2)

DIFFERENTIAL DIAGNOSTIC

-FELINE LYMPHOPLASMACYTIC GINGIVITIS-STOMATITIS COMPLEX

-FELINE CALICIVIRUS INFECTION

-FELINE HERPESVIRUS INFECTION

-FeLV-FIV

-FELINE EOSINOFILIC SINDROME

-NEOPLASIA

FURTHER INVESTIGATIONS

-FELINE CALICIVIRUS Ac –NEGATIVE

-FELINE IMMUNODEFICIENCY – FIV Ac-ELISA –NEGATIVE

-FELINE LEUCHEMIA –FELV Ag-ELISA – NEGATIVE

-THE CORONAVIRUS Ac TITRE – INCREASE

-CITOLOGY FROM IMPRESSION SMEAR – INCREASE NUMBER OF BACTERIA AND NUMEROUS ACTIVE INFLAMATORY CELLS

BLOOD TEST (BIOCHEMISTRY)  WAS NORMAL

-HEMATOLOGY REVEALS LYMPHOCYTOSIS

-CYTOLOGY AND HYSTOPATOLOGIC EXAM CONFIRMED THE DIAGNOSTIC – FELINE LYMPHOPLASMACYTIC GINGIVITIS STOMATITIS COMPLEX

 

DIAGNOSTIC

FELINE LYMPHOPLASMACYTIC GINGIVITIS STOMATITIS COMPLEX

TREATMENT

UNTIL WE GOT THE RESULTS THE OWNER BEGINS TO TREAT THE CAT WITH

-STOMODINE GEL TWISE A DAY, 14 DAYS

-CEFA CURE 20MG/KG/DAY, 10 DAYS

-SYNBIOTIC D-C 1CPS/DAY, 10 DAYS

-K9 IMMUNE SUPPORT CAT

 

-AFTER 10 DAYS OF TREATMENT THE INFLAMATION BEGAN TO REDUCE BUT THE ULCERS DO NOT HAVE THE TENDANCE OF HEALING

AFTER WE GOT THE DIAGNOSTIC THE CAT GETS THE FURTHER TREATMENT

-PREDNISON 2MG/KG/DAY, 5 DAYS; THEN 1MG/KG/DAY , 5 DAYS FOLLOWEDBY EVERY OTHER DAY

-STOMODINE GEL TWICE A DAY LOCAL

-HONNEY WITH PROPOLIS LOCAL

WHEN SHE CAME FOR THE EVALUATION AFTER 5 DAYS OF TREATMENT WE SAW THAT THE LESIONS HAD A TENDANCE TO REDUCE, BUT AFTER ANOTHER 5 DAYS THE LESIONS WERE EXACTLY THE SAME AS THE BEGINNING

-WE DECIDED TO INTRODUCE CYCLOSPORINE IN THE TREATMENT

-CYCLOSPORIN 7MG/KG/DAY

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-THE CAT IS PERMANENTLY MONITORIZED ; HLG IS MADE EVERY 2 WEEKS

-AFTER 2 WEEKS OF TREATMENT THE LOCAL INFLAMATION BEGINS TO REDUCE

-AFTER 1 MONTH OF TREATMENT THE LESIONS FROM ONE SIDE WERE HEALD

-THE CAT IS STILL UNDER TREATMENT

-THERE IS NO SIGN OF SECOND EFFECTS OF CYCLOSPORINE

 

How to start up an exotic animal department in your private clinic

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Dr Ama Groza Mrcvs

If you have already realised that providing high quality veterinary medicine services to exotic pets can increase your turnover and enhance clientele then let me congratulate you! This article will give you an easy step-by-step guide to follow in order to make the best of your new venture.

Have you wondered why so few vets are seeing exotics? Some frequent explanations include:

  • Most vets get little training in caring for exotic pets and as a consequence they get stressed when having to see an exotic pet. Many clinicians will refuse to see them unless it’s a first aid situation and the ones that do, probably won’t generate sufficient income to cover their time.
  • If surgical intervention is required, the price for the time spent with an exotic animal, a rabbit for example, is almost half that compared with the same time spent caring for a dog or a cat.

It is no surprise that exotic animal medicine is not high on the preference list of any sensible practice owner. But this is because you’ve been doing it all wrong!

These steps will guide you in starting up a successful exotic animal department in your clinic.

 

  1. Don’t cut corners, practice good quality medicine

The slogan “Gold standard practice” is unfortunately overused these days. Many practices advertise gold standard protocols, however these apply to dog and cat patients only. When it comes to seeing an exotic pet, basic investigations like a simple blood sample or a faecal test are often not even offered to owners and this is where the clinic is losing money and clients.

Through having your staff trained and consequently confident in carrying out specific procedures on exotic pets this will not be the case.

Protocols for different alignments should be in place for exotic animals as well as for small mammals to secure the best care for all pets. Having protocols in place will facilitate a fast treatment set-up at the best standard, easily followed even by inexperienced vets when there’s no support around.

There are a wealth of specialised procedures to be carried out on exotics and trained veterinarians and/or nurses will be able to offer all this to customers, generating more income for the practice.

Encouraging best care practice will stimulate your staff to keep up to date with their training; practice high standard procedures and good outcomes will not stay unnoticed for long. As a consequence more owners will register with your practice. Your staff will be delighted to be at the top of their job taking pride in what they do.

 

  1. Train your staff

Having your staff trained into caring for exotic animals their procedures can be fast, successful and stress free. Because major differences exist between exotic and small mammals, one must have specialised training in order to be able to look after exotics.

Knowledge and confidence is what you need in your team. Offering a generous list of fairly priced specialised procedures will generate more work for the practice and can only be an asset comparing with your competitors (I will return to this later in this article).

Naturally, trained staff will exude confidence and gain owners trust. Consequently, owners will be more likely to agree to more high risk or specialised procedures which they might otherwise hesitate upon; again, thus increasing your revenue.

Practices with trained staff to care for exotics are scarce, so letting your customers know what your team can do and what their level of training is, will not only serve to retain existing clients but will also attract new customers to the practice, and these new customers will often have more than one pet. And who doesn’t like a growing client base?!

 

  1. Charge a fair price for your services

Establishing a fair price is the key factor in setting up your business for failure or success.

Firstly, it is important to understand that there is no relation between the purchase price of a pet and the costs for its medical treatment.

Some people will adopt stray dogs and request for expensive laparoscopic rather than traditional neutering. No surgeon would hesitate to give them an accurate estimate. However when contemplating performing a tortoise spay, most surgeons will doubt the owners’ willingness to accept the surgery as a first option because of the costs involved. However, this is only our assumption!

pic 1

I always try and explain before an estimate that the medicines and consumables we use are the same price for all pets. My practice overheads are the same regardless of whether I work with dogs or parrots so why should my work time be priced up differently?

Set your pricing to charge fairly for your time, your assistants’ time, the materials used and not least for your skill.

Pricing all  materials used (like catheters, swabs, gloves etc.) separately will show owners how much the consumables cost, otherwise owners have no idea how much an urinary catheter is and not giving them a detailed bill can lead to confusion. Pricing of the consultation fee should cover time spent with the client and overhead costs such as rent, electricity, water etc. Pricing for the individual procedures carried out (like “placing an IV catheter” or” blood collection”) must cover your salary costs and the cost of ongoing training. The message here is that all costs should be factored in rather than just absorbed.

To your advantage is the fact that few veterinary surgeries offer good quality medicine for unusual pets. If you are clearly the best at it, you have little competition. There is nothing inherently wrong with being expensive but you should not forget that this approach requires continuous training and investment in equipment.

My experience has shown that owners shopping around for price rarely become good, loyal clients. They will always be difficult to convince to agree to investigations and will be likely to complain more if things don’t work out immediately (this is natural, because they can’t afford to spend more money for further tests if needed). The question is not whether you need these clients, but whether you can afford them. Charitable care organisations might be more appropriate for financially challenged clients.

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This is a baby Russian tortoise (Agrionemys horsfieldii ), has a lifespan of 75 years

Customers shopping for quality and excellence in veterinary care will be yours for life and will pay fairly for your services because they understand and appreciate your approach. Make this group your target clientele and your efforts will pay off.

 

pic 2

This is a replica cake of a Russian tortoise (Agrionemys horsfieldii ), it survived for 1 day”

  1. Facilities

Working with exotic pets requires that some adjustments to the hospital facilities and dispensary are made. Exotic pets are escape artists, easily stressed and some of them are poikilothermic, will need special hospitalisation facilities like a vivarium or even an incubator. With a modest budget you’ll be able to adjust your clinic to their needs (to keep costs down you can consider buying vivariums, loupes or surgical instruments second hand).

Most medication used is similar to that for small mammals, however, be aware that dosage is not, so be careful and make sure to consult your exotic medicine library.

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My favourite books which I have always at hand

ARAV.ORG, AAV.ORG  , AEMV.ORG are prestigious, reliable sources of information, so do invest in membership to this organisations. This will give you access to updated care sheets, up to date research data, specific event information and most important, a lot of colleagues to get in touch with in case you need advice on your cases.

 

  1. Advertise

There’s not much gain, except of course personal gain, in being very good at your job if nobody knows about it. In order to keep the business going one should make sure existing and prospective clients know about the range of services the clinic is offering.

You could periodically inform clients about any new equipment purchased and about what training your staff has undertaken. This will not only act as a “refresher” on what your service offering is but will also spread by word of mouth. You may be surprised to find how much impact the users of specialised forums have when a new exotic pet owner is looking for a knowledgeable vet. Make sure your name appears there, next to a good review of course.

Always remember to keep your colleagues informed about your services. Referral cases are a good source of income and a great way of practicing your specialist skills. Organizing open days and continual professional development courses will keep you on the radar of colleagues and clients alike, they should know that you exist and are doing well.

An unusual pet can easily become a news subject and this can get you free advertising. Don’t be shy, let the world know about your successful cases, consider local newspapers, TV and radio as well as social media.

  1. Stay at the top

Don’t ever stop learning.

Exotic animal medicine is developing fast, trends are changing and new protocols are being elaborated at an incredible speed. Refresh your library (very important: change your Carpenter’s Exotic Formulary with any new edition) periodically.

Re-evaluate your protocols every year, attend refresher courses, learn new surgical procedures, and stay updated. When you are the best you can be, you have no competition other than yourself.

Enjoy your success!

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Next event of Dr Ama Groza, soon in Bucharest, Romania!

 

Encephalitozoon cuniculi – associated Phacoclastic Uveitis with Second Glaucoma in Rabbit

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Dr Vesela Elenkova

Dr Vesela Elenkova – master scintific in veterinary ophthalmology and surgery, veterinary clinic “Eskovet”– Bulgaria, Sofia

Case presentation :

A nine month female rabbit presented for a right eye lesion of two weeks duration. There was cataract on the same eye from birth. The referring veterinarian had prescribed a course of topical and systemic antibiotics but it continued to deteriorate. The eye was become very painful. The lesion appeared as a whitish-yellow mass into the hyperemic iris, slightly protruding into the anterior chamber. There was a mature cataract formation and the pupil was mydriatic with no response to light. The intraocular pressure (IOP) of the affected eye was 40. On the other was 11and it was not clamped. Fluorescein staining was negative for corneal lesions on both eyes. On the ultrasound examination there was no changes into the posterior segment of the affected eye.

12540490_1258197917527518_1937293050_n

The right eye of the rabbit with E.culiculi-assosiated lens-induced uveitis. Note the mature cataract, the large mass into the hyperemic iris and the midriatic pupil not responding to light. IOP is 40.

There was only seen the hyperechogenic lens and the lesion in the iris. The rabbit was in pain when touched and didn’t want to eat well.

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Ultrasound image of the eye. Note the hyperehogenic lens and the 7mm lesion behind the iris. The posterior chamber is not affected.

The patient history and appearance of the lesion were compatible with Encephalitozoon cuniculi-induced phacoclastic uveitis, and a tentative diagnosis was made. Other diagnostic defferentials included granuloma caused by Pasteurella or other bacterial infections, but they were unlikely considering cataract formation. Diagnostic included complete blood count, biochemical profile and serology testing.
The complete blood count and serum biochemical profile were within normal limits. The serum IgG-antibodies were not so high, but the IgM-antibodies indicate active infection in most cases. They bought are not indicative for utero infection.

We opted medical management. 12570932_1258201610860482_1705138233_nExcept of the antibiotic therapy (with enrofloxacin PO and ciprofloxacin eye drops), the treatment was continued with fenbendazole at 20 mg/kg PO q24h for 28 days. 12607270_1258201650860478_1726829549_nPrednisolone acetate ophthalmic drops were prescribed to treat the uveitis and dorzolamide hydrochloride and timolol maleate drops for the eye pressure.

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The left eye of the rabbit appeared unaffected

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After one week recheck. The iris is not so hyperemic and IOP is 6.

After 1-week recheck, the lesion had not changed, hyperemia was decreased, the IOP had become low – 6. There was no pain in the eye and the rabbit was doing well. The pupil still does not respond to light. After 2 weeks more, there was no change. The rabbit was in very good condition, but the vision in the right eye was compromised. Surgery might be necessary in the future depending on progression of the lesion, discomfort, and long term effects on the eye.

Discussion

Encephalitozoon cuniculi (E. cuniculi) is a protozoal parasite. The parasite primarily affects rabbits, but cases have been reported in sheep, goats, dogs, cats, monkeys, guinea pigs, foxes, pigs and humans. It is a recognized zoonosis, but the zoonotic risk seems to be minimal to healthy individuals observing basic hygiene and to date there have been no reported cases of direct transmission from a rabbit to a human. However, those individuals who are immunosuppressed should implement strict hygiene and if possible avoid animals suspected or confirmed of being infected with E. cuniculi. Spores are shed in infected animals’ urine and transmission is usually by ingestion of contaminated food or water, or less commonly by inhalation of spores. Transmission from mother to young (transplacental) also occurs so that offspring are born infected. Most of the time, these organisms do not cause any obvious clinical disease. When E. cuniculi reach nerve tissue, rabbits can experience neurologic impairment, characterized by partial or complete paralysis, loss of coordination, seizures and head tilting.
E.cuniculi-assosiated phacoclastic uveitis is recognized in rabbits. There is no sex predisposition and the condition is often seen in younger rabbits. The mechanism by which the protozoan causes cataract is unclear in detail, but its lifecycle gives clues as to aetiopathogenesis of cataract. Passage of parasite between adult and young happen in utero with the parasite circulating in the fetus and sometimes ending up residing in the developing lens. The parasite migrates through the anterior lens capsule causing liberation of lens protein into the iris and anterior chamber and subsequent development of lens-induced uveitis, however, the posterior chamber usually remains unaffected. Normally this uveitis presents as a white-yellow mass in or near the pupil, sometimes with neovascularisation rendering it red or pink.
Serum ELISA antibody titers are helpful in making a diagnosis, however, serology only indicates past exposure and is not diagnostic of or necessarily correlated with clinical disease and infection. Immunofluorescence assay and polymerase chain reaction (PCR) testing of tissue, urine and feces samples, as well as cerebrospinal fluid and removed lens material. These test looks for antigens, unlike serology, which test for antibodies. Simultaneous testing of IgG and IgM-specific antibodies can give an indication of infection status because IgM antibodies indicate active infection. If transmission is transplacental, bought IgG and IgM antibodies may be low.
In this cases treatment options include antiprotozoal medication, topical corticosteroids for the uveitis, surgery to remove the affected lens and granuloma if it is possible. The other option is enucleation, but it is not common if the eye is functional, because it is unlikely to eradicate the infection. In other cases the eye may atrophy without surgery (phthisis bulbi).

Conclusion

E.cuniculi-assosiated phacoclastic uveitis should be always suspected for rabbits presenting with ocular lesions and uveitis and oral antiprotozoal medications are always recommended, as affected rabbits may develop infection in the brain and encephalitis, that can lead to death.

PERITONEAL DIALYSIS IN A SPHYNX CAT WITH ACUTE RENAL AND LIVER FAILURE

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Dr Bogdan Vitelaru

Bogdan Alexandru VIŢĂLARU

University of Agronomic Sciences and Veterinary Medicine of Bucharest, 59 Mărăşti Blvd, District 1, 011464, Bucharest, Romania, Phone: +4021.318.25.64, Fax: + 4021.318.25.67, Email: alexandrumv@yahoo.com

Corresponding author email: alexandrumv@yahoo.com

Abstract

A 11-year-old 3.1 kg, castrated, female Sphinx cat was referred to the Clinic of the Faculty of Veterinary Medicine Bucharest for acute onset vomiting, loss of appetite, anorexia, faintness, sharp breath, inability to exercise, oliguria and lethargy. Results from a complete blood (cell) count (CBC), serum chemical profile, and urinalysis submitted at that time were abnormal. The patient had hyperglycaemia (Glu-164mg/dl), acute renal failure (Crea-3.4mg/dl, BUN-117mg/dl) and acute liver failure (ALT-744U/L, TBIL-11.8mg/dl). The ALKP was 155U/L. The rectal temperature was 37,4ºC, the patient presented anaemic mucous membranes, mild dehydration (persistent skin fold thickness 2-3 seconds) and slight sensitivity to palpation in the renal lanyard. The established treatment consisted in peritoneal dialysis, rehydration and electrolyte balance, parenteral nutrition. We used PD4 peritoneal dialysis Dianeal 200 ml (1000ml / sqm). The patient was submitted to intravenous fluidotherapy with 5% Dextrose, Sodium Chloride 0.9 %, Aspatofort, Ondansetron, Metoclopramide and Duphalyte, CRI for 18 days. Abdominal ultrasound showed bile duct obstruction, abundant sludge in the gallbladder and mild modification in kidneys. Recommendation for oral treatment: Ipakitine bid, Azodyl bid and kidney diet food. The patient started to eat voluntary after 8 days of treatment. TBIL went up to 23.3mg/ml after the first 7 days and then started to decrease until it reached 0.9mg/dl at the end of the parenteral treatment. BUN and Creatinine values decreased to normal after the first 7 days of peritoneal dialysis and parenteral treatment. Peritoneal dialysis therapy plays an important role in renal failure in cats, especially in the elderly and weighing up to 10 kg. Elevated levels of creatinine and urea, hyperkalemia, hyper phosphatemia, or metabolic acidosis which do not yield to treatment can be solved using peritoneal dialysis. It also has a good effect in acute liver failure, cleaning the high levels of bilirubine.

Key words: peritoneal, dialysis, creatinine, urea, bilirubine

INTRODUCTION

Peritoneal dialysis is a technique whereby infusion of dialysis solution into the peritoneal cavity is followed by a variable dwell time and subsequent drainage. During peritoneal dialysis, solutes and fluids are exchanged between the capillary blood and the intraperitoneal fluid through a biologic membrane, the peritoneum. Inadequate renal function leads to disturbance in the removal of the extra fluid and waste products. It removes the waste product and extra fluid from the body in renal failure in small animal practice. Peritoneal dialysis is more accessible, more affordable and easier to administer to the small animal patient. The most common indication for peritoneal dialysis in cats is acute renal failure (ARF). Peritoneal dialysis is an important therapeutic tool for mitigating clinical signs of uraemia and giving the kidneys time to recover in cats with acute kidney injury when conventional therapy is no longer effective (Bhatt et al., 2011).
Peritoneal dialysis is a modality of renal replacement therapy that is commonly used in human medicine for treatment of chronic kidney disease and end-stage kidney failure. Peritoneal dialysis uses the peritoneum as a membrane across which fluids and uremic solutes are exchanged. In this process, dialysate is instilled into the peritoneal cavity and, through the process of diffusion and osmosis, water, toxins, electrolytes, and other small molecules, allowed to equilibrate (Cooper and Labato, 2011).
Peritoneal dialysis uses the peritoneum as a semi permeable layer for dialysis in which excess water, ions and solute in the blood pass through a semi permeable membrane to sterile solution which is known as dialysate via diffusion, osmosis and filtration. The three-layered peritoneal membrane consists of 1) themesothelium, a continuousmonolayer of flat cells, and their basement membranes; 2) a very compliant interstitium; and 3) the capillary wall, consisting of a continuous layer of mainly non-fenestrated endothelial cells, supported by a basement membrane. The mesothelial layer is considered to be less of a transport barrier to fluid and solutes, including macromolecules, than is the endothelial layer (Clough and Michel, 1988). Solute transport rates are assessed by the rates of their equilibration between the peritoneal capillary blood and dialysate. The ratio of solute concentrations in dialysate and plasma at specific times during the dwell signifies the extent of solute transport. Creatinine and urea clearance rates are the most commonly used indices of dialysis adequacy in clinical settings. Contributions of residual renal clearances are significant in determining the adequacy of dialysis (Flessner et al., 1985).

MATERIALS AND METHODS

An 11-year-old, 3.1 kg, castrated, female Sphinx cat was referred on November the 10th 2014 to the Clinic of the Faculty of Veterinary Medicine Bucharest for acute onset vomiting, loss of appetite, anorexia, faintness, sharp breath, inability to exercise, oliguria and lethargy. The physical examination revealed that the patient was anorexic, lethargic, had inability to exercise and a pronounced yellowish colour of skin and mucosa. Results from a complete blood cell count (CBC), serum chemical profile, and urinalysis submitted at that time were abnormal. The rectal temperature was 37.4ºC the patient presented slight sensitivity to palpation in the renal lanyard. Abdominal ultrasound showed mild modification in kidneys. The established treatment consisted in peritoneal dialysis, rehydration and electrolyte balance, parenteral nutrition. The patient was also submitted to intravenous fluidotherapy with 5% Dextrose, Sodium Chloride 0.9%, Aspatofort, Ondansetron, Metoclopramide and Duphalyte, CRI (Kushwaha and Singh, 2008).

RESULTS AND DISCUSSIONS

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Fig 1

The patient was presented with abnormal blood biochemistry values in the first day. The patient had hyperglycemia – Glucose – 164 mg/dl (reference range 71-159 mg/dL), acute renal failure (Creatinine – 3.4 mg/dl – reference range 0.8-2.4 mg/dL, BUN – 117 mg/dl – reference range 16-36 mg/dL) and acute liver failure (ALT – 744 U/L – reference range 12-130 U/L, TBIL – 11.8 mg/dl – reference range 0.0-0.9 mg/dL). The ALKP was 155 U/L – reference range 14-111 U/L. The rectal temperature was 37.4ºC, the patient presented yellow anaemic mucous membranes, mild dehydration (persistent skin fold thickness 2-3 seconds) and slight sensitivity to palpation in the renal lanyard.
Abdominal ultrasound showed mild modification in kidneys. Recommendation for oral treatment: Ipakitine bid, Azodyl bid and kidney diet food.
The established treatment consisted in peritoneal dialysis, rehydration and electrolyte balance, parenteral nutrition. We used PD4 peritoneal dialysis Dianeal 200 ml (1000 ml/sqm) after placing the peritoneal catheter and after we managed to accommodate the patient with the peritoneal distension. Aseptic technique is imperative for the peritoneal dialysis (the use of surgical scrub and sterile surgical technique during catheter placement, as well as the use of sterile gloves, disinfectants, and the careful handling of dialysate fluids, catheters, and catheter line during dialysis), (Thornhill, 1981). The catheter enters the abdomen on midline at the level of the umbilicus and it is directed caudally and positioned in the lower pelvis (Figure 1).

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Fig 2

The patient was also submitted to intravenous fluidotherapy with 5% Dextrose, Sodium Chloride 0.9%, Aspatofort, Ondansetron, Metoclopramide and Duphalyte, CRI.
On 11th of November 2014, the first day of treatment, the patient was presented with 37.5°C body temperature and we started administrating fluidotherapy IV in a volume set at 30 ml per hour twice a day: Dextrose 5% 15 ml, Sodium Chloride 0.9% 30 ml, Aspatofort 1 ml and subcutaneous Emeset 0.4 ml. Peritoneal dialysis was performed infusing 200 ml Dianeal PD4 (1000 ml/sqm) and we collected 130 ml after 4 hours of dwelling (Figure 2).

On the next two days we used the same protocol of peritoneal dialysis and we managed to recover this time 160-180 ml after 4 hours. The fluidotherapy remained the same, 30 ml/h and the temperature dropped at 37°C. On the 13th of November the blood tests showed: Glu 196 mg/dL (reference range 71-159 mg/dL), BUN decreased to 73 mg/dL (reference range 16-36 mg/dL), and the creatinine decreased at a normal value of 1.6 mg/dL (reference range 0.8-2.4 mg/dL). The transaminaze ALT and ALKP also decreased: ALT 509 U/L (reference range 12-130 U/L), ALKP 121 U/L (reference range 14-111 U/L) but the total bilirubin (TBIL) increased at 18.4 mg/dL (reference range 0.0-0.9 mg/dL). The pancreatic lipase dropped at 59 U/L (reference range 100-1400 U/L).
On November the 14th, the patient presented hyperthermia (40.2°C) and we performed a second abdominal ultrasound exam where we noticed the bile duct obstruction and abundant sludge in the gallbladder. The IV fluidotherapy was modified to: Dextrose 10% 7.5 ml, Sodium Chloride 0.9% 50 ml, Aspatofort 2 ml, Duphalyte 15 ml and Metoclopramide 0.3 ml twice a day. The same protocol of peritoneal dialysis have been used and we managed to recover 160-180 ml after 4 hours. We followed the same treatment for the next two days and the temperature decreased at 39.2°C. On the 16th of November we performed a complete blood count which shown granulocytosis and thrombocytosis which indicated mostly an infection corroborated with a kidney disease. The following days the temperature dropped at 38.4°C and we administered, at a constant-rate of infusion of 20 ml per hour for 12 hours per day, Dextrose 10% 30 ml, Sodium Chloride 0.9% 200 ml, Aspatofort 8 ml, Duphalyte 15 ml and Metoclopramide 2 ml.
On the 18th we run biochemistry blood tests and the results were quite remarkable: BUN, creatinine and glucose came back to normal reference rates. Glu 120 mg/dL (reference range 71-159 mg/dL), BUN decreased to 33 mg/dL (reference range 16-36 mg/dL), and the creatinine maintained at a normal value of 2.0 mg/dL (reference range 0.8-2.4 mg/dL). The only parameters which remain high were ALT, TBIL and GGT. ALT was 469 U/L (reference range 12-130 U/L), TBIL decreased to 5.8 mg/dL (reference range 0.0-0.9 mg/dL) and GGT decreased to 10 U/L (referance range 0-1 U/L). The same protocols of peritoneal dialysis have been used and we managed to recover 180 ml after 4 hours.
We followed the same treatment for the next four days and the temperature went back to a normal value of 38.4°C. On the 21st of November we run biochemistry blood tests and the ALT decreased to 387 U/L (reference range 12-130 U/L), TBIL decreased to 3.5 mg/dL (reference range 0.0-0.9 mg/dL) and GGT decreased to 8 U/L (reference range 0-1 U/L). The same protocols of peritoneal dialysis have been used and we managed to recover 180 ml after 4 hours. On the 21st of November, our patient presented appetite for the first time and eat voluntary. From this moment it started to eat every two hours renal diet and drink by herself. We decided to stop the peritoneal dialysis, the peritoneal catheter was removed and dialysis was discontinued. The patient’s condition has improved significantly (Table 1).

We followed the same venous treatment for the next seven days and the temperature maintained at a normal value of 38.4°C. On the 28th of November we run biochemistry blood tests and BUN was 46 mg/dL (reference range 16-36 mg/dL) and all the other parameters maintained in normal ranges of value. The patient’s condition has improved significantly

Parameter 10.11 13.11 18.11 21.11 28.11
Glucose
(71-159 mg/dL) 164 196 120 129 94
BUN
(16-36 mg/dL) 117 73 33 34 46
Creatinine
(0.8-2.4 mg/dL) 3.4 1.6 2.0 1.7 1.4
ALT
(12-130 U/L) 744 509 469 367 109
GGT
(0-1 U/L) 0 15 10 8 0
TBIL
(0.0-0.9 mg/dL) 11.8 18.4 5.8 3.5 0.9

We decided to discontinue the venous treatment and we recommended oral treatment: Ipakitine bid, Azodyl bid and kidney diet food.
In comparison with the literature, the decrease in BUN and creatinine were quite remarkable, the BUN decreasing from 117 mg/dL to 33 mg/dL in eight days and the Creatinine from 3.4 mg/dL to 1.6 mg/dL in three days.

CONCLUSIONS
Peritoneal dialysis therapy plays an important role in renal failure in cats, especially in the elderly and weighing up to 10 kg. Elevated levels of creatinine and urea, hyperkalemia, hyper phosphatemia, or metabolic acidosis which do not yield to treatment can be solved using peritoneal dialysis. It also has a good effect in acute liver failure, cleaning the high levels of bilirubine.

REFERENCES
Bhatt, R. H., Suthar, D. N., 2011, Peritoneal dialysis in acute renal failure in canines: A review. J. R. UkaniVet. World, Vol.4(11): 517-521
Clough, G. and Michel, C. C., 1988. Quantitative comparisons of hydraulic permeability and endothelial intercellular cleft dimensions in single form capillaries. J Physiol ; 405:563–576.
Cooper, R. L. and Labato, M. A., 2011. Peritoneal dialysis in veterinary medicine. 41(1):91-113.
Flessner, M. F., Dedrick, R. L. and Schultz, J. S., 1985. Exchange of macromolecules between peritoneal cavity and plasma. Am J Physiol ; 248: 15.
Kushwaha, R., Singh, N., 2008. Peritoneal dialysis în animals – A review. The Internet Journal of Veterinary Medicine. Volume 7 Number 1.
Stojimirovici, B.; Trbojevic-Stankovic, J., 2007. Animal models în peritoneal dyalisis, Scand. J. La. Anim, Sci. Vol. 34, No 4
Thornhill JA. 1981. Peritoneal dialysis în the dog and cat: an update. Compend Cortin Educ Prac Vet, 3, 20-34

 

Polycystic kideny disease (PKD) in ferret

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Dr Krasimira Kodjanikolova, DVM, Mr Sc Imaging diagnostic

Dr Krasimira Kodjanikolova, DVM, Mr Sc Imaging diagnostic

Veterinary Clinic NOVA, sofia,Bulgaria

Clinical case

Ferret Sunny, 5 years old, castrated

Anamnesis :

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Fluid therapy in ferret

The feret presented at the clinic apatic,not active from 1 month, the appetite went down, dehydratated.

Exam:

Normal temperature

Blood test: light form of anemia, the biochemical part of the test was normal.

Ultrasound examination:

Ultrasonographic evaluation indicates the presence of cysts of varying size in the right kidney, as the body has lost its normal arhistructure.

Single cyst in the left kidney associated with renal pelvis;

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Right kidney

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Cyst of the right kidney

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Right Adrenal Gland

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Right Adrenal Gland

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Left kidney

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Left Adrenal Gland

Adrenal glands –without changes.

Treatment:

Fluid therapy and NSAID

TREATMENT OF A RETROPERITONEAL ABSCESS BY OMENTALIZATION IN AN ORANGUTAN (PONGO PYGMAEUS PYGMAEUS

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Norin Chai, DVM., MSc., MSc.V., PhD, Dipl. ECZM (ZHM)

 

Norin Chai, DVM., MSc., MSc.V., PhD, Dipl. ECZM (ZHM)

Clinical case

 

A 38-yr-old female wild-born Bornean orangutan (Pongo pygmaeus pygmaeus) with no major clinical problems, presented with chronic lethargy and difficulty in locomotion. The animal was housed at the Me´nagerie du Jardin des Plantes- National Museum of Natural History (Paris, France) with two males and two females, all captive-born. The orangutan developed mild lethargy, anorexia, and at times, mental deficits. Clinical signs progressed from weakness and less frequent ambulation to permanent dorsal recumbency, lateral recumbency, or both.

On day 1, 1 wk after the onset of clinical signs, the orangutan was immobilized with 300 mg of ketamine hydrochloride (4.8 mg/kg i.m.) by Blow dart. Anesthesia was maintained by intermittent supplemental boluses of 200 mg of ketamine every 20 min (3.2 mg/kg i.v.). A constant slow rate infusion intravenously of 0.9% NaCl was administered.

The orangutan’s respiratory rate, heart rate, and pulse oximetry were monitored with a hand-held pulse oximeter. Physical examination and palpation revealed a mild chronic periodontal disease and a left retroperitoneal mass. Hematology, serum biochemistries, thyroid panel, and transthoracic echocardiogram were within normal limits. Serologic titers for herpes simplex type II, herpes B, and herpes SA8; human and simian immunodeficiency; measles; and rubella were negative. Lateral and ventrodorsal abdominal radiographs demonstrated no clear and remarkable lesion other than mild arthrosis on the lumbar vertebras.

blood sampling

TREATMENT OF A RETROPERITONEAL ABSCESS BY OMENTALIZATION IN AN ORANGUTAN (PONGO PYGMAEUS PYGMAEUS)

Abdominal ultrasonography revealed a mass composed by two hypoechogenic cavities with regular margins compatible with a 12-cm X 8-cm X 8-cm left retroperitoneal abscess, cranial and dorsal to the bladder. Guided by ultrasonography, aspirate from the fluid pocket resulted in the collection of purulent liquid. A cytology examination of the fluid revealed high cellularity, with an inflammatory cell population composed entirely of neutrophils and a heterogeneous bacterial population composed of high numbers of cocci and bacilli, often observed intracellularly.

DSC_0197

TREATMENT OF A RETROPERITONEAL ABSCESS BY OMENTALIZATION IN AN ORANGUTAN (PONGO PYGMAEUS PYGMAEUS)

The specimen was sent for bacterial culture and sensitivity. On the basis of these findings, a diagnosis of a retroperitoneal abscess, pyometra, or both was made. The animal received 40 mg of meloxicam (0.64 mg/kg s.c.). An exploratory laparotomy revealed a normal uterus, a retroperitoneal abscess, and enlarged lymph nodes. The abscess was adhered to the bladder, the mesentery, and the soft tissues adjacent to the mass. The mass ruptured upon handling, thus releasing a substantial quantity of pus into the abdominal cavity. The abdominal and abscess cavities were drained using surgical suction. The volume of pus was estimated to be approximately 500 ml. The site was initially rinsed with sterile 0.9% NaCl. Suction was used to evacuate the fluid, and the process was repeated several times. In addition, 800 mg of gentamicin (12.8 mg/kg) was then poured into the abdominal cavity and evenly distributed. Digital exploration of the abscess revealed a ramification close to the vertebral canal.A lumbar-sacral fistulization was suspected. Because of the difficulty separating the abscess from its attachments, only a small portion of the visible membrane was removed. Two bacterial species were cultured from the initial ultrasoundguided aspirate of purulent fluid: Streptococcus and Escherichia coli. Both of these organisms were susceptible to cephalosporins and fluoroquinolones. Histologic examination of the membrane confirmed an inflammatory component rather than a neoplastic process.

The decision was made to create a physiologic drain of the abscess with a functioning omental flap, as described previously in humans, dogs and cats. The remaining abscess cavity was then packed with omentum. The omentum was attached to the abscess membrane with two simple large sutures by using an absorbable suture material. The abdominal wall was closed in two layers (peritoneum and muscular layers) with a continuous suture pattern by using a monofilament nonabsorbable suture material. The skin was closed by a hypodermic running suture, and a simple interrupted suture pattern by using an absorbable suture material. After completion of the surgery, and while still immobilized, the animal was administered 40 mg of meloxicam (0.64 mg/kg s.c.) and 5 ml of a solution containing ascorbic acid, thiamine, pyridoxine, and niacin (Nutra B, Fort Dodge; 0.2 ml/kg i.m.). Systemic antibiotics were administered via injection and include 560 mg of cefovecin (8.58 mg/kg s.c.) and 540 mg of danofloxacine (8.28 mg/kg s.c.). In total, 1,200 mg of ketamine had been administrated to the orangutan to achieve a 125-min period of anaesthesia. The total surgical time was 50 min, and recovery was uneventful and rapid. The animal was placed in its enclosure in lateral recumbency. Forty-five minutes after the last ketamine bolus, the animal demonstrated normal activity and was moving and sitting. A postsurgical analgesia treatment was initiated with 45 mg of meloxicam (0.69 mg/kg p.o., s.i.d. for 5 days.

In humans, retroperitoneal abscesses are not common clinical conditions. The causes of retroperitoneal abscesses include psoas abscess, necrotizing fasciitis, pancreatitis, perforated acute appendicitis, and duodenal diverticulum perforation. The abscesses are often diagnosed by a computed tomography scan. Draining of the abscess without any surgery may be sufficient in some cases, such as a psoas abscess. However, in rare cases, retroperitoneal abscesses may be lethal, even after surgical drainage. In both dogs and cats, retroperitoneal abscesses are usually unilateral. They can be associated with trauma, infection, and depositions of foreign material during surgical procedures and urinary extravasation. In this report, culture isolation of Streptococcus and E. coli suggests that infection was consistent with an ascending bacterial infection from the lower urinary tract, reproductive system, or digestive system. However, no cultures of other organs or fluids were performed to attempt to localize the source of infection. Actually, omentalization is considered to be the treatment of choice for prostatic and pancreatic abscesses in dogs as well as for large and chronic nonhealing wounds, uterine abscesses, and idiopathic chylothorax in a cat. The omentum contains aggregates of blind lymphoid capillaries that provide lymphatic drainage of the peritoneal cavity.  This treatment has not been reported previously in orangutans. Omentalization was successful in providing a continuous method of fluid drainage for this retroperitoneal abscess, with minimal requirement for postoperative procedures of the animal.

Fibrocartilagenous embolic myelopathy

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Dr. Ionuţ Alexandru Ciupercă, CCRP, CVA (IVAS)

Dr. Ionuţ Alexandru Ciupercă, CCRP, CVA (IVAS)

VetPhysioCenter Bucureşti

Email: ionut@vetcenter.ro

Fibrocartilagenous embolism it is a spinal cord infarction caused by a vascular emboli, presumed to be fibrocartilage. It may produce bilateral or unilateral signs and can happen anywhere in the spinal cord, the thoraco-lumbar region being the most common. Usually it has a sudden onset and a full development in 12 hours. There are 50% chance of spontaneous recovery if it shows signs of improvement within the first week.

It is a nonpainful acute disease, seen only in nonchondrodystrophic breeds. It is very important to differentiate from the intervertebral disk disease, either protrusion or extrusion. This condition is less common in small dogs or cats. Any region of the spinal cord may be affected, and the spinal cord segments dictate the specific neurologic deficits. Very common are also asymmetric or unilateral signs. Also, ataxia, paresis or paralysis may affect all limbs or only pelvic limbs. There can be a loss of deep pain sensation caudal to the lesion.

Diagnosis is based on the clinical picture and by exclusion of other possible causes. The most important clues are the signalment, the acute onset, the stationary course of the disease and the absence of pain. The differential diagnosis include intervertebral disk disease, trauma, neoplasia and inflammatory disease. The best imaging modality is the MRI showing usually signal changes suggestive of focal spinal cord infraction.

There isn’t any specific treatment for this condition even though corticosteroids are used, but there is a lack of scientific evidence that they might work. Physical therapy and nursing care are the most beneficial treatment modalities to use; about 85% of the patients recover, depending of the severity of the lesions (De Risio and others, 2007).

Sara - assisted walking

Sara-assiced walking

Sara it is a 2 years old intact female Labrador retriever with a sudden onset of paraplegia; the disease started with a lameness of the left hind leg, then with a proprioceptive ataxia and in 2 hours she was already paraplegic.

Sara X-ray

Sara X-Ray

Sara MRI

Sara MRI

Sara did an MRI immediately which revealed a unique hyper signal medullary lesion of about 3 centimeters localized at the level of L2-L3 intervertebral disk. The lesion was consistent with a vascular disorder caused by a fibrocartilagenous emboli.

Sara started a therapy with corticosteroids for a week and also vitamins and antioxidants. The second day after the incident she started also rehabilitation.

At the first visit the patient was paraplegic with no deep pain sensation and also incontinent. The spinal reflexes were present and normal and the cutaneous trunci reflex was lost at the level of L3 – L4.

Sara on ground treadmill

Sara on ground treadmill

For the first sessions she did transcutaneous electrical nerve stimulation for 30 minutes followed by   class IV laser therapy, 8 – 10 joules per square centimeter. After that modalities we started static balance exercises on the peanut shaped physio roll and reflex exercises on the proprioceptive plate. We introduced also the underwater treadmill but she was not able to move the hind legs.

For the home exercises we recommended to the owners to perform passive range of motion exercises and assisted standing followed by weight shifting exercises, 2-3 times a day; also, we instructed them to try the flexor – reflex exercise.

Sara - therabands on ground treadmill

Sara – therabands on ground treadmill

The sessions were performed twice a week and after 10 days she was already able to maintain the standing position on her own, and also started to show some motion in the hind legs. After 5 sessions she started to perform walking in the underwater treadmill; for the home exercise we instructed the owners to start with assisted walking exercise and more weight shifting and balance exercises.

After 6 sessions she became ambulatory but with severe proprioceptive and motor deficits, so we introduced also ground treadmill with incline and then with resistive elastic bands. We increased the time spend in the underwater treadmill up to 25 minutes and also, gradually, we introduced cavaletti rails and weave polls exercise.

For the home program she had to walk assisted on inclines, on stairs, on sand and grass, and also to start sit-to-stand exercises.

Sara - underwater treadmill

Sara – underwater treadmill

After 12 sessions, Sara is now ambulatory with mild proprioceptive deficit on the left hind leg at walking, and a little bit more uncoordinated at trotting and turning. The strengthening exercises were increased with more resistive elastic bands on the ground treadmill and with more speed on the inclines, and of course with higher speed and lower water in the underwater treadmill.

She is still doing rehabilitation because we need to correct all the proprioceptive deficit, as much as possible, and also to increase the muscle mass in the hind legs. We are also very happy because during the rehabilitation we were able to reduce her weight with 6 kilograms, from a body condition score of 8 out of 10 to a 6 / 10.

References:

  1. Bockstahler, Barbara; Levine, D.; Millis, D. “Essential Facts of Physiotherapy in Dogs and Cats. Rehabilitation and Pain Management”  –  2004
  2. Millis D.L.; Levine D. “Canine Rehabilitation and Physical Therapy” 2nd; Elsevier, 2014

Treatment of uterine leiomyoma , Case report

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Dr Miroslav Todorov Blue Cross Small Animal Veterinary Clinic , Sofia, Bulgaria

Uterine tumors consist of 0.3 to 0.4% of all canine tumors. Leiomyomas and leiomyosarcomas are the most common, accounting for approximately 90% and 10%  respectively. These are tumors which arise from smooth muscle cells. The gastrointestinal tract is most commonly affected, but these tumors could affect also the genitourinary tract, the spleen, the liver and the subcutaneous tissue.

The etiology of uterine tumors is still unknown. Mutations of the fibroid-type mediator subcomplex 12 gene (MED12) have been found in a few canine genital leiomyomas but the role of these mutations in uterine tumors is unknown. Canine uterine leiomyomas may be hormone-dependent, as this appears true in humans and in the case of canine vaginal/vulvar leiomyomas.

Uterine tumors can be clinically silent for a long period of time. Intact females may exhibit abnormal estrous cycles, with or without vaginal discharge. Dogs with uterine neoplasia may be infertile. Stranguria, dysuria and or constipation may occur secondary to physical obstruction by the mass. Abdominal distention, with or without a palpable abdominal mass, may be detected. Nonspecific signs of anorexia, lethargy, depression, weight loss, polydipsia, polyuria and vomiting may also be present. Some of these signs may be related to concurrent pyometra within the abnormal uterus.

Paraneoplastic syndromes associated with these tumors (more often with gastrointestinal location) are hypoglycaemia, diabetes incipidus and secondary erthyrocytosis.

Case history:

A  6 year old huskey, female intact was presented with complaints that it hasn’t been able to defecate normally for about a week. The dog was anorexic and during the last 2 days it started vomiting.

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Blood test

Clinical examination: The dog was in a depressive state, with normal temperature – 38,6˚C. The dog felt discomfort after abdominal palpation. The heart and lung sounds were normal. After examination of the genital area pale secretions from the vulva were discovered.

We took blood for blood count, biochemistry analysis and heartworm testing. The results on the blood count were WNL. From the biochemistry there were only increased numbers of ALAT – 116,9(5 – 60) IU and ASAT – 244.8 (5 – 55)IU. (fig.1) Heartworm – negative.

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x-ray

An X-ray of the dog’s abdomen was taken and a large mass located at the caudal part of the abdomen was discovered(fig.). This mass was compressing the urinary bladder, and the small and large intestines. The rectum was empty. After that we did an ultrasound of the abdomen and we found that this is a solitary mass, with hyperechoic density. Before going to surgery we took another X-ray of the thorax – everything was normal.

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Fig .3

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Fig. 4

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Fig.6

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Fig 7

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Fig. 5

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Fig.8

The dog was put under general anaesthesia and diagnostic medial laparotomy was performed. A large mass, coming from the uterine cervical area, was discovered. This mass was connected with the rectum and the urinary bladder (fig.3;4)The surgery from the begging started as normal ovariohysterectomy. The two ovaries were visualised and a ligature was placed on around the suspensory ligament and the vessels of the ovaries within the broad ligament and after that the uterus was separated from the mesometrium. When we reached the mass, we started to bluntly dissect the mass from the urinary bladder and the rectum. We managed to remove the mass from the rectum without complications. We separated the urinary bladder and about 3 cm of the urethra (fig.5). We did one linear cut of the proximal part of the mass – about 1-1,5 cm away from the urethra. This was tissue that was covering the tumor and when we opened a hole in it the neoplastic lesion was accessible for removal (fig.6). Slowly we separated the tumor from the rest of the tissues and we put a circular suture around the remnant vaginal tissue.Additionally we put several simple interrupted sutures of the same structures and at the end we managed to close the defect (fig.7 and 8).

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Fig. 9

After that the area was cleaned with saline and the surgery was finished in a standard way.

 

 

The removed mass was with size 27/14 cm and weight of 1,3 kg. This is the biggest uterine mass removed at this point at my practice (fig.9). The mass was sent to a foreign laboratory for histology (fig.10). The results were consistent with Leiomyoma.

 

The only complication during the postoperative period was urinary incontinence. We treat this with Propalin(Phenylpropanolamine) but to this point the dog didn’t respond and is still incontinent. During the last conversation with the owner we discussed control check-up and additional treatment plans for the incontinence.

Leiomyomas are benign tumors that comprise 85-90% of all canine uterine tumors.2 They tend to be slow growing, noninvasive, and do not metastasize.Usually  an ovariohysterectomy is curative.