Hypothyroidism in dog

10615967_4509428271902_7318235873151930765_nDr. Marta Todorova

Veterinary Clinic Ruse, Bulgaria

 

Clinical case

Case description

Dog , male , entire, five years old was evaluated because of signs of hair loss. The name of the dog is Ares. He lives in apartment with his owners.

History

About two years ago the dog has easily epilated hairs. The coat is typically thin on the neck  , on the head and on the trunk symmetrically. The is crusts  on the all body. Some parts of the skin are depigmented. Alopecia is growing to the tail. Hair regrowth non  existent.It was unhappy dog.

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Diagnostic approach

  • Skin tests
  • Brushing test- a lot of crusts
  • Scotch test – negative
  • Cytology – negative
  • Scratch test – negative
  • Trichogram – more hairs in telogen phase
  • Blood test – FT4 7.84 pmol/l

 

 

Therapy

-Levothyroxine 10micrograms/ kg/2twise daily

-Dermoscent – ones a week, for four weeks

-Dermacomfort

– washing with Sebolytic

 

There are visible results two months after therapy and the dog regained his previous behavior.

Blood test after therapy – FT4 19.17pmol/l

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WSAVA, Hill’s 2017 Announce ‘Next Generation’ Veterinary Award Winner

wsava logoJudges praise commitment to raising standards of veterinary care in the Balkans

TOPEKA, Kan. (21 July 2017) – Dr. Luba Gancheva, a Bulgarian veterinarian who now lives and works in Romania, has been named by the World Small Animal Veterinary Association (WSAVA) and Hill’s Pet Nutrition as the winner of the 2017 ‘Next Generation’ Veterinary Award.  The award acknowledges the work of a veterinarian who graduated within the past ten years and who has contributed significantly to the betterment of companion animals, the veterinary profession and society at large.

 

“Millennial vets carry the future of the profession with them,” said Dr. Jolle Kirpensteijn, ‎Chief Professional Relations Officer at Hill’s Pet Nutrition.  “Luba has demonstrated a strong commitment to improving the experiences and education of early-career veterinarians. She has also taken positive steps to connect these next-generation professionals with ones who are already established in the field.”

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Dr Luba Gancheva

Dr. Gancheva will be presented with her award at the WSAVA World Congress 2017, which takes place Sept. 25-28 in Copenhagen, Denmark.  She will also give a lecture entitled: ‘A high professional level of veterinary medicine is offered in the Balkans.  True or false?’

The Balkan Peninsula extends from Central Europe to the Mediterranean Sea and includes the countries of Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Greece, Macedonia, Montenegro, Romania, Serbia, Slovenia and the European part of Turkey.

Dr. Gancheva graduated from the Faculty of Veterinary Medicine of the University of Forestry in Sofia, Bulgaria, in 2010, and began working in a small animal practice in the city. She demonstrated her commitment to continuing education and received a Master of Science in Infectious Diseases from Triaka University in Bulgaria.  She now lives in Bucharest, Romania, and works at the Cabinet Filip Veterinarul animal hospital.

 

Her PhD thesis, entitled ‘Clinical Manifestation of Brucellosis in Dogs, caused by Brucella Canis,’ was based on a study she conducted on the incidence of this disease in the Balkans.  As a result of her thesis, Dr. Gancheva was invited to speak at two congresses in the Balkans, where she realized how enthusiastic her colleagues in the region were to continue their professional development.

 

In 2015, she launched an online veterinary journal called ‘Vets on the Balkans,’ with the goal of helping regional veterinarians work more collaboratively and share their experience and knowledge.  The journal has presented more than 90 cases and has developed a strong readership. It has also built partnerships with many of the key companion animal veterinary associations in the region.

Building on this success, Dr. Gancheva in 2016 launched an initiative called ‘Learn and Travel with Vets in The Balkans’.  The program enables veterinarians to increase their knowledge and experience by working in clinics in nearby countries. The first placements were made earlier this year, and they were supported through sponsorships and donations from 12 participating practices in Bulgaria, Turkey, Romania, Belgium, Italy and Croatia.

Dr Käthi Brunner, Chair of the WSAVA’s Leadership and Nomination Committee, said: “Tackling the inequality of education and resources available to veterinarians depending on where in the world they are working is one of the key challenges facing the profession.  Dr. Gancheva has taken some very practical steps to support the development of the profession in the Balkans, both through launching the journal and through the new ‘Learn and Travel’ scheme.  We congratulate her and hope that both of these initiatives continue to prove successful.  She is a great example of a Next Generation veterinarian who is showing a very personal commitment to raising standards of veterinary care.”

 

As the winner of the 2017 ‘Next Generation’ Veterinary Award, Dr. Gancheva will receive a monetary gift, an engraved plaque and a WSAVA certificate.

 

Dr. Gancheva said: “I would like to express my gratitude for the Award. It is the biggest honour of my life and I am excited to be part of WSAVA World Congress this year.  During my lecture, I will present clinical reports from my journal from each country in the Balkans to show that, while we may have economic difficulties, our passion for knowledge and love for animals give us strength.  When you cure an animal, you change the world for someone, so veterinarians change the world. Thank you WSAVA!”

 

Hill’s will fund Dr. Gancheva’s attendance at the 2017 WSAVA World Congress so that she can accept her award.

 

Candidates for the WSAVA, Hill’s Next Generation Award can come from any country and must meet the following criteria:

  • Graduated within the past 10 years
  • Active in continuing education
  • Have a strong record in community service
  • Working to bridge the gap between their generation and others

 

The WSAVA’s 101 member and affiliate associations represent more than 200,000 individual veterinarians from around the globe.  They work together to advance the health and welfare of companion animals.  Hill’s is the WSAVA’s most long-standing and significant industry partner.

 

Candidates for the 2018 Next Generation Award can nominate themselves by sending an email to yourwsava@wsava.org by Jan. 1, 2018. They should include a letter of intent, a CV and at least one reference letter. Further information can be found at www.wsava.org.

 

 

About Hill’s Pet Nutrition

 

Founded more than 75 years ago with an unwavering commitment to pet nutrition, Hill’s mission is to help enrich and lengthen the special relationships between people and their pets.  The right nutrition, combined with the devotion of veterinary professionals can transform the lives of pets; and healthier and happier pets can transform the lives of pet parents.  Hill’s is dedicated to pioneering research and ground-breaking nutrition for dogs and cats based on a scientific understanding of their specific needs.  HILL’s® Prescription Diet® therapeutic pet foods. HILL’s® Science Diet® and HILL’s® Ideal Balance™ wellness pet foods are sold through veterinarians and pet speciality retailers worldwide.  For more information about Hill’s, our products and our nutritional philosophy, visit us at HillsPet.com, HillsVet.com for Facebook, keywords “Hill’s Pet Nutrition.”

” A neoplasia in left midbrain in dog”

dim

Dr Dimitar Ivanov

Dr Dimitar Ivanov,
Veterinary surgeon, Neurology specialist
Dobro hrumvane veterinary clinics
Sofia, Bulgaria

 

 

 

Case report

Dog, Bleki, toy terrier, M, 5 yo.

Came in the clinic on 11.04.2017 with left circle movements, menace deficit on the left and no reaction when stimulating the nasal mucosa.  On the right, spinal reflexes are decreased and there are no conscious proprioception.

Doubt for brainstem problem.

Differential diaggnosis:

V – vascular – it’s with peracute onset

I – inflamatory – it’s possible but no changes in blood sample

T – toxic – The dog did not take any medication, fed the same food and was not seen taking unusual things, but it’s not unpossible

A – anomalous – тhe dog is 5 years old and it is unlikely that there will be any manifestation of these diseases

M – metabolic – there is no other clinical signs or any changes in blood samples.

I – idiopathic – there is no seizures and vestibular signs

N – neoplastic – it’s more possible

D- degenerative – the dog is too young for cognitive dysfunction and too old for other degenerative diseases.

We made MRI on 12.04. and found a lesion in the left mesencephalon.

dhs dhs1 dhs2

 

 

 

 

 

 

 

 

 

 

The final diagnosis is neoplasia in left midbrain.

 

We started to prepare for surgery.

The antibiotic preoperative was Ceftriaxone 30 mg/kg i.v., Manitol 1 g/kg i.v. and Methylprednosolone 20 mg i.v.

The surgery was on 22.04.2017 and we made a left craniotomy and displacement of the temporal lobe dorsolaterally until the lesion was reached.

Bleki preoperative video:

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Pic 1

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Pic 2

The skull was open and we enlarged the hole with Kerrison rongeur (pic 1 and 2)

 

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Pic 3

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Pic 4

We aspirated the brain liquor and very slowly reverse the left temporal lobe.( Pic 3 and 4)

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Pic 5

When we found the lesion we punctured the cyst formation and drew the liquid contents.( pic 5)

 

 

 

 

 

 

 

 

 

 

The reason to do this surgery was to try to reduce the pressure in the tissue and to improve the dog’s condition.

After surgery we continued the antibiotics in the same dose and methylprednisolone in the same dose for three days. After then the dose was reduce to 2 mg /kg.  After few days the methylprednisolone was change with prednisolone and started to reduce the dose.

Until the methylprednisolone is reduced, the patient is better every day, improves motor activity, appetite, but fails to maintain a constant temperature. A corneal ulcer of the left eye appears – I guess the cause is a trauma to the left oculomotor nerve and reduced lacrimation.

On 28.04. we included one more antibiotic – amoxicillin with clavulonic acid.

On 29.04. the prednisolone was reduced to 0,5 mg/kg, the dog was with anisocoria (myosis on the right eye and mydriasis on the left). On 30.04. the circle movements on left started again.

We tried to find Lomustine for chimiotherapy but we couldn’t and increased the dose of the prednisolone to 2 mg/kg

 

Bleki 22 days after surgery:

 

 

Bleki 23 days after surgery

The dog is good, he walk normally but when he stops, he start to make circle movement on the left.

 

1st Bulgarian Dermatology Congress , organised by BAVD

14612382_553114001550481_6070253379668782534_oFirst Congress of Bulgarian Association of Veterinary Dermatology held in 27-28th of April, 2017 at city of Plovdiv, Bulgaria. There were more then 120 veterinarians from Bulgaria, Macedonia, Romania, Greece and Cyprus.

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Dr. Emmanuel Bensignor and Dr. Sebastian Viaud, who impressed the audience with the way information was provided, but also the way all the scientific information was presented so to be useful in every-day-practice. They   discussed which one is the best elimination diet, which medicine is effective in the control of canine atopic dermatitis and how to use them appropriately? How to do Desensibilisation therapy? How to perform biopsy from unusual places? How to recognize vasculite lesion and how to deal with it?18209350_640038969524650_2972147177502418052_o

Vets on The Balkans support BAVD submit one free ticket for 4th Latin American Congress of Veterinary Dermatology to be held in
Merida, Mexico from 13th to 16th of June 2018  and one free ticket for 4th Romanian Dermatology Congress , October, 2017. Their members are presenting clinical reports and the best one will win. All of the cases will be posted in the journal Vets on The Balkans.

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Dr Ana Maria Boncea, Vetderm Therapy in Bucharest, Romania

 

“I would like to thank you one more time for this opportunity. It was great event!! Congratulations for everything! See you soon!!”

 

Dr Daniela Bajenaru, Tazy Vet Veterinary Clinic in Bucharest, Romania

 

“Dear Luba, the 1st Bulgarian Veterinary Dermatology Congress was excellent, the lecturers gave us a lot of useful information and the organization was great!”

 

Dr Adriana Cosma, Conforvet on Bucharest, Romania.

 

“ Hi Luba! I wanted to tell you that we thank you for everything…we had wonderful time. We liked very much the BAVD Congress and the city of Plovdiv!”

 

 

The team of Vets on The Balkans congratulated BAVD for the high professional level of organizing and the brilliant scientific program.

Learn and Travel……. stories from the vets! Dr Daniela Bajenaru at Central Vet Clinic in Sofia

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Dr Daniela Bajenaru and Dr Ivelina Valcheva

Dr Daniela Bajenaru, working in vet clinic Tazy-vet in Bucharest, Romania with the sponsorship of Pamas Trading SRL have done her externship at Cenral Vet Clinic in Sofia, Bulgaria. Let’s her tell us about it :

                   My wonderful experience in Sofia at the Central Vet Clinic

It all started with a simple decision to try my luck at a contest organized by the Vets on The Balkans, that was a first step in a wonderful walk. Dr. Luba Gancheva told me about this possibility of externship at the Central Vet Clinic in Sofia, and I said why not, we always have something to learn from those around us.
At the Central Vet Clinic I met only welcoming and beautiful people. The management is at a very high level, they are very well organized. I admired very much their way of dealing with the hospitalized patients and their X-ray techniques.There the doctors, besides their great experience, have all the necessary equipment to establish a quick diagnosis of certainty.
On my first day I remember that I was very impressed by the large number of patients who walk into the clinic, I think they were around 150. They always manage this with a lot of professionalism.16 5 3
The surgery rooms are very rarely free. I think that the most difficult cases from Sofia (and not only) come to them.
Because my greatest passion in the veterinary field is dermatology, my time spent in the Central Vet Clinic has been allocated , for the most part of it, in the dermatology department with Dr. Iveline Vacheva. For her I have only wonderful words. I see in her a very dedicated doctor, with many ambitions. I had the opportunity to see a lot of interesting cases, one of them was about a young cat with degenerative mucinotic mural folliculitis. I know that this affection is quite rare…so, great job Dr. Iveline!7111 2
My days were my own to plan and fill. I had a little time to visit also Sofia. I took a walk on the Witashe Mountains, I climbed up to the Boulder slopes, called ” stone rivers” or “morains” in Bulgarian and in some English language guidebooks.
It was a great experience for me, I left with a lot of practical ideas for home. I will definitely come back again in Sofia to the Central Vet Clinic!8 9

14
Thanks to the all team for all the goodwill they have shown, they always answered to my questions.
Thank you Dr. Ranko Georgiev for all the kindness, for sure in the future you will do more then that for the Central Vet Clinic!
Thank you Vet on The Balkans, Dr. Luba Gancheva, Pamas Traiding and Tazy-vet, because you made this possible!12814393_1673705086236432_1339900710371625092_n

Learn and Travel…..stories from vets!

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Dr Constantin Ifteme

endo8

externship

In March 2017, Dr Nadejda Tsureva, working at Veterinary Clinic ” Dobro Hrumvane” in city of Sofia, Bulgaria, has done her externship at Centru de Endoscopie si Chirurgie Minim Invasiva Veterinara with Dr Constantin Ifteme in city of Bucharest, Romania.endo3endo6

What is the opinion of Dr Nadejda Tsureva:

“Dear colleagues and friends,

I want to thank you for the opportunity of spending some precious time in Centru de endoscopie si chirurgie digestiva veterinara in Romania. Thanks a lot to Vets on the Balkans and the Vet team of the endoscopic center.
I had the chance of meeting new friends and family. Had the chance of learning from great professionals and great people. Working with love for the animals is really important and when combined with knowledge and great skills that is how “magic” is happening. I am really pleased to know that there are more people of that special “breed”.
Thank you all for the knowledge and the smiles you shared with me.
Hope to see you again.
To my Romanian family with love.
d-r Nadezhda Tsureva
We would like to express our gratitude to Dr Constantin Ifteme and brilliant team for everything. We are proud to have you on The Balkans , such a high level of professionalism and big heart!endo4 endo2 endo5

Learn and Travel……. stories from the vets!

learn and travelLast month started for the first time our project ” LEARN AND TRAVEL WITH VETS ON THE BALKANS”. Dr Andrey Ginchev from Bulgaria, working in Blue Cross veterinary clinic in city of Sofia, and Dr Cristian Badulescu, main vet and owner of Blue Point Vet veterinary clinic in city of Bucharest, Romania have done their externship at Clinica Veterinara Lago Maggiore – Dr Lugi Venco , Dr Luca Formaggini and Dr Mariangela De Franco. Both of them have stayed 2 weeks. I think is better they to speak about the adveture.

Dr Andrey Ginchev:

I have so many good things to say about this externship. Firstly, it was the best experience of my life! The doctors  are amazing,especially Dr Luca Formaginni and Doctor Luigi Venco –  the best doctors I ‘ve ever seen in my life.17309856_1747923415519034_2303429150324906549_n 17342975_1747923572185685_5866766753935364961_n

The team was very well organized,very welcoming and really friendly with me. I met a lot of people from Italy and had great time with them. I became more flexible to changes, more ambitious and more sociable. My desire to travel is increased. Also this practise  helps me to gain my confidence in my own abilities,so now I am more self – confident in my work.I improved my English language and also I learned a little bit Italian…,Grazie and Thank you!!!I hope to see my  Italian friends again.

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Dr Andrey Ginchev with the team of the clinic

I´m so thankful for this experience, Thank you very much for this opportunity that you gave to me!17352518_1843303222609950_1508220180873091218_n


Dr Cristian Badulescu :

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Dr Cristian Badulescu with the team of the clinic

Before I go to Lago Maggiore Clinic, I looked on the internet to see what’s going on there. I saw them with equipment high-technology facilities. I saw that they are capable and do surgical maneuvers excellent and it’s a veterinary clinic with a very good reputation. I can therefore expect to find here and a little superciliousness, or even some superiority. But it was not so! I found wonderful people, full of positive energy. Highly trained people who know exactly what they do. But what I liked most is modesty and their openness to sharing information. They do not want to hide anything. If you know what questions to put, you get all the information you need. 17522631_1751933485118027_6444855593354748323_n 17498712_1751933001784742_8726199192797128569_nI had the honor to talk to Luca Formaggini, Luigi Venco and Giorgio Romanelli. They are true celebrities in the world of veterinary medicine in Italy. I talked a lot about a lot. The impression to me of all is that all are governed by modesty and good will. So, I thank you Vets on the Balkans for this oportunity to meet great people! Great job! Bright future!17626459_1751932908451418_3868390825708698876_n 17554387_1751934088451300_4726607108209581561_n

And of course the opinion of Dr Luigi Venco:

It ‘s Always a great experience to meet and work with enthusiastic and motivated people like Dr. Andrey Ginchev and Dr Cristian Badulescu. Exchanging knowledge and experiences and find to be friends at the end. Thanks Andrey and Cristian! Thank you Vet on the Balkans!
 Vets on The Balkans
The team of Vets on The Balkans would like to express their gratitude to ALL THE VETS included in the project! THANK YOU Clinica Veterinara Lago Maggiore – Dr Lugi Venco , Dr Luca Formaggini and Dr Mariangela De Franco for the opportunity! In fact, You are Vets on The Balkans, we are just the technical part.
Thank you as well to our sponsors Pamas Trading SRL , Romania and Bayer , Romania. Because of you Vets on The Balkans is alive.

 

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

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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

 

CANIN HYPERCORTISOLISM (CUSHING SYNDROM)

daniDr Daniela Bajenaru

Tazyvet veterinary clinic

Bucharest, Romania

 

Singalment and hystory

 

Bella, presented on 12/13/2016

10 year old, female, Labrador retriever

5 month history of polydipsia, polyuria, polyphagia and pruritus

 

Physical examination

 

Abdominal enlargement

Palpable hepatomegaly

Thin, hypotonic skin, easy bruising

Phlebectasias

Erythema

Calcinosis cutis over the dorsal neck, thorax and rump

Bacterial pyoderma

 

 

 

6 1 unnamed7

 

 

 

8 9 4 10

Investigations

Ultrasound

Urinalysis

Coagulation time

Serum chemistry panel

Trichogram, scoch test

Bacteriological examination

ACTH stimulation test

 

Laboratory results

Ultrasound- hepatomegaly

Urinalysis – low specific gravity (1.005)

Coagulation time – 5’

Serum chemistry panel: GPT -361,  ALP>1980, CHOL- 215, CREA -0,587, UREA -25,2

Trichogram/ scoch test – no significant findings

Bacteriological ex. – Staphylococcus aureus  (++++)

Basal cortisol level  > 10 µg

ACTH stimulation test – cortisol= 29,4 µg/dl

Diagnosis

CANIN HYPERCORTISOLISM (CUSHING SYNDROM)

SUSPICION: PITUITARY DEPENDENT

 

Treatment

TRILOSTANE -120 mg once daily

Amoxicillin with clavulanic acid -12,5 mg/kg/12h, 30 days

Probiotics

Topical: – moisturizing and desinfectant shampoo, once weekly

– antiseptic, anti inflammatory and healing gel, once daily

EFA supplements

Diet: low fat

EVOLUTION

After 3 days of topical treatment

15

After 3 days

Basal cortisol level      > 10 µg/dl

13

After first bathing

 

 

Bella1

21

After 7 weeks basal cortisol – 5,3 µg/dl

22

After 7 weeks basal cortisol – 5,3 µg/dl

Bella3

The evolution to be continued ….

Resection of a chest wall mass- surgical technique and peri-operative analgesia

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Dr Vladislav Zlatinov

Corresponding authors :

Dr. Vladislav Zlatinov, Dr. Aglika Yordanova (Clinical pathologist), Dr. Nadejda Petrova (Anaesthetist)

 

Central Veterinary Clinic

Chavdar Mutafov str, 25 B, Sofia, Bulgaria

 

Introduction

 

Rib tumors are uncommon in small animals. Osteosarcoma (OSA) is the most common (73%). Other types include chondrosarcoma (CSA), fibrosarcoma (FSA), hemangiosarcoma (HSA).

Rib tumors tend to occur in large breed dogs and the usual location is in the costo-chondral junction. Radiographic changes include lysis, sclerosis, or a mixture of lytic and blastic patterns. Intra-thoracic invasion of adjacent pericardium and lung lobes is relatively common, so CT scans are recommended to determine the location and extent of the tumor, planning of the surgical resection, and clinical staging for pulmonary metastasis1.

 

Chest wall resection is recommended treatment for the rib tumors 2. The surgical approach is the identical to intercostal thoracotomy, but caudal and cranial margins include a minimum of one intercostal space and rib, while ventral and dorsal margins should be a minimum of 2 cm from the tumor.  Because of the large defect present, a need for autogenous and/or prosthetic reconstruction techniques is often necessary. Autogenous reconstruction techniques include the latissimus dorsi and external abdominal oblique muscles, and diaphragmatic advancement following resection of caudal rib tumors 3. Prosthetic reconstruction with non-absorbable polypropylene mesh, alone or in combination with autogenous techniques, is recommended for large defects. Autogenous reconstruction is preferred in humans because of a high complication rate associated with prosthetic mesh, such as infection and herniation. These complications are rarely reported in dogs following chest wall reconstruction with prosthetic mesh. Up to six ribs can be resected without affecting respiratory function in dogs 4.

Thoracic surgery in small animals is considered a painful procedure, resulting in alterations in pulmonary function and respiratory mechanics. Appropriate analgesic protocol may improve outcomes. Systemic administration of opioids and NSAIDs, intercostal and intrapleural blocks, and epidural analgesia are among the most common options for pain management after thoracic surgery in small animals 5.

 

 

Case report

 

A 10 years old male pitbull dog, weighting 24 kg was presented to us. The owners had been to three veterinary consultations before, the chief complaint being lameness at the right front limb. The cause was suggested to be a “lump” on the right thoracic wall. Based on an X- rays study and clinical examination, so far the owners were discouraged to pursue the further surgical treatment, because the procedure was supposed to be too aggressive and painful. The dog was prescribed palliative NSAIDs therapy.

 

 

Clinical examination

 

Fig1

Fig.1

We did a thorough clinical exam, revealing normal behaviour, good over-all body condition; signs of multiple joint arthritic diseases were found- elbows and stifles decreased ROM and capsules thickening. On the right cranio- ventral thoracic wall we found protruding, egg- size oval mass, widely and firmly connected to the rib cage (Fig.1).

 

 

 

Diagnostics

 

Radiograph of the right elbow revealed advanced elbow arthritic changes.

Fig 2

Fig.2

Additionally, orthogonal thoracic radiographs (+ oblique one) were done, demonstrating large infiltrating mass, with heterogenous lytic and proliferative mineralised pattern, originating at the costo-chondral junction of the 4-th rib (Fig.2).

 

 

 

 

 

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Fig.3

A fine needle aspiration was done and evaluated (Fig.3).

The pathologist remarks:

“Clusters of  fusiform mesenchymal cells, with obvious signs of malignancy- pleomorphism, increased anisokaryosis and anisocytsosis, basophilia, multinucleated cells . Occasional osteoclasts, macrophages and neutrophils were noted. No osteoid/chondroid was found in the examined material. The tumor was classified as malignant mesenchymal– fibrosarcoma, chondrosarcoma or osteosarcoma.”

 

 

Fig4

Fig.4

A computer tomographic study was accomplished and the mass’s margins investigated carefully. A mineralised tumor centre (from the distal third of the 4-th rib) was found; also soft tissue aggressive expansion in the neighbour intercostal spaces -3-th and 5-th. Typically for the chest wall masses, there was an eccentric growth- the 2/3 of the mass volume protruding into the throracic cavity, extruding the pulmonary parenchyma and contacting the heart on the right side. No lung metastases were noticed on the scans (Fig.4, video 1).

 

Complete blood work was done and found normal. Including normal Alkaline Phosphatase level, considered favorable prognostic factor.

 

After a discussion with the owner, a decision for surgical resection was made.

 

 

Anesthetic protocol

 

Premedication with Medetomidine and Butorphanol was used, followed by Propofol induction. The maintenance was sustained by Isoflurane and Ketamin drop in the fluid sack.

 

Peri-operative analgesia, Anesthetists remarks

 

fig 5

Fig.5

fig 6

Fig.6

The thoracic wall resection is considered very painful procedure, so a corresponding analgesic strategy was built and applied. A continuous post operative segmental epidural analgesia application was provided. T13—L1 epidural puncture (by Tuohy needle), was done and an epidural set catheter (B. Braun) was inserted till the 5-th thoracic vertebra(Fig.5-6). The catheter was safely attached and maintained for 48 h post op, during the patient’s stay in the clinic. The agent delivered through, was Levobupivacain (0,5 %), one 1ml every 4 hours, including pre op.

 

 

After the mass removal, a soaker catheter was sutured at the ribs resection edges; another one was applied between the skin and muscle flap, covering the defect. Both catheters were connected to an elastomeric pump (B. Braun), delivering locally 5 ml/h of 1% Lidocain for 96h (including outpatient period) post operatively.

 

The rationale behind additional soaker catheters was to suppress maximally the nociception transfer, including the sensation through the non- blocked cervical spinal nerves. Also we contemplated- removal of epidural catheter at the time of discharge, but leaving the delivery pump, providing residual local analgesia.

 

Cimicoxib (Cimalgex) was prescribed for 10 days post op. No opioids were used in the recovery period.

 

 

 

Surgical protocol (surgeon remarks)

 

Fig7

Fig.7

Fig 8

Fig 8

Fig 9

Fig 9

fig10

Fig10

After macroscopic mapping and drawing, a rectangular shaped, full thickness (skin, muscle, ribs and pleura) en bloc excision was done (Fig.7).  This included partial ostectomy of 3-th, 4-th and 5-th ribs. Caudal intercostal thoracotomy was performed first, permitting evaluation of the intrathoracic extent of the tumor. Special attention was applied at the proximal approach to ligate safely the three intercostal arteries and veins. No visceral lung pleural or pericardium adhesion were noticed. Careful electrocautery haemostasis was done at the muscles’ cut edges.  The removed mass was macroscopically evaluated for “clean” margins, and a reconstruction of the large defect was preceded (Fig.8). A double (folded) polypropylene mesh (SURGIPRO®TYCO) was sutured to the wound edges, using simple interrupted pattern (3-0 PDS material). A latissimus dorsi muscle flap was advanced to cover and “seal” the defect (Fig.9). The air content was evacuated with aspirator on the final closure; no chest drain was left in the thorax. Two soaker catheters were applied in the wound; the skin was closed by double pedicle advanced flap technique and simple interrupted pattern (Fig.10).

 

 

 

 

Post operative care and follow up

 

 

 

Fig 11

Fig. 11

The dog’s chest was loosely bandaged; the elastomeric pump and epidural catheter were securely fixed to the body(Fig.11). I.v. antibiotics and fluid support was continued for 24 hours post op.

Provided very effective local analgesia- the dog revealed excellent comfort immediately after the surgery (video 2,3,4). We paid special attention to any pain signs- excessive vocalization, hyper-excitement, panting, tachycardia, behavior abnormalities, etc. No such were present and the patient started eating the next day after surgery; it was discharged 48 after the procedure. No ambulation deficits were seen with the Levobupivacain application. The elastomeric pump was removed on the 4-th day. Mild to moderate serosanguineous discharges from the wound were present for 10 days after the surgery.

On the 14 days recheck the wound was healed and the sutures were removed; the patient showed excellent clinical recovery (Fig.12).

 

 

 

 

Discussion

 

 

The surgical excision is considered the first treatment of choice for malignant rib tumors, but a question about the long term prognosis and rationale behind an aggressive surgery could be raised. As mentioned above, the most common rib tumors are osteosarcomas (OS)  and chondrosarcomas(CS). They have quite different prognosis- OS is rarely cured, whereas CS could be cured with surgery alone. Dogs with osteosarcoma that have elevation of the Alkaline phosphatase level have a much lower median survival times 6. Chemotherapy significantly increases the survival of dogs with rib OS- from a few months to about 9.5 months. Roughly survival time is increased 4 times with chemotherapy + radical resection, compared to surgery alone. Chondrosarcomas have a very good chance to be cured with surgery alone with median survival times exceeding 3 years. The other common type -fibrosarcoma and hemangiosarcoma have intermediate metastatic potential between the other two. Survival times ranging from 120-450 days with chest wall resection alone 7.

 

Dealing with motivated owners, a patient in good general health, with normal AP, and need for moderately large rib case resection size, we found good indications for tumor removal without preliminary histological verification. We suggested acceptable life expectancy in the worst tumor type scenario (the option for chemotherapy was available). While respecting previous vets’ opinions, we took into consideration the stated in the literature fact that dogs tolerate removal of a large portion of the rib cage very well.

 

Despite all this encouraging decision making facts, we would have fought ethical issues in a scenario we weren’t able to provide sufficient peri-operative analgesia of the patient. Except the ethical side, the pain associated with thoracoectomies may have potentially lethal consequence for the patient cardiopulmonary status after surgery. A thoracoectomy requires a very painful excision, involving multiple muscle layers, rib resection, and continuous motion as the patient breathes. Sub-optimal management of pain has major respiratory consequences. Inspiration is limited by pain, which leads to reflex contraction of expiratory muscles, and consecutively to diaphragmatic dysfunction (decreased functional residual capacity and atelectasis, hypoxemia).Treatment of acute post-thoracotomy pain is particularly important not only to keep the patient comfortable but also to minimize pulmonary complications 8.

 

In the veterinary literature there are suggestion for various types of analgesia provided after thoracotomies-  intercostal blocks, intrapleural lidocaine, incisional pain soaker catheters9; systemic agents as NSAIDs, opioids, NMDA antagonists (ketamine),etc. There is plenty of space for objective evidence based studies, proving the best analgesic protocol, yet.

In the presented case we applied sophisticated but uncommon noxious stimulus blockage strategy. The thoracic epidural catheter insertion is technically demanding procedure but it is very powerful tool for both intra and post operative pain control 10. Even more, it allows even preemptive pain blockage. So-called preemptive analgesia is intended to prevent the establishment of central sensitization caused by surgery induced injuries. Evidence from basic research has indicated that analgesic drugs are more effective if administered before, rather than after, a noxious stimulus.  Human studies report that the area of post-thoracotomy pain is more discrete and largely restricted to the site of surgery. Hence, any benefit of preemptive epidural analgesia is, theoretically, more apparent in thoracic surgery than in abdominal surgery.

 

It is interesting if the present tumor or the arthritic elbow lesions caused the primary clinical sign- front right leg lameness. Lameness of the forelimb had been described with costal tumors, located within the first four ribs 11. Possible mechanism is pain translation to the nerves to the limb, mechanical interference with movement or invasion into the muscles of the forelimb. After the surgical excision the owners reported lameness disappearance, supporting the tumor as the real cause.

 

 

CONCLUSIONS

 

Excision of malignant chest wall masses could be very successful. It is feasible to achieve clean cut margins; large residual wall defects could be managed with combined reconstruction techniques. Never mind the aggressive character of the procedure, an excellent patient comfort should be achieved with a combination of thoracic epidural and local wound nerve nociception blockage, as in this case.

 

 

Comments:

 

Just before the submission of this case report the histopathology result was received. It concluded:

 

Mass, originating from spindeloid to pleomorphic cells, highly cellular. The cells were round, organized in bundles and solid formations. There was moderate to marked anisokaryosis and anisocytsosis; mitotic figures frequently present, multifocally there is osetoid production.

 

Diagnosis: Malignant pleomorphic neoplasia, suspicious for osteosarcoma.

 

Long term prognosis:

 

In the case, no local recurrence is expected because of the wide margins excision. Generally the median survival time (MST) for dogs with rib OSA is 90-120 days with surgery alone and 240-290 days with surgery and adjunctive chemotherapy, and death is caused by distant metastases.  Age, weight, sex, number of ribs resected, tumor volume, and total medication dose do not influence survival disease-free interval 12.

 

A chemotherapy protocol is already being contemplated:

Carboplatin 300mg/sq.m.; 4 treatments q 21 days (Withrow and MacEwen Small Animal Clinical Oncology,2007)

 

 

If available, the long term result and the survival time of the patient will be followed and shared through the journal.