My Clever Friends (and What´s Your Diagnosis?)

Hi Everyone!

I hope you are all well, wherever you are in the world. It´s been lovely to catch up with some of you via email, and to those of you that I haven´t heard from lately, well I hope that you are having fun at work/holiday/home.

As I´ve mentioned before, I´m currently working at a vet clinic in West Bromwich. I was supposed to work here for 3 months, but the other day they asked me if I could stay a little longer, so at the moment it looks like I´ll be here at least until mid-August.

I have had a rather unusual case at work recently- a dog with a marked, moderately regenerative anaemia. After doing a couple of tests, and talking to the clinical pathologist at the lab here who looked at the dog´s bloods, and failing to find a cause for the anaemia, I got in touch with Brad and Karen in Manhattan (see earlier post in Kansas) to ask for some advice. They asked me to email them the results from the earlier blood test for them to look at. After looking at it, they made some suggestions on what they thought it could be and what tests I could do next (this dog was insured, so money wasn´t really an issue in the process of finding a diagnosis). And guess what? They were right!

So, I really just wanted to brag about how smart my friends are, and also say how grateful I am for all the help and advice they gave me. I can´t wait for them to become specialists (and move back to Australia), when I can refer all my difficult cases to them (or at least pick their brains, then take all the credit from the clients!!).Karen and Brad Acting Intelligent

Now, last year my former boss, Pete, suggested that I include some interesting cases in my blogs. So here it is for you Pete (and any other vets or medical personnel who still read this- so it might just be you Pete!). Perhaps Brad and Karen aren´t as brilliant as I thought, and maybe it´s just that I´m not as smart as the average vet, see how you go:

WARNING: The following contains some content which may be boring to some readers.
What´s Your Diagnosis?
A four and a half year old female neutered, crossbreed dog presented on Tuesday 6th May with a 2 week history of lethargy, inappetance, and weight loss (she weighed 16.6kg and had been 18kg in January and had the body condition of a skinny German Shepherd). She had vomited up bile once during that 2 week period. On clinical exam, her mucous membranes were pale and her temperature was 39.5C, otherwise there was NAD. Bloods were taken.

Results:
Haemoglobin Lo 6.2 g/dL (11.5 - 18.0)*
Red Cell Count Lo 2.57 x 10¹²/L (5.10 - 8.50)*
Packed Cell Volume Lo 0.20 (0.35 - 0.55)*
Mean Cell Volume Hi 77 fL (62 - 76)*
Mean Cell Haemoglobin 24.2 pg (20.0 - 25.0)
Mean Cell Hb Conc. 31.6 g/dL (30.0 - 36.0)
White Cell Count 7.7 x 10^9/L (6.0 - 16.0)
Neutrophils % Lo 50 % (55 - 75)*
Eosinophils % 3% (1 - 9)
Lymphocytes % Hi 43% (12 - 35)*
Monocytes % 4% (1 - 8)
Neutrophils Absolute Nos 3.85 x 10^9/L (3.30 - 12.00)
Eosinophils Absolute Nos 0.23 x 10^9/L (0.06 - 1.40)
Lymphocytes 3.31 x 10^9/L (0.72 - 5.50)
Monocytes 0.31 x 10^9/L (0.06 - 1.28)
Platelets Hi 546 x 10^9/L (200 - 500)*

Comments:
Moderate degree of red cell regeneration, (reticulocytes 5.9%)
Cytology appears poorly preserved
Anisocytosis

ALT/GPT Hi 55 U/L (10 - 40)*
AP 66 U/L (20 - 180)
Total Bilirubin 4.5 umol/L (0.2 - 6.8)
Cholesterol Lo 3.2 mmol/L (3.8 - 7.0)*
Serum Creatinine 94 umol/L (0 - 120)
Creatinine Kinase 107 U/L (30 - 150)
Gamma GT 5 U/L (0 - 28)
Glucose 4.4 mmol/L (3.3 - 5.8)
Total Protein 58 g/L (53 - 73)
Albumin 31 g/L (31 - 45)
Protein Globulin 27 g/L (18 - 38)
Urea 4.2 mmol/L (1.7 - 7.4)
Amylase 692 U/L (100 - 1000)
Inorg. Phosphorous Hi 1.7 mmol/L (0.9 - 1.6)*
Sodium 150.7 mmol/L (139.0 - 154.0)
Potassium 5.4 mmol/L (3.6 - 5.6)
Albumin/Globulin Ratio 1.1 (0.5 - 1.6)
Urea/Creat Ratio 0.04 (0.00 - 0.05)
Sodium/Potassium Ratio 28 (27 - 38)

Chloride 114mmol/L (99 - 115)
Calcium 2.2 mmol/L (2.1 - 3.0)
Bile Acid 6.4 umol/L (0.1 - 9.0)
Calcium/Phos Ratio Lo 1.3 (1.6 - 3.5) *

The results came back on the Wednesday afternoon, and as there was no external signs of haemorrhage, I prescribed prednisone at a dose of 1mg/kg BID whilst I waited to speak to the pathologist as to whether there were any spherocytes noted on morphology.

When I finally got hold of the pathologist on Thursday afternoon, he informed me that although cytology was poor, there was no sign of spherocytes and no evidence of haemolysis (total bilirubin also normal) and this anaemia was most consistent with a haemorrhage.

I phoned the dog´s owners and informed them to stop her prednisone, and to bring her in the next morning for further examination. When I examined the dog on the Friday morning, there was still no external evidence of haemorrhage. On questioning the owner, there was no evidence of melena, no blood noted in the dog´s bilous vomit, and absolutely no access to rat bait. She also reported that the dog had improved the previous day and was eating well again (after pred). So I admitted the dog to do some chest and abdominal radiographs (this clinic has no endoscope in-house). Apart from there being poor serosal detail in the abdominal rads (this dog is very thin, so not much fat for contrast), there was NAD on radiographs.

A stool sample was sent off for Faecal Occult Blood.

At this point, I sent the dog home with Cimetidine at 200mg BID, Sucralfate at 500mg BID, Ampicillin at 250mg BID and told the owner to start back on the prednisone.

It was at this point that I emailed Brad and Karen the above history and blood results.

So, there you have it: all the information that Brad and Karen had to ¨Crack the case¨. Now just ignore all the mistakes that I made, and not think about what you may have done differently from the start... What is your next step? What is the potential diagnosis?

The Faecal Occult Blood results came back on the Monday as Not Detected (I must admit that I didn´t put the dog on a red-meat free diet 5 days before doing this test).

For those of you who are interested in the results, email me, or comment here, and I´ll post what happened next in a future blog.

For those of you who aren´t interested, I apologise for boring you with the above entry and I´ll try to post a more entertaining blog next time!

Love,
Lis x.