scott@vtx-cpd.com

Replying to Emma Holt 02/07/2024 - 11:02

Hi Emma,

Thank you so much for these really brilliant points! How is maternity leave going?

This was a lab sample sent to an external lab, so it would not be unusual to get mild hypoglycaemia and hyperkalaemia due to transit, such as glucose consumption in transit and potassium increase due to haemolysis.

Your key problem list and DDX are perfect! I think ruling Addison’s out in this case is a great idea. We did run a basal cortisol test which returned at 100 nmol/L. Any result over 55 nmol/L is not consistent with Addison’s, so we were confident this was not the problem in this case. I was less suspicious of Addison’s due to the lymphopenia, but it was a good rule out. I love the possible link between Addison’s and GI bleeding, anaemia, and low albumin too. We can sometimes see increases in potassium due to haemolysis, which is not uncommon in samples transported to the lab. If in doubt, I would run the sample again on a fresh one in-house.

Regarding the possibility of liver disease, for glucose and albumin to decrease there would have to be over 75% liver function loss, which I think is less likely in this case. Albumin can decrease slightly with a negative acute phase response due to infections or inflammatory diseases. Often, globulin will increase in these situations (as it is an acute phase protein), which has not occurred in this case.

In the emergency setting, we did a POCUS scan of the chest and abdomen, and there was no free fluid. The in-saline agglutination was negative, and we examined a blood smear. I have shared the blood smear images below. I would love to hear your thoughts.

Again, great thinking and thank you for your valuable insights!

Best regards,

Scott 🙂

Replying to Yvonne McGrotty 01/07/2024 - 17:17

Thanks pal.

Scott x

Hello everyone!

I hope you are well!

I wanted to share the details of a radiographic report for one of my ongoing cases, Fluffy. Based on these findings, I recommended to the owner that we proceed with a CT scan and bronchoscopy, but these were declined at the time.

Radiographic Report:

Findings:

Multifocally throughout the pulmonary parenchyma, there are mild to moderate bronchocentric soft tissue opacities, some of which are slightly nodular in appearance.
In the DV projection, within the right middle lung lobe, there is a region of increased soft tissue opacity that completely silhouettes with the pulmonary vasculature. In the left lateral projection, an air bronchogram is present.
The cardiac silhouette is mildly displaced to the right and is otherwise normal. The pulmonary vasculature and pleural space are normal.
The included cranial abdominal and osseous structures are normal.
Conclusions and Recommendations:

Multilobar moderate bronchial to structured interstitial pulmonary pattern.
Right middle lung lobe alveolar pulmonary pattern.
Rightward mediastinal shift.
This constellation of findings is most consistent with inflammatory airway disease. The alveolar pattern in the right middle lung lobe combined with the rightward mediastinal shift may be indicative of lung lobe collapse due to bronchial mucus plugging.

Given the area of consolidation observed, I prescribed a two-week course of doxycycline, which seemed to resolve the clinical signs initially. However, these signs have since returned.

This is an ongoing case, and I am currently in discussion with Fluffy’s owners about investigating further with CT and bronchoscopy to get a clearer diagnosis and guide appropriate treatment.

Any thoughts?

Best regards,

Scott 🙂

Replying to Ursula Lanigan 23/06/2024 - 22:40

Hello Ursula,

I hope you are well!

I wanted to share the details of a radiographic report for one of my ongoing cases, Fluffy. Based on these findings, I recommended to the owner that we proceed with a CT scan and bronchoscopy, but these were declined at the time.

Radiographic Report:

Findings:

Multifocally throughout the pulmonary parenchyma, there are mild to moderate bronchocentric soft tissue opacities, some of which are slightly nodular in appearance.
In the DV projection, within the right middle lung lobe, there is a region of increased soft tissue opacity that completely silhouettes with the pulmonary vasculature. In the left lateral projection, an air bronchogram is present.
The cardiac silhouette is mildly displaced to the right and is otherwise normal. The pulmonary vasculature and pleural space are normal.
The included cranial abdominal and osseous structures are normal.
Conclusions and Recommendations:

Multilobar moderate bronchial to structured interstitial pulmonary pattern.
Right middle lung lobe alveolar pulmonary pattern.
Rightward mediastinal shift.
This constellation of findings is most consistent with inflammatory airway disease. The alveolar pattern in the right middle lung lobe combined with the rightward mediastinal shift may be indicative of lung lobe collapse due to bronchial mucus plugging.

Given the area of consolidation observed, I prescribed a two-week course of doxycycline, which seemed to resolve the clinical signs initially. However, these signs have since returned.

This is an ongoing case, and I am currently in discussion with Fluffy’s owners about investigating further with CT and bronchoscopy to get a clearer diagnosis and guide appropriate treatment.

Any thoughts?

Best regards,
Scott

Replying to Janette B. 24/06/2024 - 08:59

Hi Janette,

Great to see you again! Thanks for continuing to work with us. Your expertise in Anaesthesia and Analgesia is incredibly valuable, and I’m looking forward to your whirlwind tour. There’s indeed so much to learn and discuss.

Best regards,

Scott 🙂