scott@vtx-cpd.com
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Replying to Nadia C. 20/07/2023 - 20:05
Hello.
I am glad the recording was helpful.
Yes, there did seem to be a protective benefit of L4 over L2, so generally L4 would be recommended for that reason:
“In conclusion, being vaccinated with L4 was strongly associated with decreased odds to be diagnosed with leptospirosis compared to unvaccinated dogs, suggesting a protective effect against the disease. This finding is in contrast to the lack of association observed for L2-vaccinated dogs. Considering the level of evidence available at this time, results of our study support use of quadrivalent antileptospiral vaccines as core vaccines for dogs living in areas with a high incidence of leptospirosis caused by the included serogroups”.
Interesting question regarding the FISH. Yes, it can be run on samples in formalin. Most of the time FISH would be requested after the histopathology had been assessed, so normally it would be a test that is added later.
Hope that helps.
Scott 🙂
Replying to Nadia C. 20/07/2023 - 20:33
Hello Nadia.
I agree, it is much better to do it with someone/watch someone for your first one.
I was lucky with BM biopsies during my residency and got lots of support. We are actually currently discussing doing some practical days next year and this might be something we could try and do in person. Watch this space!
Scott 🙂
Replying to Nadia C. 20/07/2023 - 21:06
Hello Nadia.
Thank you so much for these brilliant comments. I love the case summary. This is exactly what we should be doing with these challenging cases, always go back to the initial problem list!
I think the red blood cell fragmentation changes are the really interesting part of this case. There are smaller number of spherocytes and ghost cells which would be consistent with IMHA. However, the other fragmentation changes are more prevalent and would not be consistent with IMHA. There are some boxes being ticked here for IMHA, but it would not be a confident diagnosis of IMHA in my opinion.
I think faecal occult blood testing would be a very reasonable test to run. Low albumin and globulin would be consistent with bleeding, but we do not see this in every case. The lack of low albumin and globulin does not rule out GI bleeding. Faecal occult blood testing was negative.
The 4DX would also be a good idea. None of the infectious disease organism that would be detected on this test would cause direct haemolysis, but could be part of a secondary IMHA type situation.
We did carry out chest radiography, which was unremarkable.
I agree, the PK deficiency is really unlikely.
SO… I think we have 2 main questions:
1. The splenic FNA’s are ‘normal’. Does this give you enough confidence to move on from the spleen?
2. Would you be confident enough based on the information you have to treat for IMHA?Thank you again for all of your brilliant thoughts.
Scott 🙂
Replying to Siriol B. 20/07/2023 - 22:05
Hey Siriol.
Lovely to hear from you!!! I am so glad you have enjoyed the course.
This is an interesting case. To my knowledge, most of the congenital cases have undetectably low levels of cobalamin:
https://pubmed.ncbi.nlm.nih.gov/23535754/
However, I would absolutely supplement cobalamin in this case. Honestly, the folate is probably less significant, but also worth supplementing in this case.
Would you be able to attach/send me the full blood results? You can attach here or email them to me scott@vtx-cpd.com.
Has the dog had any imaging? Thanks again for sharing this interesting case!
Scott 🙂
Replying to Nadia C. 16/07/2023 - 21:18
I think so!
FeLV is a really interesting topic… I find it super confusing too! I always have to review the diagnostic options and what they mean.
If you end up watching the webinar, let me know what you think!
Scott 🙂
Replying to Rosie Marshall 16/07/2023 - 21:32
Hey Rosie.
Thank you again for your brilliant questions. I do not think we have definitive guidelines regarding when to use CRP to stop antibiotics in pneumonia cases. I am happy stopping when the CRP is normal, but I would be understanding that other may err on the side of caution and continue a little longer.
HAHA, I agree regarding your comment regarding SRMA… a few year ago, that was the only condition I used CRP to monitor!
The use of CRP for ‘wellness’ is a really interesting discussion. They definitely use CRP in a much more sophisticated way in human medicine. They use it much more for decision making and also for antibiotic decision making. We have less evidence:
https://pubmed.ncbi.nlm.nih.gov/36713872/
https://pubmed.ncbi.nlm.nih.gov/32434519/I hope that helps.
Scott 🙂
Hello Talia.
Thank you so much for the brilliant questions.
1. Great question. I agree, any patient presenting with azotaemia and anaemia could be a possible hypoadrenocorticism. I think the electrolytes are less suggestive in this case. A basal cortisol would have been a reasonable screening tool. I would have been less inclined to think about cobalamin. Cobalamin can cause haematological issues, but normally these are the patients with congenital cobalamin problems. The link between anaemia and low cobalamin in dogs and cats is actually not strong, it is much stronger in human medicine:
https://pubmed.ncbi.nlm.nih.gov/30499147/
2. Your approach to darbepoietin sounds good to me. The exact starting point is not definitively determined. I would consider it with a PCV of 25% and under. It also depends a little on the patient. If I strongly think the anaemia is contributing to the clinical signs, I will intervene sooner. I will indeed give iron injections in these cases without measuring iron status if I am giving regular darbopoietin cases.
3. Great question. In renal disease patients there is evidence to support reducing the proteinuria as it will improve survival. I agree, we have to be careful with these drugs and if you are seeing more than a 30% increase in your creatinine level then I would be reducing the dose of drug. There is quite a bit of evidence to support the use of telmisartan now and many people are using that first line. I would still use these drugs in renal patient with proteinuria, but I would continue with your understandable caution.
Thanks again. I hope that helps.
Scott 🙂
Replying to Talia C. 18/07/2023 - 15:46
Hello Talia!
Thank you so much for your reply. Really appreciate it, I know how busy life in practice must be!
I completely agree that blood smear is the next steps here. I have shared the blood smear images on the thread and would love to hear your thoughts.
The occult blood is a good shout. I would probably make the decision about whether to run this test based on whether my investigations revealed any other cause for bleeding. It is very uncommon for B12 deficiency to cause problems with anaemia in dogs and cats. This is much more common in humans, but still not wrong to measure B12.
Completely understand your comment regarding the Na:K ratio and lack of stress leukogram. Based on the lymphopenia, hypoadrenocorticism is very unlikely.
Ultrasound is a really important step and there was a mass in the spleen!
Thank you so much for your brilliant contribution. I have popped more information about the case in the tread.
Looking forward to hearing your thoughts.
Scott 🙂
Replying to Nadia C. 16/07/2023 - 21:22
Hey Nadia.
Thanks for your reply.
I agree. Lots going on. The stand out thing for me are the red blood cell shape changes, there are a lot of them! More than I would be comfortable with.
We did indeed do coagulation parameters in this patient. I would not routinely carry out PT and aPTT before doing abdominal FNA’s. My main concern would be platelet number. If there are enough platelets, then normally I am good to go!
I agree though, it this case the PT and aPTT was a good shout. Both these parameters were normal. We did preform FNA’s of the spleen. These came back as extramedullary haematopoiesis. Frustrating!
Next steps?
Scott 🙂
Thanks for sharing this Liz.
The RR seem like the most significant thing to me! I am never sure how to interpret the significance of heart murmurs if I am honest!
I look forward to hearing others thoughts!
Scott 🙂
Hello everyone.
I thought I would share the blood smear images form this dog. They are probably the most thought provoking part of this case and always the right thing to do in an anaemic patient!
Let me know your thoughts!
Scott 🙂
Replying to Liz Bode 29/06/2023 - 20:40
Thanks Liz.
I will share the blood smear results as they are the most interesting bit!
Scott 🙂
Replying to Francesca Lamb 06/07/2023 - 09:17
Thanks Fran!
I also wanted to shout your radiograph bravery!
Good job!
Scott 🙂
Hello Felipe.
This is a super interesting topic. This is something that I have been definitely been asked about. Honestly, my knowledge on the topic is super limited, so I try not to get too deep in discussion!
My main concern would be understanding what formulation to use? Is there anything on the market for cats and dogs?
I worry owners are getting many random products online.
I would be interested to hear others experience.
Scott 🙂
Thank you for all of the replies so far!
A 5-year-old neutered male DSH was presented to a referral hospital in Scotland for lethargy, coughing and wheezing of 1 month’s duration, as well as hypercalcaemia (3.3 mmol/l; reference interval [RI] 2–3 mmol/l) detected by the referring veterinarian. Defaecation, thirst and urination were normal. The cat was fed a good-quality commercial diet, and routine vaccinations and prevention against external and internal parasites were up to date. It was an indoor/outdoor cat and an avid hunter, with no travel history outside of Scotland. On physical examination, the cat had harsh lung sounds with a normal respiratory rate (25 breaths/min) and effort. The peripheral lymph nodes were increased in size; the remainder of the physical examination, including a retinal examination, was unremarkable.
Haematology, serum biochemistry (including thyroxine) and urine analysis were unremarkable, except for hypercalcaemia (ionised calcium [iCa] 1.75 mmol/l [RI 1.1–1.35 mmol/l]). Ionised hypercalcaemia was confirmed with a repeated blood sample, and there was no haemolysis or lipolysis. Feline immunodeficiency virus antibody and feline leukaemia virus antigen were negative, and blood pressure was normal.
What are your DDX for the hypercalcaemia?
Could this tie in with the respiratory changes and does this help narrow down your DDX?Scott 🙂
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