scott@vtx-cpd.com

Replying to Helen S. 12/07/2023 - 16:35

Thank you so much for this Helen.

Thank you for taking such time and consideration with this answer, I really appreciate that.

This all makes a lot of sense. The examples of core values that you have given are also really helpful.

I would say the Huel’s number 2 is also my favourite… I think if I could only chose one it would be that.

Thanks again.

Scott 🙂

Replying to Liz Bode 06/07/2023 - 19:57

Thanks pal.

Really helpful. I have a funny feeling you might have actually scanned this patient?!

I will share what we did next!

Scott 🙂

Hello Nadia.

Thank you so much for reply. Brilliant, there are indeed lots of signs of fragmentation injury to the red blood cells.

I have copped part of the smear report from the pathologist below:

“Microscopic Description

A single blood film is examined. The history reports a moderate acute anaemia, icterus, and suspected
immune-mediated haemolytic anaemia.

Platelets: platelets of variably distributed across these films and rare small platelet aggregates identified,
precluding definitive assessment of numbers. Morphology appears unremarkable.

Erythrocytes: Anisocytosis +. Polychromasia +. Echinocytes +. Acanthocytes + Schistocytes +. Keratinocytes
Spherocytes +. Occasional metarubicyte. Rare erythrocytes. Occasional ghost cells.

Leukocytes: Dohle bodies +. Occasional neutrophils demonstrate mild cytoplasmic basophilia. Rare band
neutrophils are identified. The analyser differential is confirmed and morphology appears unremarkable.”

So… A mixed bag really! There are low numbers of spherocytes and ghost cells. While the latter may be artefactual, depending on sample age, this keeps the possibility of immune mediated destruction on the table. However, low numbers of spherocytes are slightly non-specific and therefore in saline agglutination at 1:50 or Coomb’s testing could
be considered for further clarification. The remaining erythrocyte changes may be observed with increased
erythrocyte fragmentation injury, but also with altered erythrocyte membrane phospholipid composition for
which differentials include renal or hepatic disease. Fragmentation can occur because the red blood cells are being damaged as they travel through the vasculature (e.g. being sheared through fibrin clots in disseminated intravascular coagulation; DIC) or they are mechanically fragile (e.g. iron deficiency anaemia). In these situations, acanthocytes are frequently accompanied by other red blood cell changes, indicative of fragmentation injury, i.e. schistocytes and keratocytes.

We did perform an in saline agglutination which was negative and we then performed a Coomb’s which was also negative.

Full abdominal ultrasound was performed and revealed a 3cmx4cm splenic mass. No free fluid was detected.

What would be your next steps?

Scott 🙂

Replying to Nadia C. 09/07/2023 - 12:42

Brilliant!

Maybe our paths will cross! Thank you again for the great questions.

I really hope you are enjoying the course!

Scott 🙂

Replying to Nadia C. 08/07/2023 - 22:29

Hello Nadia.

Thank you for your response. I agree, practically we also take blood from the catheter at the time of catheter placement. We will then be using those catheters for multiple IV infusions/IV lines. We would then normally take repeated blood samples from the jugular vein. It think it is less practical to take a blood sample from a peripheral catheter when it has been in for a few days. The exception would be if we have a central line in place. The great benefit of central lines is the ability to take repeated blood samples.

Really interesting that you work as an in patient vet. That must be quite a rewarding role?

Scott 🙂

Replying to Carolyn C. 28/06/2023 - 06:46

Hello Carolyn.

Your key problem list and DDX are perfect!

I think ruling Addison’s out in this case is a great shout. We did run a basal cortisol which was 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 as there was a lymphopenia, but good rule out! I love the possible link between the Addison’s and GI bleeding and anaemia and low albumin too. We can sometimes see increases in potassium due to haemolysis. This is not uncommon in samples that have been transported to the lab. If in doubt, I would run the sample again on a fresh one in house.

Again, great thinking regarding the possibility of liver disease in this case. In order for glucose and albumin to go down there would have to be over 75% liver function loss. I think this is less likely in this case. We can sometimes see albumin go down a little with a negative acute phase response. This could be due to almost any infections or inflammatory disease. Often the globulin will increase in these situations (as it is an acute phase protein), which it has not in this case.

In the emergency stetting we did do a POCUS scan of the chest and abdomen and there was no free fluid. The in saline agglutination was negative and we had a look at a blood smear. I have shared the blood smear images. I would love to hear your thoughts.

Thank you again for your brilliant suggestions.

Scott 🙂