George III – Losing it
A 2-year-old male collie, George III, was presented for the acute onset of epistaxis, hematemesis, hematochezia, weakness and depression. Physical exam revealed a lethargic, poorly responsive patient with pale mucous membranes, tachycardia, tachypnea, and evidence of recent hemorrhage around the nostrils and anus. In addition, both stifles, the left hock and the right carpus were swollen. The owner related that 4 days ago she had a commercial exterminator out because she was experiencing a problem with field mice getting into her home.
During the initial hospital visit, the dog suddenly develops acute respiratory distress, cyanosis and severe dyspnea.
Your initial laboratory results taken upon George’s admission have just come back, and you quickly consult them as you formulate a plan to handle this acute crisis. Significant changes from normal are listed in the report.
Test / Result / Reference intervalCBC
RBC / 3.78 / 5.5–8.5 × 106
HGB / 9.1 / 12–18 g/dL
HCT / 28.0 / 37–55%
WBC / 18.1 / 6–17 × 103
SEG / 15.2 / 3–11.4 × 103
BANDS / 0.18 / 0.0–0.3 × 103
LYMPH / 0.724 / 1.0–4.8 × 103
PLT / 873 / 200–900 × 103
PLASMA PROT / 5.2 / 6.0–7.5 g/dL
URINALYSIS
PROT / 3+
BLOOD / 4+
RBC/High power field / Too numerous to count
CLINICAL CHEM
ALT / 158 / 4–66 mU/mL
TP / 4.8 / 5.3–7.8 g/dL
ALB / 2.2 / 2.3–4.3 g/dL
GLOB / 2.7 / 2.7–4.4 g/dL
BUN / 33 / 5.0–28.0 mg/dL
CREA / 0.9 / 0.0–1.5 mg/dL
ACT / 141 / 60–100 sec
APTT / 33 / 11–19 sec
PT / 46 / 5–12 sec
FIB / 270 / 150–300 mg/dL
Things to know:
1. Major differential diagnoses
2. Reasons for some of the changes in CBC and clinical chemistry
3. Emergency therapy intervention
4. Aftercare
Questions
1. Based on history and lesions displayed, which of the following is the least likely tentative diagnosis?
a. Acquired platelet deficiency from bone marrow toxicant
b. Congenital factor VIII deficiency
c. Anti-vitamin K anticoagulant toxicosis
d. Autoimmune hemolytic disease
e. Subacute aflatoxicosis
2. The most likely cause for hypoproteinemia observed in George III is:
a. Hemorrhage and hematemesis
b. Bone marrow suppression
c. Renal failure with excess protein loss
d. Dilution with extracellular fluids
e. Interference with hepatic protein synthesis
3. What is the significance of mild azotemia as reflected by the elevated BUN?
a. Ammonia absorbed from digested blood enters the urea cycle
b. Loss of whole blood falsely increases blood urea nitrogen
c. BUN is increased because liver is compromised by probable aflatoxin exposure
d. Renal tubules are damaged as evidenced by increased protein in urine
4. What is your preferred etiologic diagnosis, and what tests would help to confirm that for insurance purposes? Select the one best answer.
a. Brodifacoum poisoning. Confirm with whole blood sample for PT and APTT, blood for brodifacoum assay and suspect bait to confirm source
b. Chronic aflatoxicosis. Confirm with serum bile acids, liver enzymes and aflatoxin assay of stomach contents
c. Brodifacoum poisoning. Confirm with serum for PT and APTT, but there is no chemical test for brodifacoum
d. Idiopathic thrombocytopenic purpura: Submit whole blood for platelet count and serum for Coombs Test
e. Brodifacoum poisoning. Confirm with whole blood sample for PT and APTT, blood for brodifacoum assay and stomach contents to confirm source
5. With the sudden crisis in George III's condition, what efforts (CHOOSE 2) are most direct, rapid and likely to result in saving his life?
a. Activated charcoal and high enema to remove remaining toxicant
b. Thoracic radiograph with thoracentesis as needed
c. Vitamin K1 IV @ 5 mg/kg body weight
d. Whole blood or fresh plasma transfusion
e. Oxyglobin and masked oxygen administration
6. Having saved George III and with his status good after 3 days hospitalization, you are ready to send him home. The animal samples submitted revealed 1.2 ppm brodifacoum and metabolites. Treatment and follow-up vary somewhat among practices. What package of recommendations would you consider most reliable to send home with the owners?
a. Oral vitamin K3 at 5 mg/kg daily for 10 days; if no complications discontinue after 2 weeks
b. Oral vitamin K1 at 5 mg/kg daily, check PT and ACT at 7 days, and if no complications discontinue K1 at 14 days, followed by ACT and PT at 3 days post therapy (50% credit)
c. Oral vitamin K1 daily at 5 mg/kg with ACT and PT at 7 days, 14 days, 21 days and 28 days. Discontinue K1 at 28 days and check ACT/PT again 3–4 days post treatment. Continue therapy for another week if ACT/PT are elevated. (100% credit)
d. Oral vitamin K1 at 5 mg/kg daily for up to 10 days; if no complications, discontinue treatment