Sunday, March 6, 2011

355. Sunday Mar 6, 2011 interesting cases

Bright sunshine day. My assistant phoned to say I had 2 appointments at 10 am.

CASE 1. A slim mother came with a black and white rabbit and two slim pre-teen daughters. The mother said: "The rabbit has this roughness on his feet and ears. What is the cause and whether the disease will infect people?

"I felt itchiness in my elbows," the mother flexed her left arm and scratched her left elbow.

"It is scabies mite infestation," I said to the mother and took out the Hills' Vet book of illustrations to show the mites. "Rabbit scabies don't infect people. However, it is possible that the mites may try to bite you but will not be successful. Hence you felt the itchiness in your elbow."

But Hills' book has only the dog scabies. "The mites look similar to these in the pictures," I said. "Rounded bodies burrowing under the skin and causing itchiness and pain to the rabbits."

I asked my assistant to scrape the skin to get the mites after intern Michelle failed to find any. After 3 failed attempts, Mr Saw scraped deeper into one paw till the blood showed. He got ready the bottle of oil to put a drop onto the slide. I stopped him, "There is no need to use oil," I said. "Oil is recommended by professors in college but actually a drop of water will be better. Michelle, get a cover slip to put on top of the skin scraping."

As Michelle who just got 3As in her A-level results on Friday and would be eligible to study veterinary medicine in Australia looked blankly at me, I realised that she did not take Biology in her A-levels. So, I asked Mr Saw to get one. Mr Saw has the habit of putting another slide on top of the skin scrapings for some peculiar reasons. It is difficult to change his mindset sometimes.

This will also do but is not the correct way to do microscopic examination as a cover slip is much thinner and allow better viewing. I took over the viewing of the skin scrapings as the interns and assistants were taking some time and I dislike making other clients wait. There was an owner with a Beagle pacing outside.

I spotted one moving fat brown mite and asked the mum and 2 daughters to see. "You need to adjust the focus," I said to the be-spectacled elder sister who had some difficulty seeing anything. The 3 members of the family finally saw the mite and so were convinced.

"Where do I buy the Hills' book?" Mum asked me. "You can't buy it," I said. "It is given free to vets. But nowadays, the internet will give you all the pictures of rabbit scabies, and so you will get all the information." Elder daughter nodded her head vigorously.

Younger sister was afraid of seeing the rabbit being injected with ivermection 0.1 ml with saline and closed her eyes. "This daughter can't become a doctor," I told the mum. "Elder sister can as she is not afraid of such things," mum said. The thin 1-year-old rabbit squealed after injection. "It can be quite painful," I said to the mum as elder sister looked worried. "I will rub the skin to spread the injection. This rabbit is very thin and it is not good for his health. Feed more hay and pellets."

The younger rabbit at home had the same problem. I gave a Revolution syringe and advised one drop on the skin weekly for 2 weeks as the younger one would be too thin for the injection. "Usually one injection would kill all mites and skin crust will drop off in 7 days' time," I said to the mum. "As to where the rabbit got infested, it would be from another rabbit in the pet shop or breeder. It is a curable disease."

"What happens if I don't get the rabbit treated by the vet? Will the rabbit die?"
"If the rabbit is healthy, it may not die soon. The crusts on the paws, ear edges, nose and eyelids get thicker and thicker. I have seen some becoming cauliflower in shape. It is a painful condition as the rabbit can't get rid of the mites by itself and the mites keep burrowing under the skin and reproducing."

"What about the male scabies mite?" the mum noted that Hills' book stated that female mites burrow under the skin and lay eggs which hatch to become mites. "Male mites do burrow too but the Hills' book did not mention the males." Sometimes, the illustrator or writer can overlook the fact that male scabies mites still need to burrow inside the skin to survive being washed off or killed by sunlight. I have no doubt that the male scabies must burrow under the skin to mate with the female. Well, the book can't mention every aspect of the scabies mite's sexual behaviour.

CASE 2. The 15-year-old Beagle had his dental treatment more than one month ago but now, she had a problem. The man in his 50s took out his video camera and showed me what was happening in real life. He switched on the camera. The Beagle started to eat heartily. Then he made a gulping sound or movement as he tried to swallow the dry dog food. "As if he had a bone inside his throat," the owner said. "I did feed him pork knucle bones after the dental treatment. Could there be pieces of bones stuck inside the throat?"

I put the dog on the examination table, asked my assistant for a torch-light. "The beagle bites," the owner forewarned me. The Beagle refused to open his mouth. My assistant suggested that he opened the mouth while I shine the torchlight and said: "There is a swelling on the left side of the throat." I had not gone into palpation yet as I wanted to see the inside of the mouth. The Beagle didn't co-operate.

"It is unlikely to be a bone fragment or abscess inside the throat for the past 4 weeks," I said. "There is a 50-cent lump on the left side of the neck, where the thyroid gland is located," I said. "It is a painless lump but large. It may be a thyroid tumour or infection. Or possibly a traumatic wound caused by some sharp object into the side of the throat."

The owner did not want blood test or X-rays. So it was difficult to get a definitive diagnosis. "There is slight pain when I palpated the lump deeper," I said as the dog objected in mild pain. At the age of 15 years, this dog had survived anaesthesia during dental work at Toa Payoh Vets some 4 weeks ago. The owner would not want another anaesthesia or surgery as this may kill off his favourite companion. Antibiotics and an anti-inflammatory injection were given and we would wait 7-14 days to see if the lump of 10 cm x 10 cm disappears. I would think it is a thyroid tumour in view of the dog's age of 15 years which is equivalent to a person at 105 years.


CASE 3. I thought I had seen all hamster conditions thanks to various Singaporean hamster owners over the years. Yet this hamster puzzled me. His right hind foot was swollen 50X in two parts. The foot and ankle was swollen as one lump of 1 cm x 0.5 cm. Then there was a narrow normal width of tissue which spreads out to another similar big swelling of the leg muscle.

"How did my hamster get two big swollen lumps in his leg?" the young lady owner asked me. She had previous hamsters treated by me before but this one sure was puzzling.

"It looks like the hamster's leg had been strangulated by a rubber band, stopping blood flow to the foot and toe at first," I said as the lady told me that she observed a swollen right hind foot first some 2-5 days ago. Then, another swelling above the foot. "Then the blood flow above the strangulated thin area is interrupted and the area swells 10X! Now, the hamster starts licking the swollen areas to relieve its pain. The area becomes shiny and purplish."

However the lady disputed my hypothesis. In any case, there is no such small rubber band inside the hamster's crate. Therefore, what would be the cause of the strangulation?

Fortunately, there was a square piece of cloth with holes and loose threads. This was the clue. "This hamster likes to chew towels and cloth," the lady said. "He lives alone."

"It was possible that the leg got trapped inside the hole and the threads wound round the leg above the ankle when the hamster tried to get free," I postulated. "The more he struggled, the tighter the threads wound round his leg, stopping blood supply for some hours. That is why you see a normal thin strip of leg in between the two bulging masses."

The owner was not fully convinced, I think and thought she could take the hamster home. The hamster was warded for treatment and observation. He had a good appetite and even exercised on his wheel despite his handicap. Facts are stranger than fiction sometimes. However, this hamster must be treated or the swellings would be severely infected by bacteria. The swellings have become purplish and that meant gangrenous.

I told the owner that the hamster might not survive long as gangrene had set in. If the right hind was to be amputated, the hamster might die during anaesthesia and so it was not wise to suggest amputation which should be the course of action. If a hamster died during surgery, the vet costs would be higher and the outcome of death would be the same as when the hamster would be treated conservatively with drugs. In either case, the outcome would be the same. Therefore, I did not advise amputation as the risk would be very high.

Veterinary medicine throws up some challenging cases now and then. In most days, cases are routine but the Divine Powers, if you believe there are such existing, throws in a surprise to keep the vet on his toes.

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