1024. A male mongrel has high fever - blood test - evidence-based medicine

A 2-year-old Boxer-looking factory dog from Joo Koon Circle
 came in as he was not eating or active for the last 2 days. He has a golden brown coat and so Whiskey was an appropriate name.

A high fever (40.5 deg C). I sought permission from the factory owner to do a blood test as I suspected viral or tick fever infections. It is always important to do blood tests but the owner's permission must be given as he pays for it.

Total WCC  44 (6-17) 
N 91%,  L 6%, M 0.8%, E 1.6%, B 0%

Surprisingly, platelets were low  154 (200-500) for this young dog. Platelet clumping was noted.
SGOT/AST 128 (<81 br="br" high.="high." was="was">
Factory dogs don't get vaccinated and so they are not well protected. This dog had one vaccination. Anti-fever medication IV, antibiotics and drips were given for 2 days. The dog recovered and went home.

1023. Did the maid cause the perineal hernia?

Today Saturday, I came to work at 9 am. Reviewed the case of the Jack Russell who had passed away on the op table yesterday.

This was a case of a very poor prognosis because

1. The bladder was twisted. During surgery, this bladder was  dark red and bleeding when seen from the hernia side, only a small portion of the neck of the bladder was the normal pink (images).
2. The associate vet was not able to catherise and lots of dark red blood inside the swollen bladder leaked out).
3.  In addition, fresh blood leaked out from the anus.

An emergency surgery to reduce the bladder size was done but the dog passed away after the repair of the right perineal hernia. The owner said that around 4 weeks ago, the dog gave a loud cry as the maid had hit him. He was frightened of the maid since then. "Did the backside swelling disappear after some time?" I asked the father. "Yes," he said. "I could feel some water inside the swelling. It disappears but now it comes back again and grows much bigger."

So, was the maid's hitting cause the perineal hernias (left and right) to develop? It is a possibility but I don't think so. Old male, not sterilised dogs do develop perineal hernias and this Jack Russell fitted the picture. He was around 10 years old, not neutered and had a large perineal swelling that could reduce. I diagnosed perineal hernia.

The associate vet diagnosed tumour e.g prostate tumour as there was too much bleeding from the penis. "Are you sure?" the vet asked me. "Yes, I am 100% sure. I based this on the history of the backside swelling increasing in size and disappearing when pressed some 4 weeks ago." The father requested an X-ray to confirm the diagnosis of tumour. "Normally, no X-ray will be done if it is a perineal hernia," I said to the vet. "However, the owner had requested X-ray to confirm. It should be done. In any case, this dog would die soon as he could not stand up and was in great pain, passing blood in the urine and stools. This is serious and the owner has been told. I had shown the owner past case images of perineal hernia from www.toapayohvets.com and he understood what the problem was."

X-RAY
Showed a large swollen bladder

Blood test - the owner did not want a blood test.









  

1022. The CKC has a gum tumour that grows very fast

Aug 1, 2012

Cavalier King Charles, Male, 10 years

"Most likely cancerous," I said to the owners of a gentle distinguished-looking CKC. "If a gum tumour doubles in size every week, it is cancerous and needs early removal."

Blood tests were not normal. Surgery was done the next day. Unlike the Lab Retriever's epulis which is not cancerous, this case seems to be poor prognosis. Electro-surgery by Dr Daniel. "Transect at least 2 mm from the tumour and remove the entombed incisors," I said. The owner agreed to sending the tumour to the lab for check.

BLOOD TESTS
Total WCC  17.8 (6-17)
N 81%, L 15%, M 3.2%, E 0%, B 0.4%. Indicative of a bacterial infection going on.

RBC 5.6 (5.5 - 8.5)
Platelets 81 (200-500). No platelet clumps seen but few giant platelets present.

HISTOPATHOLOGY
Squamous papilloma with reactive atypia and chronic inflammation. No definite dysplasia or malignancy.
Good news for the owner. However, the papilloma may return as it is extremely difficult to completely excise it.

ANAESTHESIA
The old dog survived the anaesthesia and that was what counted for the owners. Dom + Ket at 25% was sufficient for electro-surgical excision. "No intubation, as we need good access to the gingival tumour and to excise all, if possible. It is growing fast."  Dental scaling was done too.


Older dogs must be checked by the owner daily and any mouth tumour be removed when it is small. In this case, the tongue covered the papilloma till it became chronically infected and swollen. It could have existed for some weeks without the owner seeing it.

1021. The Beagle with bladder cancer passed away on Jul 31, 2012

"My Beagle is in great pain. The pain is in the back disc," the wife phoned for a house-call at 9am. I asked Dr Daniel to do the house-call with the intern who was studying in England and wanted to be a vet.

"How about passing blood clots again as you had told Dr Daniel 2 weeks ago?" I had operated on this dog for bladder cancer and had removed a portion of the tumour.

"It lasted a week and no more blood," the wife said. "The usual incontinence when sleeping but he was able to control his bladder when awake."

Later, the working couple came to pay the bill and went home. The wife phoned and said that the Beagle had passed away. This was surprising and I asked Dr Daniel what happened. "His rectal temperature was 35 deg C," he said. "I had told the owner of the poor prognosis." The normal temp is 38.5-39.5C.

The wife would never euthanase her beloved Beagle of 13 years and this natural passing away was expected. The dog had fits and needed medication daily for the past few years.  So, was it the fits that caused his death?  I was surprised that he could survive the bladder cancer surgery which took more than one year.

1020. Painful throat - large dog bone treat or bone swallowed?

Hard to say. The 8-year-old male, chihuahua X came in with a big black scab of 5 cm x 4 cm under the neck. Not eating but could drink. Pain on palpation. What was it? The lady owner confirmed that the dog ate bones but had no problem.

Blood tests - Total WCC 14.9 (6-17).
N 75%, L 8%, M 15%, E 1.4%, B 1.2%

X-rays - Some radio-dense area occluded the pharynx or was it severe inflammation and ulceration?
Hospitalised for 3 days with IV drips and medication. On day 2, dark thick liquid stools were passed out. More IV drip and anti-spasmodic. No more passing stools for next 2 days.

The dog recovered and would be sent home today. No further complaints as at 3 days after going home.

1019. Providing value for money: Dematting a ferocious Himalayan cat

Aug 1, 2012 case

"My cat is very fierce," the undergraduate daughter from Bukit Batok put the cat carrier down on the table. She had made an appointment for sedation to de-mat her cat for the 2nd time. "She even scratched the vet nurses."

The mum said: "The nurses had to take a towel to wrap her for her IV injection."

The daughter said: "No, no, they put her inside a cage."

Yet this grey 6-year-old female Himalayan cat was docile inside the cage. I could see her eyes and her body language presented a picture of serenity and peace. The daughter continued to frighten me: "My mother was clawed. I would be clawed if I attempted to brush her belly area which is now matted and that is why I needed the sedation to get her lower body hair clipped bald. She does not mind me brushing her upper body and enjoyed it. But once I attempt to brush the lower body, she would claw me and run away."

I was wondering why didn't they go back to the first vet who had done the first de-matting. This must be really aggressive cat as the daughter said that the first vet had put the cat inside a cage to effect the sedation. There was a bit of confusion here as the owners did not actually see the sedation or did they?

In any case, I got my assistant Min to take the cat out by the scruff of the neck. There was no hissing nor raised hairs nor a meow. I could inject it IM and that was so much like the other cats. Mr Min clipped off the lower body coat in less than 5 minutes and went out as this was his day off.

PROVIDING VALUE FOR MONEY
Most vets would just consider dematting as a job done by the groomer and that's it.

For me, I checked the teeth. They were white and clean, surprisingly for a 6-year old cat.
I had the nails clipped. Most important I thought the owner how to express the anal sacs.
"Have you heard of the Bishop's nose, that is the backside gland of a chicken that some people love to eat?" I asked. "Your mum would know it." Mum nodded her head. "This gland produces oil for the chicken and is very smelly. The cat also has an equivalent called anal sacs at 4 and 8 o'oclock near the anus. It produces oil daily to mark the cat's stools and if there is a blockage, the oil stays inside and changes colour from light yellow to brown and accumulates. That is why you see so much of the oil."

FOLLOW UP THE 2ND DAY
I gave xylazine 0.2 ml + ketamine 0.8 ml IM for sedation to de-mat the cat yesterday. A lower dose of xylazine 0.15 + ketamine 0.6 ml IM could be given but this was a 6-kg cat and this formula was correct. The cat was said to be very ferocious.

I phoned the daughter at 9 am today. "My cat is eating at 8.30 am the next day but did not meow as usual. She appears drowsy. Yesterday, she vomited twice."
"It takes at least one day for the cat to recover from the sedation," I explained. "She will be back to normal tomorrow."  

The cat never had it done for 6 years as nobody thinks of the cat's anal sacs. As the daughter did not know how to do it, I showed her. The oil that shot out was around 2 ml of thick brown oil. "Normally, there should be little oil or light yellow oil," I said.

REASON FOR NOT GOING BACK TO THE FIRST VET
The owners were phoned to take the cat home yesterday afternoon. "Would my cat have allergic reaction from the injection in the front leg?" the lady asked yesterday. "The first vet gave me a cream to apply."
"How is the leg now?" I asked.
"It is OK."
"Your cat was given an injection via the muscles at the left backside. Is the 'allergic' reaction the reason you did not go back to the first vet?" I asked. She nodded her head. It is difficult to give a frightened cat IV sedation but some vets/nurses prefer this route and are very good at it. For me, I don't see the need to struggle with the fine veins and gripping the frightened cat. I just do IM injection and that has never been any "allergic" reaction" in my cases.

1818. Struvite bladder stones in Singapore dogs

Struvite Bladder Stones in Singapore dogs
Dr Sing KongYuen, BVMS (Glasgow), MRCVS
Toa Payoh Vets
July 31, 2012

Difficulty in peeing, not able to pee and peeing urine with blood are the most common reasons for dog owners to seek veterinary advices at Toa Payoh Vets.  Sometimes, the owner sees stones passed out in the urine.  



Urolithiasis in dogs is such a large topic of a few hundred pages as there are several types of bladder stones affecting the dog and their diagnosis and treatment vary. Therefore, only struvite urinary stones, being most commonly seen at Toa Payoh Vets will be discussed in this article.

Breeds usually affected include the Miniature Schnauzer, Shih Tzu, Bichon Frise, Miniature Poodle, Cocker Spaniel and Lhasa Apso, but any breed can be affected. Female dogs are said to form  approximately 85% of bladder stone cases.

Some dogs may not show clinical signs of blood in the urine, difficulty in urination or inability to urinate until much later in the disease with severity of signs depending on the location, size,and number of uroliths formed. These stones can be formed anywhere along the urinary tract in the kidneys, the urethra and the bladder.

Struvite stones are composed primarily of Magnesium, Ammonium and Phosphate (MAP). They are formed within the urinary tract and occur when the urine is supersaturated with MAP (i.e. large quantities of the crystals are present). MAP supersaturation of urine may be associated with several factors, including urinary tract infections, alkalineurine, genetic predisposition and diet.

Your vet will take a comprehensive history to determine the commencement and the severity of the disease. Physical examination include bladder palpation to feel the crepitus (sounds of gas and stones rubbing against each other) inside the bladder or the solid stones if they are large.

However, a complete blockage of the urinary tract is life-threatening as the dog can't pee and the full bladder may rupture with delays in treatment.  In such cases, a urinary catheter will be used to unblock the obstruction or the urine is extracted via the bladder as soon as possible. This is done to protect the bladder and kidney from further damage.

X-ray of a dog that cannot pee (left). If the dog cannot pee, the likely cause is urethral obstruction caused by urinary stones being stuck inside the urethra.


Blood screening, urine analysis and radiographs are usually performed to confirm the presence of urinary stones. Abnormal blood work may show if the obstruction of the urinary tract is severe. Blood tests may show changes to the kidney function or an increase in white blood cell counts affecting the health of the dog.

Urine analysis is the most useful and should always be done. A sterile sample is taken either via catherisation (passing a tube into the bladder) or cystocentesis (straight from the bladder). With the urine sample analysed, MAP crystals can be  present but this is not always the case. For example, stones that are too well formed or too large may not shed crystals. Therefore, the vet should not deem the absence of crystals in the urine as no struvite or urinary stones being present in the affected dog.

X-ray of a catheter to push back the stones into the bladder in a female dog that could not pee at all as the stone was stuck inside the urethra









In addition, urine pH gives the vet a good idea of the nature of the stone. Struvite crystals are formed very commonly in an alkaline environment in which bacteria is present. A urine sample can show the presence of bacteria. The bacteria be cultured to know the type of bacteria causing the infection and antibiotic sensitivity tests can be performed by the laboratory to advise on the appropriate antibiotics to be prescribed.

Struvite uroliths are radio-dense and can be detected on radiographs.


However, they need to be of a certain size before they are evident. The number and size of urinary stones seen in the X-ray may not correlate with the severity of clinical signs.

However, a radiograph is highly recommended for the vet to know the number and size of stones and where they are located prior to surgical removal, if surgery is to be advised.

Clients need to understand that in spite of all the tests above, the composition of the actual stone cannot be determined unless a stone sample (from the surgery or that has been urinated out)  is sent to the laboratory for analysis.

Treatment options for struvite bladder stones revolve around surgery or medical dissolution of the stones.

Benefits of surgery include faster recovery times, and the ability to identify the actual type of stone involved. Surgery is indicated if the stones are too large or too well formed as they may not dissolve medically. Disadvantages of surgery are that it is more invasive and there are risks associated with general anesthesia in a sick and/or older dog.

For clients that are not so comfortable with surgery or in cases where surgery is not advised due to health concerns (e.g. the dog is very old and in poor health), the alternative is medical dissolution. This medical solution is non-invasive but takes a much longer time to show the effect as the stones are dissolved slowly. However, large stones may not dissolve at all. One important note to take into consideration is that there is no way to accurately determine the nature of the stone without sending it for laboratory analysis. Obviously, the medical solution is not applicable to all types of urinary stones (e.g. calcium oxalate stones), but it is especially effective and useful in struvite stone dissolution.

Medical dissolution revolves around 3 main concepts. They are to acidify the urine, to reduce the intake of MAP such that it does not saturate in the urine and to dilute the urine so crystals do not have a chance to form. For struvite uroliths, there are specially formulated diets such as the Canine S/D, C/D or W/D that I have used to dissolve the stones. 

Medical dissolution of stones takes a mean time of 3 months. The time taken for complete dissolution is varied depending onthe size of the uroliths and the quantity. Severe cases can take up to 6 months before the stones are fully dissolved. However, very large stones will not dissolve. 
Along with this diet change, I prescribe an appropriate antibiotic course to treat any primary or secondary bacterial infection. During treatment, only the prescription diet should be used. I usually advise no dog treats or other food and to encourage the dog to drink water.

The S/D diet is used initially for 1-6 months before switching over to the C/D or W/D diet. It is not recommended for:
1.      Use concurrently with urinary acidifiers
2.      Feeding longer than 6 months
3.      Dogs with non-struvite uroliths (urinary stones).

Transition to feeding S/D should be done over a period of seven days, gradually introducing the amounts during the transition period and monitoring the patient. Most dogs will not eat the S/D diet immediately and so the owner must be educated to switch to the S/D diet gradually over at least 7 days.

After successful dissolution of struvite stones confirmed by urine analysis and X-rays, Canine C/D or W/D can be used for maintenance. Canine S/D should not be used for the prevention of bladder stones as the diet is low in MAP and protein. Long term use of this diet is not recommended as the nutrients are not be sufficient.

Key benefits of Canine S/D include:
·        Low levels of MAP to aid in dissolution of struvite uroliths and crystals.
·        Promotion of acid urine by reducing the urinary pH to 5.9-6.1 (targeted) to increase the solubility of struvite crystals.
·        Lower protein levels result in increased urine volume and more dilute urine.
·        Antioxidants are added to defend cells from free radicals and to promote a healthy immune system.

In this article, I have written about the S/D, C/D and W/D prescription diets for the medical treatment of struvite urinary stones as I have used them in my practice. However, there are other equivalent prescription diets from other manufacturers and it is up to your vet to advise you as to the type of prescription diet to use or to get bladder surgery done to resolve the problem fast. 

Many Singapore dog owners do not adopt my advices to review the cases 1-3 monthly and do urine tests and X-rays to ensure that no new stones are formed after surgical removal of the stones or after using the S/D diet. They are happy to see that the dog has not passed blood in the urine and does not have difficulty in urination and continue with feeding the usual dry dog food again.

In some cases, the problem recurs and it can be heart-breaking and costly if another surgery is required. So some owners elect to euthanase the dog. Regular urine tests would have been most useful in detecting the presence of struvite stones although the absence of struvite crystals in the urine does not mean that there are no stones present. Only X-rays will be able to tell. Sometimes, a dog that has had struvite stones may become later affected with another type of stone such as calcium oxalate stones and that is why regular urine tests are so important.

In conclusion, be alert as to the urination pattern of your older dog and seek veterinary advice promptly if there are signs of discoloured urine, urinary difficulty or inability to pee.

Image of a female dog that has peed out urinary stones

For more detailed case studies of urinary stone cases seen at Toa Payoh Vets, goto:
http://www.bekindtopets.com/animals/20081201PG7_Dog_Surgery_Anaesthesia_Urinary_Tract_Problems_ToaPayohVets.htm

Acknowledgement: I thank Dr Daniel Sing for his contribution to this article and various dog owners for permitting me to record their cases in this article