Monday, August 20, 2012

1050. Sunday Aug 19, 2012 interesting cases

Sunday Aug 19, 2012 interesting cases. Another bright sunny day with blue skies.

Case 1. Samoyed with very high fever.
On Friday evening, the dog transport couple carried in the big Samoyed, recumbent and panting over 1000 times per minute. Like a dog suffering from heat stress. Dr Daniel had told me that this Samoyed was sent to Toa Payoh Vets as he was previously neutered here by Dr Jason and that the previous vet treating him (Vet 2) with a CT scan and other treatments would be releasing the dog to Toa Payoh Vets.

"This dog has a very high temp of 41.7 deg C!" I told the young dog transport couple. 
"Perhaps it is due to the traffic jam from Jurong," the couple had to ferry him from Vet 1 and this was rush-hour traffic jam.
At nearly 42 deg C, I seldom see any hope of survival for dogs with heat stress. Furthermore, this dog had fevers of 41 deg C at Vet 2 for the past 2 days. Vet 1's blood tests also showed low platelet counts.  Low platelets would mean internal bleeding would not be controllable. Very high fever burns the the internal organs.

"There is no hope for this Samoyed," I said to Dr Daniel as he suggested clipping off the thick woolly coat as part of the cooling measures. Also to give the anti-fever injections. Vet 2 had given one such injection using paracetamol but the fever returned the next day.

"Bring the dog into the bathroom and shower him with lukewarm water for 5 minutes," I said to Min, to an incredulous look from Dr Daniel. He expected immediate anti-fever treatment, I guessed. The dog transport couple put the dog into a carrier bag and Min showered the dog's body and head for 5 minutes, then dried the dog.

"You may think this is not what the professor taught," I said to Dr Daniel. "But it is an accepted method of treatment for heat stress, to be followed by anti-fever and other IV injections."  I guessed Dr Daniel had not seen much heat stress cases and they are uncommon even for me.

"Check the rectal temperature after the hair dryer had dried the Samoyed," I said to Min.
"It is 41.5 degrees," Dr Daniel said.
"Don't expect fast spiral downward temperature," I said. "A gradual lowering of the body temperature is less shocking to the dog's blood system in my opinion. Now, we commence on the anti-fever and IV drips."

Saturday morning at 9 am.  I came early to check this Samoyed as he was still alive but recumbent. His temperature was 40.7 but he was no longer panting non-stop. He was in excellent body condition.
So, this would be the 3rd day he had high fever which had not dropped despite treatment. No wonder Vet 1 had quickly referred this dog to Vet 2. Vet 1 was presented with this Samoyed who could not stand on his hind legs and had high fever. Now, I was Vet 3 and if the dog died, it would look bad on me. Owners remember the vet when the dog had died in his practice. No explanations and excuses. A beloved family member died at Toa Payoh Vets and that was what they would remember and told their friends and relatives.

I got the dog outside. He was unable to stand on his hind legs and panted a bit more.
What to do now? My repeat blood test showed what Vet 2 had shown. Anaemia and thrombocytopaenia. What causes this?

"It could be caused by Babesia," I said to Dr Daniel earlier and now to Dr Jason. Such auto-immune reactions are caused by Babesia and there was anaemia and thrombocytopenia to support my intuition. Maybe the Babesia had gone to the brain and spinal area, causing the dog to be paralysed in the hind limbs and having a very high fever not controlled by antbioitics for the last 3 days? I did not expound this hypothesia to the 2 vets as I sometimes don't do that. They are professional qualified vets. "A negative Babesia test from Vet 1, does not mean the Samoyed has no Babesiosis," I said to Dr Daniel. "Then what does it mean if we don't trust this negative test?" he would remark. "A negative test may mean that the blood smear taken did not show the parasites or they would not be abundant." I had my theory that the Babesia could be inside the nervous system.
"Did you read Vet 1's report saying that a blood smear showed no Babesia?" Dr Daniel had informed me yesterday. Now Dr Jason said, "Boss, Vet 1's blood test said no Babesia."

As the fever would shoot up again, I asked Dr Jason to inject imidazole at 70% of the calculated dose SC. He was on duty. A 100% may be too strong.

Sunday morning. The temperature was less than 40 deg. As I am typing this case from the lst floor of Hotel Panorama in Hong Kong, I don't have the exact figures.

Monday morning. From the HK Airport, I messaged Dr Daniel for the temp. It was around 38.5 and so it seemed that either I was lucky as the overall treatment had worked or imidazole was the drug that was effective. I had also instructed Min to give doxyclycline on Saturday too.

In private practice, the owner only wants to see his or her dog alive and so, understanding and  co-relating clinical signs are much more important than lab tests. Tbis could be a case of Babesiosis based on next day recovery after injection of imidazole. It could be that the dog was on the way to recovery. Whatever the reason, the dog was alive and that was what counted to the owner.

Case 2 and 3. Skin disease of a Shih Tzu with itchy paws. Case of a Westie with black irritating skin behind ears, neck and lower body. Both cases had recovered after treatment by me and so the owners came back to Toa Payoh Vets for the vaccinations after receiving my vaccination reminder cards.  Performance counts again. Not every skin disease cases can be cured. Just these two examples which I show-cased to Dr Daniel.  



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