2936. Vetoryl 60 mg for Cushing Disease

Sunday Feb 28, 2016

In 2014, his 15-year-old Shih Tzu kept looking for food every hour and drank a lot. Her body hairs did not grow back after clipping. Her belly became pot-bellied. She passed blood in the urine.

The vet diagnosed 5 bladder stones, the biggest being 0.5 cm on X-rays. However, he advised not operating as the wound would not heal well as the dog had abnormal cortisol levels from Cushing Disease.

So the ACTH stimulation test was done for half a day, costing him $200. 10mg Vetoryl was given orally for one week, then 15 mg twice a day for one month. After several months, the effective dose was 30 mg once a day. 

The dog no longer has Cushing Disease. He came to Toa Payoh Vets to get prescription of 2 boxes of 60 mg as it is less expensive.  One capsule content is divided into two. Carefully he apportioned the alloted portion to an empty capsule. The dog has a little pot-belly but would eat and drink normally.

CUSHING DISEASE - 2 types.
Brain and adrenal glands. His dog's was the brain.

Cushing's Syndrome - dogs 

SYNETHIN  15 BOXES PER MONTH - goes fast.  250 I U of per ml

VETORYL TO TREAT

2935. A 6-year-old Shih Tzu panted continuously after swallowing a large chicken treat

Feb 23, 2016

History is very important in the diagnosis of this case. To the observer, this Shih Tzu panted furiously, pulse pressure shot up, tongue became cyanotic and rectal temperature became very high.

"A heart failure," the X-ray assistant observed the cyanotic tongue and palpated the high pulse pressure. "Check the heart!"

The history was that this morning at 10 am, the Shih Tzu that loves to swallow any object, took in a large piece of dog treat made of chicken. The domestic worker said he had swallowed a bone, the length of a man's forefinger. So, the dog started to gag and panted furiously as you can hear from the video. The wife was most concerned and so the husband phoned me and another vet for a quotation

"I will check the mouth and if there is a bone, I will see whether I can pull it out." I said. Later the husband texted me to say that the dog had swallowed a large dog treat made from chicken.

X-rays showed some pieces of dog treat inside the pharynx but no chicken bone. So the domestic worker had given the incorrect info.

What to do now? The dog kept panting and panting, becoming feverish.

I gave an IV drip, with painkiller spasmogesic 1.2 ml IV and baytril 0.7 ml IV. After one hour, the dog relaxed and no longer panted furiously. He was back to almost normal and coughed a bit. So he went home.

2934. Better to put the hamster to sleep since pus flowed from the right eye?

Feb 14, 2016
The last case in this dark clouded sky evening at 4.15 pm was a hamster with both eyelids glued tightly. Liquid pus oozed out from the right eye, as if a dam had ruptured. The young man saw it and asked whether it is better to euthanize this hamster.

"I need to examine the eyes first," I told him that the left eye was still open partly. Examination of the right eye showed sticky pus which I removed with a wet cotton bud. The eyeballs were intact. "How long had the hamster not been eating?" I asked. "The lower front teeth have overgrown. I will clip them shorter"

"Don't know," the man said.        
The hamster is an in-patient on this Valentine's Day. Will see how she goes.

2933. Two-of-a-kind cases - rabbit feet, dog abdominal tumour, dog swollen tummy

Sunday  Feb 14, 2016

It is very unusual for me to receive two similar medical conditions within 3 days.

1. Case of sore feet in 2 rabbits.
    Today, Feb 14, 2016, a young man came with his rabbit having no hairs and wounds on the underside of the front and back feet. "I researched the internet and got the diagnosis," he could not recall. "It is sore something...Yes, it is sore hocks!". He was spot on for the hind feet and hocks. Only that 4 feet had the similar problem.
"I have an in-patient rabbit with large sores only on the back limbs but your rabbit has 4 legs affected!", I was surprised to see two-of-a-kind cases, known as pododermatitis in rabbits.    
Videos are shown.

2. Case of abdominal tumours in a Miniature Schnauzer and a Fox Terrier. I was talking to the owner just 3 days ago as regards the importance of taking out the bladder stones (seen in X-rays) as the dog had an emergency urethral obstruction resolved some months ago after midnight by an emergency vet. I had diagnosed bladder stones for him earlier but his lady friend did not want an operation. "No more blood in the urine," the man in his 50s said. "Maybe the stone had disappeared."  

Then yesterday, he phoned me distressed as his Schnauzer had passed away from a ruptured tumour spilling blood inside the swollen abdomen. Vet 1 had given this dog a series of anti-heartworm injections but in the last injection, the dog's abdomen became swollen. Vet 1 quickly referred to Vet 2 who said that the dog's abdominal tumour had ruptured spilling blood into the abdomen. The dog died soon after admission by Vet 2. So the owner wanted me to do an autopsy to find out whether Vet 1 had been negligent in not discovering the tumour earlier and before anti-heartworm injection. I have a conflict of interest, being a competitor and so I advised that he contact AVA or A-Star vets. It was Saturday and he had taken the body back from Vet 2. "Put the body in a freezer," I advised. "Otherwise it is not possible to do an autopsy properly."  He said he put it inside a fridge.

"The disadvantage of autopsy by the AVA is that we will not get back the dog's body for creamtion," he told me today. "As for A-star autopsy, the vet wanted a referral from another vet."

"It will be costly to do autopsies and engage lawyers," I told him that the burden of proof on negligence is on him, not the veterinarian. He would think about his next step after getting all the medical records from Vets 1 and 2.  The Fox Terrier came in for consultation as he always leaves a puddle of urine after lying down to sleep. The owner thought he was naughty, urine marking at this old age of 8 years and so had him neutered.
"There are 4 abdominal tumours, one of which is a gigantic one I could feel on palpation," I said and got the dog X-rayed. Dr Daniel had the tumours confirmed by ultrasound.

What to do?  Chemotherapy is too expensive. The neutered dog still leaks urine when lying down to sleep overnight but otherwise could control his bladder. 

"One large tumour is said to be near a major blood vessel," I said. "The descending aorta and so there is a risk of bleeding to death during removal of this large golf-ball tumour." The owners could not decide what to do. "The dog is still young, at 8 years," the wife said.

Case 3. An old Pomeranian and a Maltese had swollen abdomen. Both had dirty vaginal discharge a few days ago. Both were very ill and were unlikely to survive anaesthesia.  Closed pyometra in both cases. The Pom owner brought the dog to Vet 1 but she died on arrival.  The owner of the Maltese did not want any surgery as the dog would "die" anyway during the operation to remove the pus-filled uterus. I could not help feeling sad that the two old female dogs would have been alive if they had been spayed at 6-12 months of age. Both were in good bodily condition but time had run out for them.

The above are the twin cases appearing within a day or two and this was such a coincidence.

2932. Dystocia injuries? Inward bent hocks of newborn Dachshund

2930. Supernumerary teeth in a dog

2929. A gentle 8-year-old Fox Terrier has a gigantic abdominal tumour

The Fox Terrier, M, Not neutered, was peeing more nowadays, esp. after exercise. He will drink more after exercise and pees overnight, unlike previously. He could control his bladder.

Ultrasound showed:
An abdominal tumour or lymphoma. The liver, spleen, kidneys and intestines were normal. There were 4 separate tumours, next to the descending aorta. So, these are inoperable.

X-rays
4 separate tumours might be visible.

2928. Wishing friends good luck in their endeavours with images

Create greeting images for friends who venture to a new job or business meeting.
A picture is worth a thousand words.

KPI. How long to do a French bulldog caesarean section? 47 minutes for 7 pups

Jan 27, 2016

A very smelly vaginal discharge. A dead pup was born 3 hours earlier at 8 am. The breeder phoned me for an emergency Caesarean section at 9 am.

The black and white French Bulldog, F, 4 years appeared normal, with normal rectal temperature at 38.4. This was her 2nd Caesarean section.  Her swollen body looked symmetrical and I predicted 4-6 puppies.  Copious amount of dirty reddish brown vaginal discharge flowed onto the operation table of Toa Payoh Vets.

The dam was lethargic. "Probably all puppies are dead," the breeder said. "She's 60th day pregnant and I don't expect a dead smelly pup to be born naturally."

ANAESTHESIA AND SURGERY

B: Isoflurane gas given by mask: 10.12 am
C: Isoflurane gas stopped: 11.07 am
D: First skin incision: 10.20 am
E: Skin stitched: 11.07am

C-B = 55 min
E-D = 47 min.

7 puppies distressed. 3/7 are dead. 
Of the 3 dead pups, one was a shrivelled foetus, the other two showed yellow meconium covering the body. All pups were handed to the breeder to revive. He and his assistant had 4 live pups revived. The dam was alive and this made the breeder happy.



Details of surgery
10.23 am   incise uterine body (small incision)
10.29        4th puppy out
10.32        5th puppy
10.33        6th puppy
10.35        7th puppy to breeder.
10.36        stitch uterine body. 2 rows inverting sutures
10.49 - 10.58  stitch linea alba and muscles. lst row simple interrupted. 2nd row continuous.
10.59 - 11.07  stitch skin horizontal mattress and walk-in muscle suture

Blood test was done.
IV dextrose during operation.
IV Hartmann's + 5 ml Theracalcium to give at home. Dog vomited at the beginning of IV drip of Hartmann's.  This happened to the pre-partum Pomeranian yesterday too. She vomited yellowish brown fluid when first given the Theracalcium 1 ml but was OK subsequently and gave birth to 4 pups naturally 24 hours later.

Breeder said that the dam looks much more "solid" after the drip and would continue the drip in his place.

Surgical Technique
1. Skin incision around 6 cm. I did not exteriorise the whole uterus and hence the skin incision is shorter.

2. Finger inside abdomen to feel for bifurcation of uterus. This permits me to identify uterine body.
3. Incise uterine body of around 6 cm.
4. Milk out the pups.
5. Clamp umbilical cord with 2 forceps. Cut between forceps. hand pup with one forceps to breeder. 6. The shrivelled and another dead pup had dark brown colouration and were detached from the placenta.

Conclusion
Early foetal death of one pup. A mummified foetus. This could have become decomposed and spread the toxins to the other puppies nearby. So only 4 of the 7 puppies I took out were alive after revival by the breeder.  I advised him to use good quality commercial diet which is balanced nutritionally for pregnant dogs as he had been feeding his own chicken and fish meat mixture. Some dams would not have a balanced calcium intake.


Reference:
https://www.merckvetmanual.com/metabolic-disorders/disorders-of-calcium-metabolism/puerperal-hypocalcemia-in-small-animals

2926. When there is life, there is hope - Eclampsia & Theracalcium in a pregnant Pomeranian

1.  HOOK

On Jan 24, 2016 at 8 a.m, a dog breeder phoned me as I was driving to work.
"No hope, no hope at all!" the experienced breeder told me. My 54th day pregnant Pom collapsed. Stiff. Cannot stand up. No hope. No hope. She will not survive!"



VIDEO OF POM IN SIMILAR NECK TWISTED POSITION AS IN THE IMAGE BELOW

 2. THIS IS A BKTP


 


 




Jan 24, 2016

8.30 am   He wanted a  house-call. I got him to come to the surgery. He wanted to come after his breakfast. I advised him to come immediately as it was an emergency.

9.30 am
Pomeranian could not stand up. Her legs were stretched out rigid as if she had tetanus. Slightly fast heart and breathing rate. Rectal temperature of 39.5 deg C was considered on the high side. At 54th day pregnancy, it was too early to perform an emergency Caesarean section. My first diagnosis was eclampsia (hypocalcaemia) which is rare during pregnancy in dogs as compared to after birth.

No blood tests were performed to reduce medical cost for the breeder. Puppy prices are low nowadays owing to lack of demand for Pomeranians and alleged puppy smuggling into Singapore.

I injected Theracalcium  (France) 1 ml. slowly. The Pom vomited thrice, yellowish brown vomitus. i gave a bottle of 500 ml IV drip with amino acids and glucose till 12 noon. The dog stood up and wagged her tail. I took a video as proof

VIDEO
Since she appeared normal, I took off the IV set and asked the breeder to take the dog home. . 

3 pm
The breeder came. He said that the dog was not standing then. He phoned at 7 pm to say that I ought to have left the IV canula inside the vein so that the dog could be given another infusion. I told him that the dog had recovered and I showed him the video. He was not satisfied as the dog now was back to her original state of not being able to stand up, with the head twisted sideways rigidly.

VIDEO

7pm.    This was a relapse. The lateral right head tilt was prominently seen now. The rigid limp. But the rectal temperature was normal at 38.4 deg C. 

The calcium levels from the 1 ml of Theracalcium in the blood had not lasted for more than 6 hours. Hence the Pom collapsed again.

Dr Daniel came back from his engagment to help me out. He gave Theracalcium  1 ml slowly after setting up the IV drip of Hartmann's solution.. The dog vomited thrice, yellowish brown vomitus.
I pumped 6 ml Theracalcium inside the bottle of Hartmann's solution for slow drip at home from 8.30 pm to 2 am.

Jan 25, 2016. 
2 am
The dam recovered and ate a can of Science Diet A/D. This was good news for the breeder who expected the Pom to pass away. A bottle of 5% dextrose saline was given.

4 pm
The Pom tore off the I/V set and was back to her normal self.

9.30 pm. I visited the breeder's farm. 3 pups had been born naturally and had been kept inside a basket covered by towels. The Pom had stopped uterine contractions. "Let the 3 pups suckle her," I said. "Suckling will stimulate uterine contraction."

The Pom contracted and the 4th pup came out around one hour after the 3rd pup.

CONCLUSION
This was a rare case of eclampsia in a pregnant Pom. The 80-year-old breeder has over 50 years of breeding experience but he had not encountered such a clinical presentation. Neither will most vets as eclampsia usually occurs in the 2nd - 4th week of dogs with large litters; 

"I expected my Pom to have died, but now she gave birth to 4 beautiful puppies," the breeder remarked. He was most happy.



It was a happy ending due to the sufficient amount of calcium being given IV. This case shows the vet that "when there is life, there is hope."  The diagnosis must be correct.

Theracalcium (France)

The volume of Theracalcium must be given sufficiently and not overdosed to avoid cardiac toxicity such as arrhythmias, leading to death.

In this 5-kg Pom, the first time of 1 ml of Theracalcium IV was insufficient to last 24 hours.

The second time of 7 ml (1 ml IV direct and 6 ml in Hartmann's solution) was just right and the Pom gave birth 24 hours after the second injection.  

The manufacturer gave a guideline for IV, SC and IM injection as follows:
For dogs: 0.25 - 0.5 ml/kg.    That means 1.25 ml - 2.5 ml.
For dogs: 2-10 ml.                  I gave 7 ml during the relapse. The Pom did not die but gave birth naturally to 4 good-sized pups. I suspected the breeder had the pregnancy dates incorrect but he said that Pomeranian puppies are well developed by the 56th day. He has over 50 years of dog breeding experience. I respect his solid years of breeding experience. I am glad his prophecy was not fulfilled and we all had a very happy ending. .   

 





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POST SCRIPT.

1.  THERACALCIUM (France) PER ML
1.  Calcium  32.6 mg (as Calcium gluconate)
2. Calcium 8.2mg      (as Calcium gulcohepatonate)

IV, IM, SC
Dogs 10-20mg/kg   2-10 ml    0.25-0.5 ml/kg.    
Therefore this dam, 5 kg = 50 - 100 mg or 1.25 ml - 2.5 ml

In this case, the dam was given 1 ml direct IV and 6 ml in the IV drip  after the relapse. This 7 ml appeared to be sufficient and not cardio-toxic.


2. BSAVA POCKETBOOK FOR VETS
Hypocalcaemia
Calcium 50-150 mg/kg calcium (as calcium boroguconate}. 0.5-1.5 ml/kg of a 10% solution IV over 20-30 min. For this 5-kg Pom, it will be 2.5 ml - 7.5 ml

According to the website of manufacturer, Theracalcium has an advantage over calcium borogluconate in being longer-lasting and having less cardio-toxicity (fast heart beat due to arrhythmia) or fast breathing rate leading to death.

Calcium gluconate increases serum levels within 5-20 min for 5-6 hours
Calcium glucoheptonate increases serum levels within 3-4 hours and up to 12 hours.
Less risk of cardiotoxicity compared to calcium borogluconate as it has lower total calcium than the usual dose administered.   Calcium equivalent in Theracalcium is 32.6g + 8.2 g = 40.8 mg of Calcium per ml



FOLLOW UP ON FEB 13, 2016
Eclampsia was in Jan 26, 2016 (see video).


The 4 pups have opened their eyes and are thriving. The breeder is most happy.