Case Number: 87864301 Patient: VIOLET CANINE, MIXED BREED Born 01AUG12, FEMALE, Spayed Owner: JOSH PELAK Primary Vet: COMPANION PET HOSPITAL Primary Clinician: MARINO, CHRISTINA Supervising Clinician: HANN, LISA Service: MEDICINE Admission Date: February 3, 2014 Discharge Date: February 3, 2014 Weight: 17.700 kg(s) University of Pennsylvania · Matthew J. Ryan Veterinary Hospital 3800 Spruce St., Philadelphia, PA 19104 · www.vet.upenn.edu Appointments 215-746-VETS (8387) · Emergency 215-746-V911 (8911) · Pharmacy 215-898-7881
Diagnosis 1 (Confirmed): Chronic bronchopneumonia - resistant Pseudemonas spp.
Diagnosis 2 (Confirmed): Chronic productive coughingDiagnosis 3 (Tentative): Right sided heart enlargement
Violet, a 2 year-old female spayed mixed breed dog, was presented to the Internal Medicine Service atMJR-VHUP on Monday, 2/3/14 for a history of chronic coughing that has been refractory to multipletreatments. You first noticed Violet to be coughing in May of 2013 when you adopted her. At the timeshe was being treated for presumptive kennel cough with doxycycline and Clavamox. Unfortunately,Violet's cough did not improve with this therapy.
In 5/13 Violet was switched to enrofloxacin (Baytril), and she received three weeks of therapy. WhenViolet's cough did not improve on this antibiotic, you took her back to your regular vet. Chest radiographson 6/10/13 showed that her right middle lung lobe was consolidated, indicative of bronchopneumonia. She was started on another antibiotic, azithromycin, in an attempt to better treat her infection. WhenViolet's cough did not improve, chest radiographs were repeated on 8/1/13, showing that the right middlelung lobe was still consolidated. She also had potential milder signs of infection in her right cranial lunglobe as well. Her azithromycin was continued. On 8/15/13, repeat chest radiographs showed someimprovement of the appearance of her lungs. At this time, theophylline was added to her therapy in anattempt to control her coughing. Unfortunately, you do not feel that this helped Violet's persistent cough. Repeat radiographs on 8/29/13 showed worsening of the appearance of her right middle lung lobe, and shewas referred to a specialty center for further diagnostics.
Upon bringing Violet to a referral center on 10/7/13, her chest radiographs were consistent with what had
been seen previously. Bronchoscopy was performed to further assess her airways. This test revealed mildmucous in her right and left mainstem bronchi (the branches of her airway that continue to each side ofher lungs) and that her right middle lung lobe bronchus was completely occluded with mucus. A samplewas obtained via bronchoalveolar lavage. Analysis of the sample's cellular content was consistent withinfection (suppurative inflammation), and culture and sensitivity yielded a resistant Pseudomonasbacteria, although it had some susceptibility to marbofloxacin. Unfortunately, Violet's cough did notimprove with four weeks of therapy with this drug. Repeat radiographs on 11/20/13 showed that her rightmiddle lung lobe was still consolidated and unchanged.
Throughout this time, Violet has had a cough that started out dry but has gradually become moreproductive. Her cough is worse at night and in the cold weather, and you notice it frequently when sheplays or goes up stairs. She has been her bright, normal self during this time, though you have noticedthat she occasionally has 1-2 day periods where she appears more lethargic. She has never noted to havebeen febrile. Violet has had 2 negative heartworm tests, and she is on year-round heartworm and flea/tickpreventatives. She did have whipworms (a parasite) on a fecal examination performed in May, but it isunclear whether she was treated for them. Violet has been off antibiotic therapy since November, thoughshe does get daily ceterizine (Zyrtec) for allergies that cause her to lick her paws. Though she never gotnoticeably better on any of the antibiotics, you report that her cough is getting worse since she has beenoff of them.
On examination, Violet was bright, alert, and responsive. Her vital parameters (temperature, pulse, andrespiration) were within normal limits. She had equal airflow through both nostrils, and she had noincreased respiratory effort at rest. No abnormalities were heard upon auscultation of her trachea. Upon
listening to her lungs, Violet's lung sounds were decreased on the right when compared to the left, and
fine crackles could also be heard on the right side. Palpation of her trachea elicited a persistent productivecough. Violet had a soft heart murmur ausculted on the left side. Her femoral pulses were strong andsynchronous. Violet was in excellent body condition with a score of 4/9, with no muscle wasting noted. The remainder of her phsyical examination was unremarkable.
THORACIC RADIOGRAPHSRadiographs were obtained of Violet's chest to evaluate for any progression or improvement of herrespiratory disease. As noted on her previous radiographs, Violet's right middle lung lobe was
consolidated and also had a decreased volume. These changes could be due to persistent chronic
infection, but they could also be due to fibrosis and collapse of this portion of her lung in reaction to
chronic infection. Violet also had changes of to her left cranial lung field, which could be due to activeinfection of this region of her lungs, or could be an incidental finding due to overlying muscle. The rightside of Violet's heart was also mildly enlarged, which may be secondary to her lung disease.
Given the persistence of Violet's lung infection and the steps that you have taken so far to treat it, we areworried that she may not respond to further medical therapy. This could either be due to a particularlyresistant infection that is not responding to any of the antibiotic therapies that you have tried. It could alsobe due to the presence of an inhaled foreign object, either from her surroundings or possibly from aprevious episode of vomiting, that is sitting in her lungs and causing a persistant infection. Finally, it ispossible that her lungs have undergone changes from her chronic infection or have formed an abscess,making it difficult for antibiotics to penetrate and resolve her infection.
Computed tomography (CT) would give us a 3-D image that would allow us to better assess the extent ofViolet's lung disease, and would also allow us to identify abscesses or other regions of her lung that mightbe affected. If her diseased lung was confined to a specific area or a few specific areas, the diseased lungcould be removed, which would hopefully resolve her chronic infection. The removed lung could then becultured to identify the infection and create a treatment plan using the correct antibiotic to clear anyresidual infection. There is a changes there could be residual infection after surgery in the remaining lung,and we would hope the infection is susceptible to an antibiotic we have available to us. She would likelyneed to be on antibiotics after the surgery pending culture of her lung tissue. The cost of this surgicalprocedure would be roughly $5000-7000 if everything goes well and there are no complications. Dr. Heidi McDevitt is the surgical resident on the case, and her senior would be Dr. Adrienne Bentley. Dr. McDevitt will call you tomorrow to discuss the surgical aspect of Violet's case and can answer anyquestions relating to the surgery at that time. Together they can give you their experience on dogs similarto Violet and how they tend to do. While this is no indicator for how Violet will do, it may help you to
As discussed with you, at this point Violet's infection is unlikely to be cleared with medical therapy alone,but it is always an option to try. We discussed anesthetizing her and performing another bronchoscopywith airway wash and culture, but we would again have to treat with antibiotics for several weeks tomonths if we could find an appropriate antibiotic. This option is less apealing, and we agree that we mayend up back in this same situation in a few months. Surgery may be her best option for removing at leastthe most affected tissue in hopes of getting rid of the nidus for her continued infection.
We also discussed what may happen if you choose not to proceed with treatment. Her infection couldworsen and spread throughout different lung lobes. She may become more clinical and start to havedifficulty breathing where she needs oxygen support. The infection in her lungs could enter into the spacearound her lungs leading to a pyothorax (pus in the chest) which can be a life-threatening situation. Shecould also become very sick from the inflammation from pneumonia leading to fever, increased whiteblood cell count, bacteria entering her bloodstream, which can quickly lead to decompensation andcollapse. This is also an emergency situation. We do not know how long Violet could live with her currentinfection, but we do recommend some course of action if her quality of life at home is declining.
We understand this is a very large financial committment after all you have already been through with her. We support whatever decision you make. Please let us know if you have any further questions, concerns,or potentialy other routes you would like to pursue with Violet.
MEDICATIONSNo antibiotic therapy is recommended at this time so as not to promote resistance, though Violet cancontinue to receive her daily Zyrtec. If you notice Violet to be coughing, you can give her the hydodan (acough suppressant) at the previously recommended dose. This may make her more comfortable, especiallyin the evenings when you notice her cough to be worse.
CT AND SURGERYViolet's CT and surgery to remove her infected lung lobe could be performed as early as Wednesday. Violet would be admitted late Tuesday or early on Wednesday morning and would likely remain with usfor 4-5 days. Again, Dr. McDevitt will call you tomorrow morning to discuss this option with you.
If you choose to go ahead with the surgery, please withold Violet's food beginning at 10PM the nightbefore her surgery.
MONITORINGPlease monitor Violet for any increased coughing or respiratory noise, difficulty breathing or increasedrespiratory effort, increased lethargy, decreased appetite, or any vomiting or diarrhea.
As noted above, if you choose not to go ahead with further treatment, Violet will need to be monitoredclosely for any changes in comfort, ease of breathing, and systemic health. If her pneumonia progresses, itis possible that she may become very ill very quickly. Please contact Dr. Marino or your regularveterinarian immediately if you notice any of the above signs. If she appears to be experiencing anyrespiratory distress (difficulty breathing), please bring her in immediately to be seen.
Thank you for bringing Violet to see us at MJR-VHUP. She is a very sweet girl! You both have beenthrough a lot with Violet and you have done everything possible up to this point. We hope we can help
Please don't hesitate to contact Dr. Marino via phone or email with any questions or concerns.
Christina Marino, DVM 02/03/14Small Animal Internal Medicine Resident
_____________________________________________ Date:_________________
R E V I E W A R T I C L E Diabetes Metab Res Rev 2008; 24 (Suppl 1): S19–S24. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/dmrr.861 Advanced glycation end products and diabetic foot disease Diabetic foot disease is an important complication of diabetes. Thedevelopment and outcome of foot ulcers are related to the interplay betweennumerous diabetes
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Case Number: 87864301
As discussed with you, at this point Violet's infection is unlikely to be cleared with medical therapy alone,but it is always an option to try. We discussed anesthetizing her and performing another bronchoscopywith airway wash and culture, but we would again have to treat with antibiotics for several weeks tomonths if we could find an appropriate antibiotic. This option is less apealing, and we agree that we mayend up back in this same situation in a few months. Surgery may be her best option for removing at leastthe most affected tissue in hopes of getting rid of the nidus for her continued infection.
We also discussed what may happen if you choose not to proceed with treatment. Her infection couldworsen and spread throughout different lung lobes. She may become more clinical and start to havedifficulty breathing where she needs oxygen support. The infection in her lungs could enter into the spacearound her lungs leading to a pyothorax (pus in the chest) which can be a life-threatening situation. Shecould also become very sick from the inflammation from pneumonia leading to fever, increased whiteblood cell count, bacteria entering her bloodstream, which can quickly lead to decompensation andcollapse. This is also an emergency situation. We do not know how long Violet could live with her currentinfection, but we do recommend some course of action if her quality of life at home is declining.
Christina Marino, DVM 02/03/14Small Animal Internal Medicine Resident
_____________________________________________ Date:_________________