Refractory shock,hypercoagulability, and multiorgan thrombosis associated with hypertrophic osteodystrophy in a dog

Objective

To describe the clinical findings and case progression in a dog presenting with severe systemic inflammatory response, refractory shock, progressive metabolic acidosis, and respiratory failure that was ultimately diagnosed with hypertrophic osteodystrophy (HOD).

Case Summary

A 4-month-old male intact Mastiff presented with a 24-hour history of lethargy and generalized ostealgia. On examination, the dog was recumbent, febrile, and tachycardic with pain on palpation of the abdomen, right femur, and mandible. Appendicular joint radiographs showed changes consistent with osteochondrosis and ulnar-retained cartilaginous cores, with no overt evidence of HOD. Initial treatment included IV fluid therapy, multimodal analgesia, and broad-spectrum antimicrobials. Vasopressor therapy was initiated following hemodynamic decompensation. Synovial fluid cytological analysis and culture revealed nonseptic suppurative inflammation and no bacterial growth, respectively. Blood and urine cultures also yielded no growth. Viscoelastic testing was consistent with hypercoagulability. The dog initially had a metabolic acidosis with appropriate respiratory compensation that progressed to a mixed metabolic and respiratory acidosis despite aggressive therapies that included antimicrobials, vasopressors, positive inotropes, and corticosteroids. Humane euthanasia was elected approximately 32 hours after admission. Necropsy yielded a diagnosis of HOD.

New or Unique Information Provided

This is the first report detailing the occurrence of refractory shock and hypercoagulability associated with HOD in a dog without evidence of another identified comorbidity. HOD should be considered in any young, large-breed dog with generalized ostealgia and signs of systemic illness, even in the absence of classic radiographic abnormalities. Further investigation of coagulation status in dogs with HOD and a secondary systemic inflammatory response is warranted.     

Thrombin‐activatable fibrinolysis inhibitor activity in healthy and diseased dogs

Background: In people, increased thrombin‐activatable fibrinolysis inhibitor (TAFI) antigen has been associated with increased risk of thrombosis, and decreased TAFI may contribute to bleeding diathesis. TAFI activity in dogs has been described in experimental models, but not in dogs with spontaneous disease. Objective: The aim of this study was to compare TAFI activity in healthy dogs with TAFI activity in dogs with spontaneous disease. Methods: Plasma samples from 20 clinically healthy Beagles and from 35 dogs with various diseases were analyzed using a commercial chromogenic assay that measured TAFI activity relative to activity in standardized pooled human plasma. Results: Median TAFI activity for the 20 Beagles was 46.1% (range 32.2–70.8%) compared with 62.6% (29.1–250%) for the 35 diseased dogs, and 14/35 (40%) had TAFI activities >the upper limit for controls. The highest individual activities (>225%) were in 3 dogs with malignant neoplasms and 1 dog with thrombocytopenia. For data grouped by diagnosis, median TAFI activity was 61.7% for benign neoplasia (n=5), 64.9% for malignant neoplasia (n=8), 75.5% for Angiostrongylus vasorum infection (n=4), 68.8% for bacterial sepsis (n=7), and 58.7% for miscellaneous diseases (n=11). Compared with TAFI activity in control dogs, median TAFI activity was significantly increased only in the group of dogs with bacterial sepsis. Conclusion: Bacterial sepsis was associated with significantly increased TAFI activity, and individual dogs with increased TAFI activities were found in all disease groups. The role of TAFI in the pathogenesis of hemostatic disorders in dogs and its value as a prognostic indicator deserve further investigation.     

Thromboelastography in healthy, sick non-septic and septic neonatal foals

Objectives To evaluate citrated recalcified thromboelastography (TEG) in healthy newborn foals, and to determine intra‐assay, inter‐individual and intra‐individual (at 12 h, 24 h and 7 days after birth) variations. Additionally, to compare TEG variables, haematological values and conventional coagulation profiles from healthy, sick non‐septic, and septic foals. Design Prospective study. Methods The study group comprised 18 healthy, 15 sick non‐septic and 17 septic foals. Two citrated (3.2%; 1 : 9 anticoagulant : blood ratio) blood samples were submitted for haemostatic evaluation using a TEG analyser and conventional coagulation profile. TEG values (R time (R), K time (K), angle (α), maximum amplitude (MA) and G value (G)), complete blood count (CBC) and conventional coagulation profile (prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen concentration (Fib) and antithrombin (AT)) were evaluated. Signalment, presenting complaint, sepsis scores, blood culture results and outcome were taken from the medical records of the sick foals. Results Mean values ± SD for TEG variables in healthy neonatal foals were: R = 11.82 ± 5.35 min, K = 3.06 ± 1.34 min, α= 51.19 ± 12.66 degrees, MA = 55.06 ± 6.67 mm and G = 6361 ± 1700 dyn/cm². Mean coefficients of variation for intra‐assay/inter‐individual/intra‐individual in healthy foals were: R = 3.5/45.2/43.1%; K = 5.3/58.7/28.7%; α= 1.5/24.7/11.9%; MA = 0.3/12.1/6.1%; G = 1.6/26.7/14.7%. Septic foals had significantly greater α, MA and G values than sick non‐septic foals, and significantly greater MA and G than healthy foals, changes that are consistent with hypercoagulability. Weak correlations were detected between TEG variables and haematological or haemostatic values. Conclusions TEG could be used to provide additional information about the haemostatic system in equine neonates.     

Evaluation of plasma antithrombin activity and D-dimer concentration in populations of healthy cats, clinically ill cats, and cats with cardiomyopathy

BACKGROUND: Current coagulation tests lack sensitivity and detect disseminated intravascular coagulation (DIC) only when it is severe. Measurement of antithrombin (AT) activity and D-dimer concentration permits early diagnosis and more precise classification of coagulopathies in some species. OBJECTIVES: The objectives of this study were to validate and determine the diagnostic utility of a chromogenic AT assay and an immunoturbidimetric D-dimer assay for the diagnosis of DIC in cats. METHODS: Citrated plasma samples were collected from 30 healthy cats, 30 ill cats, and 13 cats with cardiomyopathy. Partial thromboplastin time, prothrombin time, fibrin(ogen) degradation products, platelet concentration, and erythrocyte morphology were determined on all samples to document the presence or the absence of DIC. AT activity and D-dimer concentration were then measured. RESULTS: The chromogenic AT assay was linear and precise. Mean AT activity was higher in ill cats and cats with cardiomyopathy compared with healthy cats, but the difference was only significant in ill cats (P = .003). Seven cats met the criteria for DIC. Of the cats with DIC, 2 had decreased AT activity, 1 had increased AT activity, and 4 had AT activities within normal limits. The immunoturbidimetric D-dimer assay did not appear to accurately measure feline D-dimer. CONCLUSIONS: The chromogenic AT assay appeared to measure AT in cats but was not useful for the diagnosis of DIC. AT may be an acute phase reactant in cats. The immunoturbidimetric D-dimer assay was not useful for the diagnosis of DIC in cats.     

Thromboelastographic results and hypercoagulability in dogs with surgically treated hepatocellular adenoma and carcinoma: A Veterinary Society of Surgical Oncology prospective study

Background

The most common haemostatic abnormality in dogs with cancer is hypercoagulability. A transient hypercoagulability has been documented in people with hepatocellular carcinoma (HCC) that resolves within weeks following hepatic tumour resection.

Objective

The objective was to compare the haemostatic status of dogs with liver tumours and healthy control dogs, by comparing coagulation and thromboelastography (TEG) measurements at three time points.

Methods

Liver tumour and healthy control dogs receiving surgery for liver lobectomy and ovariohysterectomy, respectively, were prospectively enrolled. All dogs had blood collected at three time points: pre-operative, 24 h post-operative and ~2 weeks post-operative. Haematological and haemostatic values were compared across time points in each group using repeated measures ANOVA tests.

Results

Ten and eight dogs were enrolled for the liver and control groups, respectively. Platelet count was significantly higher in the liver group than the control group at all time points, but within the normal range (pre-operative: 438.7 vs. 300.9 × 10⁹/L, p = .0078; 24 h post-operative: 416.2 vs. 283.9 × 10⁹/L, p = .0123; 10–14 days post-operative: 524.6 vs. 317.3 × 10⁹/L, p = .0072). The measure of the overall coagulant state (G-value) was significantly increased for the liver group compared to the control group at all time points (pre-operative: 15.6 vs. 8.6 d/sc, p = .0003; 24 h post-operative: 18.3 vs. 11.2 d/sc, p = .039; 10–14 days post-operative: 15.1 vs. 9.6 d/sc, p = .015).

Conclusion

The liver group was hypercoagulable based on elevated G-values at all time points compared to the control group. This hypercoagulability was attributed to the effect of hepatic tumours alone, and not secondary to surgery and anaesthesia.     

Pharmacokinetics and pharmacodynamics of a therapeutic dose of unfractionated heparin (200 U/kg) administered subcutaneously or intravenously to healthy dogs

BACKGROUND: Heparin treatment has been recommended for dogs in hypercoagulable states such as disseminated intravascular coagulation, however, potential benefits have to be balanced against the bleeding risk if overdosage occurs. A better understanding of the pharmacology of heparin and tests to monitor heparin therapy in dogs may help prevent therapeutic hazards. OBJECTIVES: The purpose of this study was to evaluate the effects of 200 U/kg of sodium unfractionated heparin (UFH) on coagulation times in dogs after intravenous (IV) and subcutaneous (SC) administration and to compare these effects with plasma heparin concentrations assessed by its antifactor Xa (aXa) activity. METHODS: 200 U/kg of UFH were administered IV and SC to 5 healthy adult Beagle dogs with a washout period of at least 3 days. Activated partial thromboplastin time (APTT), prothrombin time (PT), and plasma aXa activity were determined in serial blood samples. RESULTS: After IV injection, PT remained unchanged except for a slight increase in 1 dog; APTT was not measurable (>60 seconds) for 45-90 minutes, and then decreased gradually to baseline values between 150 and 240 minutes. High plasma heparin concentrations were observed (maximal concentration = 4.64 +/-1.4 aXa U/mL) and decreased according to a slightly concave-convex pattern on a semilogarithmic curve, but returned to baseline slightly more slowly (t240-t300 minutes) than did APTT. After SC administration, APTT was moderately prolonged (by a ratio of 1.55 +/-0.28 APTT t0, range 1.35-2.01) between 1 and 4 hours after administration. Plasma aXa activity reached a maximum of 0.56 +/-0.20 aXa U/mL (range 0.42-0.9 U/mL) after 132 +/-26.8 minutes; this lasted for 102 +/-26.8 minutes. Prolongation of APTTs of 120-160% corresponded to plasma heparin concentrations of 0.3-0.7 aXa U/mL. CONCLUSIONS: As in humans, the pharmacokinetics of UFH in dogs was nonlinear. Administration of 200 U/kg of UFH SC in healthy dogs resulted in sustained plasma heparin concentrations in accordance with human recommendations for thrombosis treatment or prevention, without excessively increased bleeding risks. In these conditions, APTT can be used as a surrogate to assess plasma heparin concentrations. These findings need to be confirmed in diseased animals.     

Leptospirosis with multiple organ dysfunction in a mongoose-scat-detection dog infected with Leptospira interrogans serogroup Hebdomadis,Okinawa, Japan

A 2-year-old male mongoose-scat-detection dog was diagnosed with leptospirosis by urine PCR. The patient developed acute renal failure, hepatic dysfunction, and disseminated intravascular coagulation. Treatment with antibiotics was administered, including ampicillin and doxycycline, and supportive care management was provided. Seroconversion against serogroup Hebdomadis was observed on day 8. The leptospiral gene flaB was detected only in urine collected on day 1, from which Leptospira interrogans ST329 was identified by multilocus sequence typing using seven housekeeping genes. L. interrogans serogroup Hebdomadis ST329 has been isolated from mongooses and humans in Okinawa, Japan. This patient received early treatment with antibiotics, which may have contributed to the early recovery of renal function and removal of L. interrogans from kidney tissue.     

Comparison of quantitative immunoturbidimetric and semiquantitative latex‐agglutination assays for D‐dimer measurement in canine plasma

Background: D‐dimer measurement in dogs is considered the most reliable test for detecting disseminated intravascular coagulation or thromboembolism. Objectives: The purposes of this study were to compare 2 D‐dimer assays, a quantitative immunoturbidimetric and a semiquantitative latex agglutination assay, and to assess the effect of hemolysis and storage conditions on D‐dimer concentration using the quantitative assay. Methods: The immunoturbidimetric assay was validated using canine citrated plasma samples containing different concentrations of D‐dimer. The effect of storage at various temperatures and times was assessed. Hemolysis was produced by adding lysed RBCs to the samples for a final hemoglobin concentration of 0.35 g/dL. Results: For clinically relevant values (>250 μg/L), intra‐assay and interassay coefficients of variation were 6.8% and 7.2%. The assay was linear (r²=1.00), and the tests had good agreement (κ=0.685, P<.001). Storage at 4 °C and ?20 °C and hemolysis had no significant effect on D‐dimer concentrations. In hemolyzed samples stored at room temperature for ≥48 hours, fine clots were noted and often resulted in falsely increased D‐dimer concentrations. Conclusions: Our findings suggest that the immunoturbidimetric assay validated in this study is reliable and accurate for the measurement of D‐dimer in canine plasma. Samples can be stored for up to 1 month at ?20 °C and moderate hemolysis does not significantly affect the D‐dimer concentration in frozen or refrigerated samples.     

Evaluation of latex agglutination kits for detection of fibrin(ogen) degradation products and D-dimer in healthy horses and horses with severe colic

Background: Fibrin(ogen) degradation products (FDPs) and D‐dimer are sensitive indicators of excessive fibrinolysis due to disseminated intravascular coagulation (DIC) in dogs. To the authors' knowledge, latex‐agglutination–based plasma FDP and D‐dimer assays have not been validated for use in horses. Objectives: To determine: 1) sensitivity and specificity of latex‐agglutination serum and plasma FDP and D‐dimer assays for diagnosis of DIC; and 2) their prognostic value in horses with severe colic. Methods: At hospital admission and 24 hours later, blood was collected from 30 healthy horses and 20 horses with severe colic. Horses fulfilling predefined laboratory criteria of DIC were enrolled, and their data were subcategorized by survival for analysis. Platelet counts were determined and coagulation panel testing was performed. Serum and plasma FDP concentrations were measured using separate latex agglutination kits. Plasma D‐dimer concentration was measured using 3 latex agglutination kits and a card immunofiltration test. Test sensitivity and specificity results were determined for healthy horses and those with colic. Median test values were compared between colic survivors and nonsurvivors to evaluate the prognostic usefulness of all tests. Results: Performance characteristics varied among assays and kit suppliers. The FDP assays had low sensitivity (<40%), whereas the most accurate D‐dimer kit had 50% sensitivity and 97% specificity. High D‐dimer concentration was the third most common hemostatic abnormality in horses with colic. Median antithrombin (AT) activity was significantly lower and activated partial thromboplastin time (aPTT) was significantly longer in nonsurvivors than survivors. Conclusions: Commercial latex‐agglutination D‐dimer assays might prove useful as adjunctive tests for the diagnosis of DIC in horses with severe colic; however FDP assays are invalid for this purpose. Low AT activity and prolonged aPTT at admission are associated with a poor prognosis in this patient population.     

Cytologic,histologic, microbiologic,and electron microscopic characterization of a canine Prototheca wickerhamii infection

An adult dog was presented for chronic cough and a recent development of ulcerated, erythematous nares with nasal discharge. Cytology of enlarged peripheral lymph nodes revealed many intracellular and extracellular organisms. These round or rarely oval organisms measured approximately 5-9 µm in diameter and frequently contained several globular structures, ranging from deeply basophilic to magenta. A thin, clear halo was present. Smaller 1-2 µm, magenta forms were also observed. Fungal culture yielded small, wet, raised, irregularly shaped, white to pale tan colonies. Microbiologic staining of cultured material revealed features suggestive of algae. Histopathology of the lymph nodes revealed marked granulomatous inflammation with intralesional algal organisms suggestive of Prototheca. Electron microscopic findings were also consistent with protothecosis. Polymerase chain reaction, followed by direct DNA sequencing, identified the organism as Prototheca wickerhamii. A brief literature review discussing protothecosis in veterinary medicine is included.     

The relationship between in vivo limb and in vitro tendon mechanics after injury: a potential novel clinical tool for monitoring tendon repair

Reasons for performing the study: Highly prevalent superficial digital flexor tendon (SDFT) injury results in compromised tendon function through fibrosis and high frequency of re‐injury due to altered biomechanical function. This study investigated the consequences of SDF tendinopathy on limb mechanics in relation to the mechanical properties of injured tendon. Objectives: To develop and validate a noninvasive in vivo assessment of tendon mechanics to investigate the effect of recent SDFT injury on limb stiffness index, providing an objective method to assess quality of healing. Hypotheses: Limb stiffness index would reduce as a consequence of SDFT injury and progressively increase during tendon healing and correlate with in vitro mechanical properties of the respective SDFTs. Methods: Kinematic analysis was performed at walk in 10 horses that had sustained career‐ending SDFT injury. Stiffness index was derived from limb force recorded via a series of force plates and measurement of change in metacarpophalangeal joint angle using 3D motion analysis software. Horses were subjected to euthanasia 7 months after injury, the SDFTs removed and subjected to nondestructive in vitro mechanical testing. Results: Limb stiffness index was reduced following SDFT injury in comparison with the contralateral limb and increased during the convalescent period, approximating that of the contralateral limb by 7 months post injury. There was a significant positive correlation between in vivo limb stiffness index and in vitro SDFT stiffness. Clinical relevance: The ability to assess and monitor SDFT mechanical competence through limb stiffness measurement techniques in horses recovering from SDFT injury and the possibility of corroborating this with functional tendon healing may permit a more objective and accurate assessment of optimal tendon repair in the horse. This technique may be a useful method for assessing the efficacy of treatment regimens for tendinopathy and could be utilised to predict time to safe return to performance or re‐injury.     

Paraoxonase activity as a tool for clinical monitoring of dogs treated for canine leishmaniasis

This study was designed to determine if the activity of paraoxonase (PON1), an antioxidant enzyme that works as a negative acute phase reactant, is a better predictor for the clinical recovery of leishmaniotic dogs receiving standard treatments compared with inflammatory markers such as C reactive protein (CRP) and electrophoretic fractions. For this purpose we tested 20 healthy dogs (controls) and 39 leishmaniotic dogs classified as sick (group A, n = 23) or severely sick (group B, n = 16) and tested at admission and after 3, 7, 14, 21, 28, 35 and 42 days.At admission, CRP and electrophoresis were altered in both groups, while PON1 activity was abnormal only in group B. There were no differences related to the outcome (mortality, complications or time of recovery). PON1 activity normalized in about 2 weeks in dogs that had abnormal values at admission and a final positive outcome; CRP normalized in 4–6 weeks and electrophoretic fractions were still altered after 6 weeks. The results show that, at admission, inflammatory markers did not predict the outcome of leishmaniasis. PON1 activity decreased only in some dogs with systemic inflammation but not in those with mild leishmaniasis: when decreased, PON1 normalized earlier than other markers in dogs that responded to treatment. This finding most likely depends on the rapid decrease in oxidative phenomena. PON1 activity should therefore be tested on admission: if low values are recorded, severe inflammation may be suspected and PON1 measurement may be repeated during treatment to early identify responsive dogs.     

Internal aorto-iliac thrombosis in a Thoroughbred: Unsuccessful surgical thrombectomy,a proposed aetiopathogenesis and spontaneous partial regression

A 4-year-old Thoroughbred gelding with severe left hindlimb lameness and colic-like signs lasting 30–60 min post-exercise was diagnosed with unilateral internal aorto-iliac thrombosis. The thrombus was identified using transrectal ultrasonography in the terminal aorta and was initially thought to extend into the left external iliac artery. However, attempted thrombectomy via a left femoral arteriotomy performed under general anaesthesia using thrombectomy and angioplasty catheters was unsuccessful, as the thrombus was located in the left internal iliac artery. Transrectal ultrasound evaluation was repeated monthly for 12 months post-operatively during which time the gelding remained asymptomatic at rest. As removal of thrombi in the external but not internal iliac artery may be possible, correct diagnosis of the location of the thrombus is critical in preventing unnecessary attempts at surgical correction. The aetiology remains unknown, but altered haemodynamics within the abdominal aorta with mechanical stresses during intense exercise are proposed as a cause of thrombus formation. The sequential monitoring of this case also conflicts the assumption that thrombi in this location propagate over time as partial regression was observed 6 months after referral and 9 months after onset of clinical signs.     

Remote monitoring system as a tool for calving management in Mediterranean Buffalo heifers (Bubalus bubalis)

Buffalo breeding is common in Southern Italy. Dystocia compromises dam's and newborn health and welfare. Difficult parturition could be solved through prompt calving assistance, even if the identification of the beginning of delivery is challenging. Herein, we aimed to evaluate a remote calving alarm system in 15 Mediterranean buffalo heifers. An intravaginal probe was placed close to the external cervical os once premonitory signs of delivery were observed. No vaginal discharge nor signs of discomfort were notified in the days following the insertion of the probe. Heifers calved from 48 to 72 hr after the alarm was activated. The system correctly warned the farm personnel at the beginning of stage II of parturition, except for 2 cases. In the former, the intravaginal probe was expelled but the poor carrier network coverage negatively affected phone's signal quality; in the latter, recurrent vaginal prolapse was responsible for non-retention of the probe. Overall median expulsive phase was 68 ± 8 min, while the expulsion of a female calf took 54 ± 22.0 min and 90 ± 34.0 min in males, with significant difference (p =.02). Deliveries were homogeneously distributed across a 24-hr interval. No retention of foetal membranes nor metritis was identified at postpartum clinical examination. The calving alarm system used in this work was well tolerated in buffalo heifers. The introduction of smart technology in buffalo farming could contribute to the overall farm net return by reducing calf losses, especially for calves born from sexed-sorted semen, and by increasing animal welfare through quick resolution of dystocia. Further studies will be necessary to evaluate the net return in buffalo farms which will implement a remote calving alarm system on a wider population.     

Validation of the bovine blood calcium checker as a rapid and simple measuring tool for the ionized calcium concentration in cattle

Point-of-care (POC) devices that veterinary practitioners can use to easily and rapidly measure blood ionized calcium (iCa) levels in cows immediately after withdrawing a blood sample on the dairy farm are needed. Aims of present studies was to compare the commercially available ion-selective electrode handheld iCa meter (bovine blood iCa checker) with the benchtop blood gas analyzer GEM premier 3500 and handheld analyzer i-STAT 1. Sixty-two paired-point whole blood samples were obtained from three cows with hypocalcemia experimentally induced by Na₂-EDTA infusion. Whole blood samples were also obtained from the 36 cows kept on a farm in field conditions. The results using the bovine blood iCa checker correlated with those using the GEM premier 3500 and i-STAT 1. Bovine blood iCa checker was “compatible” with the GEM premier 3500 and i-STAT 1 because the frequency of differences between the measurements within ± 20% of the mean were 100% (65/65, >75%) and 90.8% (59/65, >75%), respectively. In the field trial, the blood iCa concentration measured by the bovine blood Ca checker was significantly positively correlated with that measured by the i-STAT 1 portable analyzer. Bovine blood iCa checker was “compatible” with the i-STAT 1 because the frequency of differences between the measurements within ± 20% of the mean was 100% (36/36, >75%). Results from these findings, the bovine blood iCa checker may be applied as a simplified system to measure the iCa concentration in bovine whole blood.