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Canine Parvovirus.
FOCAL POINT
Part II.Clinical
★Aggressive treatment can
dramatically increase survival of
Signs, Diagnosis,
patients with canine parvovirus
enteritis. and Treatment*
KEY FACTS
■ In-house ELISAs allow for rapid
diagnosis, but false-positives Auburn University
can result when dogs have Douglass K. Macintire, DVM, MS
been recently vaccinated with Saralyn Smith-Carr, DVM, PhD
attenuated virus vaccine, and
false-negatives can result when
antibodies from blood in the
feces bind to antigen.
ing and diarrhea is the cornerstone of treatment for ml/kg/hr may be necessary to restore perfusion. Animals
dogs with CPV enteritis and should be continued until in shock will have pale or muddy mucous membranes
oral intake is resumed. The initial fluid of choice is a and a slow capillary refill time. Fluid therapy should be
balanced electrolyte solution (e.g., lactated Ringer’s so- administered at a fairly rapid rate until mucous mem-
lution). These solutions mimic plasma electrolyte con- brane color becomes pinker and capillary refill time is re-
centrations, are isotonic, and can be given rapidly, if stored to 1 to 1.5 seconds. If circulatory collapse prevents
necessary, to replace acute fluid losses. venous access, fluids can be administered initially via a
The route and rate of initial fluid therapy varies with 20-gauge, 3.8-cm (1.5-inch) spinal needle placed into the
the patient. If CPV infection has resulted in hypovolemic intraosseous space in the shaft of the femur. Once circula-
shock, a rapid intravenous fluid bolus of up to 90 tion has improved with intraosseous fluids, an intra-
hours to more stable patients. General guidelines are to that can reduce vomiting by stimulating gastric empty-
supply one third of fluid needs as a colloid and two ing and inhibiting the chemoreceptor trigger zone.21
thirds as a crystalloid solution. The promotility effect may prevent gastric atony and
ileus from occurring in dogs with CPV infection.
Systemic Antibiotics Metoclopramide can be added to the intravenous fluids
Hemorrhagic diarrhea and mucosal sloughing are or administered as a constant-rate infusion of 1.0 to 2.0
commonly seen in dogs with CPV enteritis and indi- mg/kg over 24 hours.
cate breakdown of the gastrointestinal mucosal barrier, If metoclopramide is ineffective in controlling vomit-
which can lead to bacterial translocation, endotoxemia, ing, a more effective antiemetic is chlorpromazine.22
and sepsis.5,16 Severe neutropenia often coincides with This drug is a phenothiazine derivative and acts on the
the severe enteritis and contributes to the risk of sys- emetic center, the chemoreceptor trigger zone, and pe-
temic sepsis. For these reasons, intravenous broad-spec- ripheral receptors to reduce the vomiting reflex. The
trum, bactericidal antibiotics are indicated for severely recommended dosage is 0.1 mg/kg intravenously every
affected puppies.1 A combination of an aminoglycoside 4 to 6 hours or 0.2 to 0.5 mg/kg intramuscularly every
(gentamicin [2.2 mg/kg] or amikacin [10 mg/kg] every 6 to 8 hours, as needed. Phenothiazine derivatives can
8 hours) with a β-lactam antibiotic (ampicillin [2 cause hypotension and systemic vasodilatation through
mg/kg] or cefazolin [22 mg/kg] every 8 hours) provides their α-adrenergic blocking effect and should only be
excellent coverage against gram-negative and anaerobic given after the patient is well hydrated.22
bacteria that may originate from the gut.17 In dogs with intractable vomiting, metoclopramide
Aminoglycosides can cause acute renal failure and and chlorpromazine may be used together, but only
should only be administered after rehydration has been with caution because the potential for side effects may
accomplished.18 Once-a-day dosing of aminoglycosides increase. Dogs should be monitored for restlessness, hy-
may minimize renal damage while maximizing bacterial peractivity, bizarre behavior, or extreme drowsiness. If
kill because of high peak and low trough antibiotic con- any of these signs occur, antiemetic therapy should be
centrations.19 The high dose, however, should never be discontinued.
given to dehydrated patients. Urine sediment should be Intractable vomiting may respond to treatment with
monitored for proteinuria or renal tubule casts, which the new serotonin antagonist ondansetron HCl
would warrant discontinuation of aminoglycoside thera- (Zofran®, Glaxo Wellcome Inc) at dose of 0.1 to 0.15
py. mg/kg intravenously every 6 to 12 hours.23 Although
Enrofloxacin (5 mg/kg every 12 hours) is an alterna- the drug is highly effective and safe, it is also very ex-
tive to the aminoglycosides. It has an excellent gram- pensive.
negative spectrum but is not approved for intravenous Anticholinergic drugs should not be given to dogs
use and may cause cartilage abnormalities in young, with CPV enteritis because these drugs increase the po-
growing animals.20 We have not encountered any prob- tential for gastric atony, ileus, and intussusception of an
lems with enrofloxacin when it is diluted 1:1 with irritated bowel segment.22 Dogs with intractable vomit-
saline and administered slowly (intravenously) for a rel- ing should always be evaluated for foreign body ob-
atively short term (usually 3 to 5 days) in puppies with struction or intussusception. Other causes of continued
CPV enteritis. Rapid administration may cause vomit- vomiting include reflux esophagitis and acute pancre-
ing. atitis. Reflux esophagitis may be manifested by signs of
Mildly affected dogs with adequate white blood cell drooling, nausea, and exaggerated swallowing motions.
counts generally do not require combination antibiotic Treatment involves administration of a systemic antacid
therapy. Appropriate antibiotic choices include ampi- (famotidine [0.5 mg/kg] or ranitidine [5 mg/kg] intra-
cillin, first-generation cephalosporins, or trimetho- venously every 12 hours) and an oral suspension of su-
prim–sulfonamide in these patients. cralfate (1 g dissolved in 10 ml warm water, every 8
hours). Ideally, the antacid should be administered 1 to
Antiemetics 2 hours after the sucralfate.
Vomiting often decreases when oral intake of food
and fluid is discontinued; but in some patients, the Immunotherapy
problem persists and must be treated to reduce fluid Bacterial endotoxemia is believed to be an impor-
losses and increase patient comfort. tant factor in the terminal acute shock that occurs in
The two antiemetics most commonly used in dogs dogs with severe CPV enteritis. A polyvalent equine-
with CPV enteritis are metoclopramide and chlorpro- origin antiserum against LPS endotoxin is available
mazine. Metoclopramide is a gastric promotility drug for use in small animals (SEPTI-serum®—IMMVAC
Inc). In one study, the mortality rate for dogs with Recombinant Granulocyte
CPV enteritis treated conventionally was 48% (10 of Colony-Stimulating Factor
21 dogs) compared with 17% (5 of 30 dogs) for dogs Recently, the use of recombinant granulocyte colony-
that received antiendotoxin plus conventional treat- stimulating factor (rG-CSF) in dogs with leukopenia
ment.24 It is recommended that the product be ad- secondary to CPV enteritis has been described.31 The
ministered over 30 to 60 minutes at the dosage of 4.4 recommended dose is 5 to 10 µg/kg per day subcuta-
ml/kg and diluted 1:1 with intravenous crystalloid neously. Animals that respond generally show an in-
fluids.25 crease in white blood cell count within 24 hours. Un-
Antiendotoxin should be most effective if it is ad- fortunately, preliminary findings do not show an
ministered before antibiotic therapy because circulat- increased survivability associated with use of this prod-
ing plasma LPS concentrations can increase dramati- uct,32 and it is very expensive (approximately $130 to
cally after an antibiotic kills off gram-negative $150 to treat a puppy).
bacteria.26 Patients receiving equine-origin antiserum
must be observed closely during administration for Eradication of Intestinal Parasites
signs of anaphylaxis. If a second administration of an- Intestinal parasites can exacerbate CPV enteritis by
tiserum is deemed necessary, it should be given within enhancing intestinal cell turnover and subsequent viral
5 to 7 days after the initial treatment. After that time, replication.2 Fecal samples should be evaluated to iden-
a severe immunologic reaction is more likely to oc- tify coccidia, Giardia species, hookworms, round-
cur.27 worms, or whipworms. Appropriate oral therapy can be
Anecdotal reports describe the use of convalescent initiated as soon as vomiting ceases, or ivermectin (250
serum (1.1 to 2.2 ml/kg intravenously or subcuta- µg/kg subcutaneously) can be given–except to collies
neously) collected from dogs that have recovered and related breeds.
from CPV infection in an effort to provide passive
immunity to exposed or infected dogs.2,28 Research is Nutrition
needed to determine the efficacy and safety of this Dogs with severe CPV enteritis may have a pro-
practice. longed course of hospitalization and may require nutri-
tional support to prevent catabolism and immune dys-
Aggressive Adjunctive Treatments function associated with negative nitrogen balance.
Steroids and Flunixin Meglumine Partial parenteral nutrition (PPN) does not supply all
Corticosteroids and flunixin meglumine have shown of the patient’s nutrient needs but can provide short-
beneficial effects in animal models of septic and endo- term support for animals that are expected to recover
toxic shock if administered early in the shock state.29 soon. PPN solutions can be delivered through a periph-
Potential beneficial effects of corticosteroids include eral vein rather than through a large central vein.33
improved tissue perfusion, decreased leukocyte mar- These solutions are usually given at a maintenance dose
gination, enhanced membrane stabilization, and re- (60 ml/kg/day); additional fluid needs are met with
duced absorption of endotoxins. Flunixin meglumine is crystalloid solutions. A commercial product that con-
a potent nonsteroidal antiinflammatory analgesic that tains 3% amino acids, 3% glycerol, and electrolytes can
has antidiarrheal and antipyretic effects and that may be used. A PPN solution can be made by adding 300
reduce the severity of the intestinal inflammation asso- ml of 8.5% amino acid solution to 700 ml of lactated
ciated with CPV infection. Ringer’s solution with 5% dextrose. The addition of
Corticosteroids and flunixin meglumine can cause se- lipid emulsions is controversial. Although lipids are rich
vere gastrointestinal ulceration.30 Because of this possi- in calories, they have been associated with immunosup-
bility, we reserve use of these agents for animals exhibit- pression through impairment of reticuloendothelial
ing early signs of sepsis or endotoxemia: fever, function and white blood cell phagocytosis.34
tachycardia, injected or muddy mucous membranes, Partial parenteral nutrition solutions are hypertonic
and evidence of breakdown of the gastrointestinal mu- and therefore often cause phlebitis near the catheter
cosal barrier. These agents should not be administered site. Catheters must be placed aseptically and the site
until after the initial fluid bolus has been given. In se- monitored carefully for redness, swelling, or pain.35
lect cases, we use either dexamethasone sodium phos- Dextrose solutions should be tapered off gradually to
phate (2 to 4 mg/kg intravenously) or flunixin meglu- prevent rebound hypoglycemia.
mine (1 mg/kg intravenously). Repeated doses are not Most practitioners offer water after vomiting has
recommended because they increase the likelihood of ceased for 12 to 24 hours. Early enteral nutrition is im-
side effects. portant to promote intestinal regeneration. A liquid
diet can be offered initially, or a gruel can be made with of canine parvovirus DNA by the nested polymerase chain
an easily digestible, high-carbohydrate, low-fat diet. reaction. Vet Microbiol 41:135–145, 1994.
11. Schunk B, Kraft W, Truyen U: A simple touch-down poly-
The addition of glutamine powder (0.5 g/kg/day in merase chain reaction for the detection of canine parvovirus
two divided doses) to drinking water has been recom- and feline panleukopenia in feces. J Virol Methods 55:427–
mended to promote gastrointestinal healing in dogs re- 433, 1995.
covering from CPV enteritis.36 12. Senda M, Parrish CR, Harasawa R, Gamoh K: Detection by
Various commercial diets are formulated for animals PCR of wild type canine parvovirus which contaminates dog
vaccines. J Clin Microbiol 33:110–113, 1995.
that are recovering from gastrointestinal illness. Intesti- 13. DiBartola SP, Autran de Morais HS: Disorders of potassi-
nal malabsorption and protein-losing enteropathy may um: Hypokalemia and hyperkalemia, in DiBartola SP (ed):
persist until the intestinal villi are repaired. Initial Fluid Therapy in Small Animal Practice. Philadelphia, WB
feeding should consist of small amounts of an easily Saunders Co, 1992, pp 89–115.
digestible diet fed frequently. The normal diet is grad- 14. Navar PD, Navar LG: Relationship between colloid osmotic
pressure and protein concentration in the dog. Am J Physiol
ually reintroduced after appetite and stool have re- 233: H295–H298, 1977.
turned to normal. After recovery, immunity to par- 15. Kirby R: Synthetic colloids. Proc 5th Int Vet Emerg Crit Care
vovirus infection lasts at least 2 years and may even be Symp:159–163, 1996.
lifelong. 16. Kreeger TJ, Jeraj KP, Manning PJ: Bacteremia concomitant
with canine parvovirus infection in a pup. JAVMA 184:195–
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17. Weeran FR, Muir WW: Clinical aspects of septic shock and
About the Authors comprehensive approaches to treatment in dogs and cats.
Drs. Macintire and Smith-Carr are affiliated with the JAVMA 200:1859–1866, 1992.
Department of Small Animal Surgery and Medicine, Col- 18. Brown SA, Barsanti SA: Gentamicin nephrotoxicosis in the
dog, in Kirk RW (ed): Current Veterinary Therapy. IX.
lege of Veterinary Medicine, Auburn University, Alabama.
Philadelphia, WB Saunders Co, 1986, pp 1146–1149.
Dr. Macintire is a Diplomate of the American College of 19. Munckhof WJ, Grayson ML, Turnidge JD: A meta-analysis
Veterinary Internal Medicine and the American College of on the safety and efficacy of aminoglycosides given either
Veterinary Emergency and Critical Care. once daily or as divided doses. J Antimicrob Chemother
37:645–663, 1996.
20. Boothe DM: Antibiotics in critical care. Proc 5th Int Vet
Emerg Crit Care Symp:330–337, 1996.
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