Veterinary Medical Teaching Hospital

Texas A&M University

(979) 845-2351
www.cvm.tamu.edu

Internal Medicine Discharge Summary

Owner: Admission Date: 1/13/2010

Staci
Discharge Date: 1/13/2010
Patient: Lucie
DOB: 11/18/08 Recheck Date: 2 weeks
Weight: 26.2 kgs
Senior Clinician: Katherine D Snyder, DVM
Referring Veterinarian:
Russell E. Johnson, DVM Attending Clinician: Jonathan Lidbury,
Neighborhood Pet Health Center BVMS
8301 Davis Blvd.
North Richland Hillls, TX 76180 Student: Brian M Cichocki
Phone: 817-605-8888
Fax:817-788-1791

Lucie was admitted to the Texas A&M University Veterinary Medical Teaching Hospital
on 1/13/2010 9:36:59 AM .

Presenting complaint: suspected vena caval aneurism

History: Lucie is a 14 month old spayed female Border Collie/Great Pyrenees cross
that presented today to the TAMU Canine Internal Medicine service for evaluation of a
vena caval aneurism and difficulty rising on her pelvic limbs. Lucy's owners initially
noted the development of nodular lesions on the borders of her ears last October, and
about one week later she began to have difficulty rising. Bloodwork done at that time
revealed no abnormalities and radiographs of the abdomen and pelvis were
unremarkable. Tick serology was performed and was negative. Lucie was started on
doxycycline and niacinamide, as well as Rimadyl. The Rimadyl has helped with Lucie's
pain and difficulty rising. Lucie was subsequently referred to a dermatologist, who was
suspicious of a reactive histiocytic disorder. Lucie was switched from doxycycline to
tetracycline at this time. This resulted in significant anorexia and both the tetracycline
and niacinamide were discontinued. Lucie's appetite subsequently returned to normal.
Lucie's lethargy and hesitation to rise did not improve further and she was referred to an
internist. Bloodwork and urinalysis were performed, revealing proteinuria which was
confirmed by a UP:C. An abdominal ultrasound was subsequently performed, revealing
an aneurysmal type defect of the caudal vena cava.

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Lucie is current on vaccinations, receives 50mg Rimadyl BID, and receives Heartgard
and Frontline monthly for parasite control. Lucie has been spayed and has had
dewclaws removed. She is an indoor dog with access to a large fenced yard, and is
around two other dogs at home. Lucie is fed Royal Canin adult maintenance dry food,
~2 cups per day and free choice water.

Physical Examination:
T: 101.5 F, P: 88 bpm, R: 24, Wt: 26.2 kg, BCS: 4/9

On physical exam, Lucie was bright, alert and responsive. She had adequate hydration
with moist pink mucous membranes with a CRT<2sec. Thoracic auscultation revealed
respiratory arrhythmia with clear lung sounds bilaterally. Femoral pulses were fair and
synchronous with ausculted beats. There was a mild amount of dental tartar. Popliteal
lymph nodes were enlarged and firm on palpation bilaterally. All other findings were
within norml limits. No abnormalities were found on neurological examination.

Diagnostic Tests & Results:

Complete Blood Count:

Test Result Reference Unit
WBC 6.6 6.0 - 17.0 ul
Red Blood Cell Count 5.03 5.50 - 8.50 M/ul
Hemoglobin 12.0 10.0 - 20.0 g/dl
Packed Cell Volume 36.3 31.0 - 56.0 %
Mean Corpuscular Volume 72.1 60.0 - 77.0 fl.
Mean Corpuscular Hemoglobin 33.0 32.0 - 36.0 g/dl
Concentration
Plasma Protein 6.8 6-8 TS-g/dl
Platelet Count (Automated) 147000 200000 - 500000 /ul
Segmented Neutrophils 69 60 - 77 %
Absolute Neutrophil 4554 3000 - 11500
Lymphocytes 22 12 - 30 %
Absolute Lymphocyte 1452 1000 - 4800
Monocytes 3 3 - 10 %
Absolute Monocyte 198 150 - 1250
Eosinophil 6 2 - 10 %
Absolute Eosinophil 396 100 - 1250
Test Interpretation: Mild thrombocytopenia
Panel Interpretation Result
RBC Morphology Acanthocyte rare
RBC Morphology Rouleaux slight
RBC Morphology Anisocytosis slight
RBC Morphology Echinocytes 1+
RBC Morphology Target Cells 1+
Platelets Estimated Count low
Neutrophil Morphology Normal

Chemistry Panel:
Test Result Reference Unit
Glucose 98. 60 - 135 mg/dl
Lactic Acid 7.0 9.9 - 46.8 mg/dl

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Cholesterol 281. 120 - 247 mg/dl
Blood Urea Nitrogen 13. 5 - 29 mg/dl
Creatinine .9 .3 - 2 mg/dl
Magnesium 1.9 1.7 - 2.1 mg/dl
Calcium 10.6 9.3 - 11.8 mg/dl
Phosphorus 6.2 2.9 - 6.2 mg/dl
Total Protein 6.3 5.7 - 7.8 g/dl
Albumin 2.9 2.4 - 3.6 g/dl
Globulin 3.4 1.7 - 3.8 g/dl
Alanine Aminotransferase 24. 10 - 130 U/L
Alkaline Phosphatase 43. 24 - 147 U/L
Gamma Glutamyltransferase <10. 0 - 25 U/L
Total Bilirubin .2 0 - .8 mg/dl
Sodium 144. 139 - 147 mmol/L
Potassium 3.8 3.3 - 4.6 mmol/L
Chloride 116. 107 - 116 mmol/L
Enzymatic Carbon Dioxide 24. 21 - 28 mmol/L
Anion Gap (Calculated) 7. 10 - 18 mmol/L
Ammonia <14.8 0 - 50 ug/dl
Test Interpretation: Mild hypercholesterolemia

Coagulation Profile:
Test Result Reference Unit
Prothrombin Time 8.4 6.0 - 7.5 sec
Partial Thromboplastin Time 10.5 7.1 - 10.0 sec.
PT-Fib 118 64 - 202 mg/dl
Fib-Clauss 109 116 - 364 mg/dl
Antithrombin III 139 > 114 %NHP
D-Dimer 2341 116.2 - 371.5 ng/ml
Test Interpretation: D-dimer elevation consistent with clot breakdown

Urinalysis:
Test Result Reference Unit
Color/Transparency yel/cldy
Specific Gravity 1.030 1.015 - 1.045 GMS/100ml
PH (dipstick) 7.5 6.000 - 7.000
Protein (urine dipstick) 300 mg/dl
Glucose (urine dipstick) neg mg/dl
Ketones (urine dipstick) neg
Bilirubin (urine dipstick) neg
Blood (urine dipstick) trace
Urobilinogen (urine dipstick) 0.2 0.100 - 1.000 mg/dl
SSA 3+
Volume Submitted 6 ml
Volume Centrifuged 3 ml
WBC - UA 0-2 /hpf
RBC-Urine 0-1 /hpf
Crystals-Amorphorous many
Test Interpretation: Proteinuria

Urine Proteine:Creatinine
Test Result Reference Unit
Microprotein-Urine 371. mg/dl
Urine Creatinine 188.2 mg/dl
Test Interpretation: 1.97, confirmatory of proteinuria

Urine Culture:Results pending

Heartworm antigen test: Negative

Tick-borne disease panel: Results pending

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Abdominal Ultrasound:
Sonographic Assessment:
1.anomalus caudal vena cava with discontinuous segment and dilated lumen
2. probable collateral vessels entering new CDV near aorta
3. cystocentesis

Sonographic Findings:
The left kidney measures 76.9 mm in length; the right is 82.2 mm. The left adrenal gland measures 4.3
mm wide caudally; the right is not seen. The left medial iliac lymph node measures 10.8 mm; the right is
6.3 mm. A jejunal lymph node measures9.6 mm. The spleen is 22 mm in thickness. The caudal vena
cava is greatly dilated. Poor transit of blood flow is seen. There is a marked dilation of the caudal vena
cava cranial to the kidneys. There appears to be a rounded blind end to the caudal vena cava. There is a
round mass with a hyperechoic border that may be due to mineral or fibrous material in the cranial blind
pouch of the caudal vena cava. No outflow of blood is seen from the caudal vena cava. The renal veins
have blood flow that courses into the caudal vena cava. The deep circumflex iliac veins enter the caudal
vena cava with flow. There is a discontinuous segment of the caudal vena cava from the blind pouch
crania to the kidneys to the diaphragm. The hepatic veins cross the diaphragm and presumable form a
new caudal vena cava on the thoracic side. There is a vein adjacent to the aorta. There are small vessel
that enter the caudal vena cava near the diaphragm. The change seen are most consistent with a
congenital malformation and anomalous caudal vena cava. The mass in the cava is most likely a
thrombus. There are likely to be collateral vessels that are not detected. No peripheral edema or
peritoneal effusion is detected. No large subcutaneous vessels are seen. Normal appearing portal
vessels enter the liver.

1 13 10 KSpaulding 190756

Thoracic, Abdominal, Pelvic Radiographs: Official report pending

Indirect (Doppler) Blood Pressure: Systolic: 132, 134, 130, 128 mm Hg

Diagnosis:
• Proteinuria
• Anomalous caudal vena cava with luminal dilation
• Subluxation of left hip- possible hip dysplasia

Lucie has an anomalous caidal vena cava. This is most likely a cogenitial problem. It
does not appear to be surgically corrctable. We would love to further characterize it if
possible. I am not certain if it is causing any clinical signs currenlty. She may have hip
disease, allthough her radiographs looked normal. This could explain her difficulty
standing up and response to carprofen. I cannot completely rule out that the venous
anomaly is causing the difficulty rising. Further imaging may be indicated to help answer
this question. Lucie is also proteinuric. We are trying to rule out infectious causes of
this. Another possible underlying cause of her proteinuria may be Histiocytic disease.
We did not appreciate any skin lesions but biopsy od skin lesions may be helpful to
confirm this. Renal biopsy may be something we advise further down the line.

Instructions to Owner

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Medications:
Medication Class or Administration Directions
Generic (trade) Indication

Aspirin, 15 mg Capsule Anti-thrombotic Give 1 capsule by mouth one time a day

until finished for Anti-thrombotic

Fenbendazole, 100 mg/mL Oral Anthelmintic Give 13 mL by mouth one time a day for
Suspension 5 days for Anthelmintic

Clopidogrel Bisulfate, 75mg Tablet Anti-thrombotic Give 1/2 tablet by mouth one time a day
until finished for Anti-thrombotic

Enalapril Maleate, 10 mg Tablet ACE-inhibitor for proteinuria Give 1 tablet by mouth every 12 hours
for urinary protein loss

Exercise: Frequent leash walks, avoid vigorous play.

Diet: No changes needed. Since there is a possibility that Lucie has orthopedic disease
it will be important to keep her in good trim body condition to help prevent additional
strain on her joints.

Call If:
• Lucie becomes more lethargic or anorexic
• Lucie begins vomiting or having diarrhea
• Lucie is febrile
• Lucie becomes acutely down or more hesitant to move her pelvic limbs
• You have any other questions or concerns

Additional Instructions: As we discussed, Lucie appears to have an anomalous,

caudal vena cava. This is most likely a congenital defect, and it is uncertain whether this
is causing her any clinical problems. The diameter of the vena cava is quite enlarged,
and there is a mass within the cranial blind end, which we presume to be a large blood
clot. We are concerned that this may predispose her to having smaller clots break off
and travel to other parts of her body. The presence of the clot may also help to explain
the decreased platelet count. Since she appears to be hypercoagulable, we elected to
start her on ultra low dose aspirin and Plavix in an effort to reduce the chances of
thrombosis.

It is possible to pursue more advanced diagnostics, including venography, CT

angiography, and MRI angiography, in an effort to better visualize the malformation.
After consultation with the some of the other clincians here we suggest venography as
the next step. This would involve sedation or anesthesia and placement of a catheter in
one of her back legs, followed by injection of contrast material. However, we feel that it
is unlikely that this problem is surgically correctable. Aside from the clotting issues,
there is the possibility that the dilatio could rupture, which in all likelihood would be fatal.
Avoid Lucie playing roughly.

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Lucie continues to be proteinuric. Her blood pressure was normal today, as were other
laboratory values consistent with renal function. Other potential causes for protein in the
urine include a lower urinary tract infection, tick-borne diseases, an inflammatory
disease of the kidney known as glomerulonephritis. We have submitted a urine culture
to look for a urinary tract infection and a tick panel in an effort to rule-out those causes.
Should these tests be unremarkable it may be necessary to perform a kidney biopsy to
further elucidate the source of her proteinuria. In the meantime we have started Lucie
on enalapril, which is an ACE-inhibitor, in an effort to help control her urinary protein
loss.

At this time we feel that the most likely cause of Lucie's difficulty to rise on her hind
limbs is an orthopedic problem. One of the orthopedic surgeons performed an exam on
Lucie and appreciated some laxity in her left hip joint. Lucie was too tense to adequately
palpate her right hip joint. Sedation would be required for a more thorough orthopedic
exam. Based on the findings today, the orthopedic surgeon was most suspicious of hip
dysplasia. Animals with hip dysplasia will generally be tolerant of activity, but painful
afterwards, and often have difficulty rising after lying down for an extended period of
time. Lucie's response to treatment with Rimadyl is also supportive of orthopedic cause.
However, her hip xrays were essentially normal which does not support a diagnosis of
hip dysplasia. I cannot fully rule out that her hindlimb issue. Further imaging may help
answer this question.

We would like to see Lucie back in two weeks for repeat urinalysis and blood work. This
will help us to gauge her protein loss. We will also ressess her hind limbs at this stage,
possibly under sedation. A repeat ultrasound would also give us an idea if the venous
anomaly is progressive in nature.

Lucie is a very sweet dog and was an excellent patient. Thank you for entrusting us with
her care!

****IF YOU HAVE ANY QUESTIONS OR PROBLEMS,

PLEASE DO NOT HESITATE TO CALL – (979) 845-2351***

_____________________________ _____________________________
Jonathan Lidbury, BVMS Brian Cichocki, 4VM

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