Speaking Out
Dear Editor:
Reference is made to the study by W.M. Adams, et al.,
“Early Detection of Canine Hip Dysplasia: Comparison
of Two Palpation and Five Radiographic Methods”
(JAAHA, 1998;34:339–47). The authors define several
problems in their experimental design but proceed to
gloss them over with statistical analysis. This, coupled
with misrepresentation of data from several references,
led the authors to conclusions that are questionable at
best. The following is presented to the readers of JAAHA
as an effort to assist in evaluation of this report and to
prevent further perpetuation of the myths surrounding
reports on canine hip dysplasia (CHD).
The authors reported on a limited population of dogs
(n=32) that consisted of 12 greyhounds (GH), four La-
brador retrievers (LR), 12 Irish setters (IS), and four
hound mix-breeds (HM). To compensate for the small
number of dogs, the authors reported on hips (n=64) but
they eliminated five hips or 8% (5/64) from their analy-
sis due to abnormal conformation (malalignment of the
femoral head with the acetabular margin, 50% or less
coverage of the femoral head, or both). The stated reason
for elimination of 8% of the data was that these hips did
not demonstrate clear evidence of degenerative joint
disease (DJD) at 52 weeks of age. The description of the
five hips indicates a dysplastic evaluation by the criteria
accepted worldwide. Inclusion of this data would affect
the results of this study.
Hip data from the four breeds were combined to
increase the number of evaluations in each age group.
This procedure is questionable, as it has been reported
that the skeletal structure of the GH is more mature at
birth and develops at a slower rate than found in the
German shepherd dog. 1 Experience indicates that the
difference should be the same, if not more pronounced,
for the other three breeds in this study. The authors also
document that the GH had significantly tighter hips than
the other three breeds. Combining the GH data with that
of the other three breeds, coupled with the selective
elimination of five hips (8% of the data), predetermines
the outcome of the analysis.
The authors concluded the study at 52 weeks of age;
yet they report a P value, percent correct, number of
false negatives, and number of false positives for 50 to
52 weeks in Table 2. Use of a statistical model or earlier
reports to project these values is questionable since there
were no subsequent radiographic studies or necropsy
findings reported to serve as the standard for
comparison.
363
It is generally accepted that reliability of radiographic
evaluations of the hip extended view is breed and age
dependent and furtherly depends on the experience of
the evaluator with hip conformation of the breed and
knowledge of the skeletal development of that breed at
the age of evaluation. The experimental protocol of the
authors did not permit providing the Orthopedic Founda-
tion for Animals (OFA) evaluator with knowledge of the
breeds being evaluated. Only the age was provided. The
authors obviously were aware of the breeds used, and
this may or may not account for some of the differences
between the two evaluators. It was surprising and com-
forting to note that there were no false positive evalua-
tions, as this means that the subjective evaluation method
is not likely to remove a normal dog from the gene pool.
The authors, however, concluded that the subjective
evaluation at six to 10 weeks and 16 to 18 weeks of age
was not reliable for predicting DJD at 52 weeks and
stated that their study does not support an OFA report of
91% reliability of evaluations at three to six months of
age. In the first place, OFA did not report 91% reliability
at three to six months. The reference2 used by the authors
reported OFA reliability of 89.6% (n=278) for normal
evaluations at three to six months and 80.4% (n=102) for
the dysplastic evaluations when compared to evaluations
at 24 months or older. The overall reliability was 87.1%
(331/380). Furthermore, the median age for the OFA
preliminary evaluations at three to six months was five
months (20 weeks). The OFA does not recommend pre-
liminary hip evaluation less than four months of age due
to skeletal immaturity. Therefore, it is not appropriate
for the authors to compare the two studies.
Data from another reference3 concerning OFA reports
was also misrepresented. The authors stated that of the
four popular breeds (Labrador retriever, golden retriever,
German shepherd dog, and rottweiler), OFA found a
significant reduction in CHD only in the rottweiler. This
was taken from Table 4 in the monograph which re-
ported the findings of excellent and dysplasia evalua-
tions by year. This data only demonstrates annual trends.
To determine change in the incidence, the data must be
segregated into generations or at least by segments of
years that minimize overlap of data from prior genera-
tions. In the same reference, Table 5 segregates the data
and reports a significant increase in excellent hip confor-
mation and a significant decrease in CHD for three of the
four breeds. Only the German shepherd dog failed to
demonstrate a change. The authors’ implication that no
improvement in the hip status has been made is a myth
that cannot be supported.
 Kaneene, et al. 4 in an independent study of 270,978
OFA evaluations clearly demonstrate an improvement of
the hip status. Leighton, 5 in a study of 2,037 German
shepherd dogs and 1,821 Labrador retrievers from the
closed Seeing Eye colony, reported a decline in CHD
from 55% to 24% in the German shepherd dog and from
30% to 10% in the Labrador retriever over five genera-
tions. The hip evaluations were obtained from the hip
extended view, and a modified OFA grading system was
used. Leighton also kept distraction index (DI) measure-
ments on the dogs but did not use the DI as a criterion for
breeding selection. Interestingly, he reported that the
mean DI measurement did not change across the genera-
tions. What the results will be when DI measurements
become a criterion for selection remains to be seen.
The authors, in their opening sentence, define CHD as
hip laxity of genetic origin. This definition is incomplete
and disregards the diagnostic criteria established by the
scientific community and used worldwide. The fact that
joint laxity plays a role in CHD is not in dispute, but
laxity is not the only factor to be considered.
Somewhere in the dispute over available test methods
for presence or absence of CHD, some members of the
veterinary profession seem to have lost sight of the ma-
jor problem in control of CHD—many breeders continue
to breed dysplastic dogs. Education of the breeders is
where emphasis should be placed. Consistent use of a
test method will result in improvement of the hip status
as demonstrated by reports of selective breeding using
the hip extended view. Unfortunately, the PennHIP
method has not been available long enough for accumu-
lation of breeding data.
References
1. Gustaffson PO, Olsson SE, Kalsstrom H, et al. Skeletal development of
greyhounds, German shepherd dogs and their crossbreed offspring. An
investigation with special reference to hip dysplasia. Acta Radiol Suppl
1975;334:81–108.
2. Corley EA, Keller GG, Lattimer JC, Ellersieck MR. Reliability of early
radiographic evaluations for canine hip dysplasia obtained from the
standard ventrodorsal radiographic projection. J Am Vet Med Assoc
1997;211:1142–6.
3. Corley EA, Keller GG. Hip dysplasia—a progress report and update. OFA,
1993:12–4.
4. Kaneene JB, Mostosky UV, Padgett GA. Retrospective cohort study of
changes in hip joint phenotype of dogs in the United States. J Am Vet Med
Assoc 1997;211:1542–4.
5. Leighton EA. Genetics of canine hip dysplasia. J Am Vet Med Assoc
1997;210:1474–9.
Respectfully,
G.G. Keller, DVM, MS, Diplomate ACVR
Executive Director
Orthopedic Foundation for Animals, Inc.
A Not-For-Profit Organization
364
Dear Editor:
The authors have reviewed concerns expressed by Dr.
Keller, Executive Director for the Orthopedic Founda-
tion for Animals, Inc. (OFA), and feel compelled to take
our turn at correcting misrepresentation of data. Five
hips were eliminated from analysis due to abnormal
conformation (as described in Dr. Keller’s letter), as they
had no clear evidence of degenerative joint disease (DJD)
at 52 weeks. We would agree that the five hips appeared
mildly dysplastic; however, our strict criterion for statis-
tical analysis required radiographic evidence of DJD at
52 weeks. Given the conformation seen in these hips,
DJD would be anticipated at some time in the future of
these hips. As this was clearly conjecture, we chose to
delete those hips from analysis. Obviously, if we had
been able to follow all 37 hips negative for DJD at 52
weeks of age to 104 or 156 weeks of age, confidence in
the accuracy of DJD assessment would be improved. Dr.
Keller expresses concern regarding conclusion of the
study at 52 weeks of age. This is a valid concern and was
addressed in the seventh paragraph of the discussion
section of the article.
We certainly agree that there is breed variation in
skeletal structure and maturation. This study was specifi-
cally designed to compare hips from a breed (greyhounds)
having a very low incidence of hip dysplasia to three
breeds of dogs that are at much greater risk for hip
dysplasia. Including greyhounds served two purposes:
1) they provided a convincing standard of excellent hips
and 2) as a check on the validity of the predictive meth-
ods being tested to consistently identify (at an early age)
hips not at risk for developing DJD.
We agree with Dr. Keller’s point that continuing to
breed dysplastic dogs is a major problem in the control
of canine hip dysplasia (CHD); therefore, accurate iden-
tification of hip dysplasia as early as possible (before
breeding age) has great potential to impact the incidence
of breeding dysplastic dogs. Puppies four to 10 weeks of
age were specifically chosen for our study to pursue the
potential of hip dysplasia detection at an earlier age than
is conventionally feasible.
Dr. Keller states hip evaluation reliability is breed and
age dependent. The authors do not take issue with this
statement; however, to our knowledge, there are no pub-
lished guidelines to rely upon regarding breed standards
for hip conformation. Therefore, the authors chose to
subjectively evaluate individual radiographs in a “blind”
manner (unaware of the breed), thereby eliminating the
subjectivity of this poorly defined variable. Breed bias
should not, therefore, have accounted for differences
between two evaluators.
In our study, 56% of the hips which developed DJD
by one year received a false-negative assessment at 16 to
18 weeks of age based on subjective criteria using the
extended-hip (OFA) method. This is our justification for
not supporting the OFA finding of an 87.1% overall
reliability of the OFA method at a median age of 20
weeks.
Dr. Keller stated that the German shepherd dog failed
to demonstrate a change in incidence of CHD, quoting
an OFA monograph (reference no. 3). Interestingly, he
also quoted a recent report by Leighton (reference no. 5)
of 2,037 German shepherd dogs which experienced a
decline in CHD incidence from 55% to 24% over five
generations. In that same article, Dr. Leighton stated that
it was no surprise that mean distraction index (DI) mea-
surements did not change across generations, as direct
genetic selection pressure was not applied to change
them. Furthermore, Dr. Leighton stated that whereas
subjective hip scores were credited with dramatically
reducing the incidence of DJD in the study population,
further progress toward eliminating CHD will require a
method of measuring hip quality that will allow distinc-
tion among the dogs currently in the breeding program,
and for this reason, (Dr. Leighton) has turned to the DI as
a means of assessing hip quality.
Dr. Keller takes issue with the simplified definition of
CHD offered in the first sentence of our introduction, but
does not offer an alternative definition for consideration.
365
Dr. Keller may be correct in concluding that the PennHIP
method has not been available long enough for its as-
sessment as a breeding selection criterion. However, the
OFA method has been around long enough for this as-
sessment, and it is clear that progress in the control of
hip dysplasia within the public domain in the United
States has been modest. Any alternative or supplemental
diagnostic method showing promise toward acceleration
of hip dysplasia eradication should be pursued. Addi-
tional imaging studies alluded to in the final sentence of
our article’s discussion section are nearing completion.
The authors intend to present results of a larger series of
three at-risk breeds of puppies studied in a similar man-
ner to those four breeds already presented, with the
additional comparison of an ultrasonographic method, in
a continuing effort to improve early, accurate assessment
of hip dysplasia status.
Sincerely,
William M. Adams, DVM
Associate Professor
Diplomate ACVR, ACVRO
Department of Surgical Sciences,
School of Veterinary Medicine,
University of Wisconsin,
Madison, WI
 Calcinosis Cutis Associated With
Systemic Blastomycosis in Three Dogs
Three dogs treated for systemic blastomycosis with intravenous amphotericin B (one case) or
amphotericin B lipid complex (two cases) developed mild to severe calcinosis cutis two to six
weeks after the initiation of treatment. Abnormalities in serum calcium and phosphorus during
treatment for blastomycosis or at the time of diagnosis of calcinosis cutis were slight or absent.
The calcification was not associated with lesions of cutaneous blastomycosis. Calcification was
limited to the skin in two cases and may have also involved the kidneys in one. The calcinosis
cutis resolved completely in all three dogs with no (two cases) or only palliative (one case)
therapy. J Am Anim Hosp Assoc 1999;35:368–74.

Kinga Gortel, DVM Introduction

Brendan C. McKiernan, DVM,
Diplomate ACVIM
Julie K. Johnson, DVM,
Diplomate ACVP
Karen L. Campbell, DVM, MS,
Diplomate ACVD, Diplomate ACVIM
C week history of rapidly progressive dorsal skin lesions. The lesions ap-
From the Departments of Veterinary Clinical
Medicine (Gortel, Campbell) and
Veterinary Pathobiology (Johnson),
College of Veterinary Medicine,
University of Illinois,
1008 West Hazelwood Drive,
Urbana, Illinois 61802 and the
Wheat Ridge Animal Hospital (McKiernan),
3695 Kipling Street,
Wheat Ridge, Colorado 80033.
Calcinosis cutis is an uncommon disorder of mineral deposition in the
dermis, which is frequently associated with spontaneous or iatrogenic
hyperadrenocorticism in dogs.1 This report describes three dogs in which
calcinosis cutis developed during or following treatment for systemic
blastomycosis.
Case Reports
Case No. 1
A 52.5-kg, four-year-old, male rottweiler was presented to the University
of Illinois Veterinary Medicine Teaching Hospital (UI-VMTH) for a two-
peared three weeks after the initiation of treatment for pulmonary
blastomycosis with intravenous (IV) infusions of amphotericin Ba at the
UI-VMTH. The drug had been administered in 5% dextrose in water over
several hours following saline diuresis, at intervals of two to five days
depending on measurements of blood urea nitrogen (BUN) and serum
creatinine. A cumulative dose of 5.5 mg/kg body weight was delivered in
six fractions over two weeks before administration was postponed due to
a transient elevation of the BUN to 68.8 mg/dL. Despite treatment, the
dog’s condition had deteriorated profoundly with 11 kg of weight loss,
anorexia, intermittent fever up to 41.3˚ C, sepsis (blood cultures,
Sphingobacterium multivorum, and Corynebacterium spp.), and necrosis
of the lateral glossal margins (presumed secondary to embolization).
Serum biochemical abnormalities during therapy included elevations in
alkaline phosphatase (ALP), cortisol-induced alkaline phosphatase
(CIALP), and gamma-glutamyltransferase (GGT). The ALP and CIALP
were markedly elevated prior to therapy (4,235 U/L; reference range, 12
to 110 U/L; and 424 U/L; reference range, 0 to 40 U/L, respectively). The
ALP fluctuated without a major increase throughout therapy, while the
CIALP rose to 734 U/L. The total serum calcium ranged from 9.1 to 11.4
mg/dl (reference range, 7.9 to 11.5 mg/dl) during therapy, and due to a
mild hypoalbuminemia, the corrected serum calcium2 was slightly el-
evated above the normal range in two serum biochemical profiles. With
concurrent elevations in serum phosphorus on three measurements, the
corrected serum calcium-phosphorus product exceeded 70 in four profiles
[see Table]. Skin lesions, initially similar to pyotraumatic folliculitis

368 JOURNAL of the American Animal Hospital Association

September/October 1999, Vol. 35 Calcinosis Cutis 369

Table
Summary of Hematological, Biochemical, and Endocrine Findings in Three Dogs
During Treatment for Systemic Blastomycosis and Calcinosis Cutis

Case No. 1 2 3
Values* Mean Mean Mean
During (Number of (Number of (Number of Reference
Treatment Samples) Range Samples) Range Samples) Range Range
Monocytes–absolute 2.50 (6) 1.22–6.37 3.91 (5) 1.34–5.75 4.37 (6) 2.23–6.69 0.2–1.4
count (x103/µL)
Monocytes 8.8 (6) 3.0–17.6 15.0 (5) 10–23 10.8 (6) 7.2–12.8 –
(percentage of WBC)
Creatinine (mg/dl) 1.25 (10) 0.9–1.8 0.77 (5) 0.6–1.1 0.51 (11) 0.3–0.9 0.5–1.6
BUN (mg/dl) 27.59 (10) 9.1–68.8 19.38 (13) 15.0–33.0 16.02 (11) 8.9–28.2 7.0–31
Albumin (g/dl) 2.30 (10) 1.90–2.54 2.11 (13) 1.96–2.82 1.68 (11) 1.30–2.40 2.1–4.3
Calcium (mg/dl) 9.90 (10) 9.1–11.4 9.06 (13) 8.2–12.0 8.15 (11) 6.9–9.6 7.9–11.5
Corrected calcium 11.11 (10) 10.30–12.45 10.60 (13) 9.60–12.75 9.96 (11) 8.80–11.70 7.9–11.5
(mg/dl)†
Phosphorus (mg/dl) 6.68 (10) 6.0–7.6 5.48 (13) 4.8–6.4 5.21 (11) 4.6–5.9 2.4–6.5
Serum calcium- 74.28 (10) 66.2–92.1 64.21 (13) 50.11–81.6 51.64 (11) 44.2–66.7 <70
phosphorus product‡
ALP (U/L) 3202.3 (6) 897–4,528 511.4 (5) 225–1,247 216.1 (11) 62–385 12–110
CIALP (U/L) 464.8 (6) 164–734 29.8 (5) 12–69 21.7 (11) 3.0–107 0–40
ALT (U/L) 72.7 (6) 42–111 33.42 (5) 23–42 20.5 (11) 14–36 17–87
GGT (U/L) 15.2 (6) 8–21 4.6 (5) 2.0–8.0 5.1 (11) 3.0–14 1.0–11
Calcium urinary 0.27 (1) – 1.16 (2) 0.84–1.48 Not measured – 0–0.57
fractional excretion (%)§
Phosphorus urinary 7.5 (1) – 31.95 (2) 25.6–38.3 Not measured – 2.0–44
fractional excretion (%)§
Ionized calcium (mmol/L)\ 1.34 (1) – 1.15 (1) – Not measured – 1.25–1.45
25-hydroxyvitamin D 77 (1) – 29 (1) – Not measured – 60.0–250
(nmol/L)\
Parathyroid hormone 4 (1) – 1 (1) – Not measured – 2.0–14
(pmol/L)\
Cortisol pre-ACTH 101.4 (1) – 15.3 (1) – Not measured – 29.3–112.3
(nmol/L)¶
Cortisol post-ACTH 382.7 (1) – 319.1 (1) – Not measured – 154.8–524.7
(nmol/L)¶

* WBC=white blood cell count; BUN=blood urea nitrogen; ALP=alkaline phosphatase; CIALP=cortisol-induced alkaline
phosphatase; ALT=alanine aminotransferase; GGT=gamma-glutamyl transferase; ACTH=adrenocorticotropic
hormone
†
Corrected serum calcium2 values calculated as:
corrected Ca (mg/dl) = serum Ca (mg/dl) - serum albumin (g/dl) + 3.5
‡
Serum calcium-phosphorus (Ca-P) product7 calculated as:
serum Ca-P product = corrected serum Ca (mg/dl) x serum P (mg/dl)
§
Electrolyte fractional clearance22 (% FCx) calculated as:
% FCx = (UxPCr)/(UCrPx)x100, where Ux = urinary electrolyte; PCr= serum creatinine; UCr= urinary creatinine; Px= serum
electrolyte
Reference ranges established by the UI-VMTH Clinical Pathology Laboratory
\
Measurements and reference ranges from the Animal Health Diagnostic Laboratory, Endocrine Diagnostic Section,
Michigan State University, East Lansing, Michigan
¶
Adrenocorticotropic hormone (ACTH) stimulation test: serum cortisol measured before and two hours after intramus-
cular administration of 40 units corticotropine
370 JOURNAL of the American Animal Hospital Association
Figure 1—Distant and close views of the dorsum of case no. 1.
Severe crusting and purulent, yellow to cream-colored exudate
are visible over most of the clipped area. The lesions extend
cranially and laterally from this region.
Figure 2—Close-up of lateral thoracic skin of case no. 1,
showing the well-demarcated borders of the erythematous and
raised affected skin. The skin has been clipped and biopsied.
(“hot spots”), first appeared on the caudal dorsum ap-
proximately three weeks after the first amphotericin B
infusion was given. The dog had been affected with
similar lesions in the past, but not in the last year. These
lesions had previously responded rapidly to corticoster-
oids. Current treatments included clipping of the hair
around the lesions, cleaning the skin with a diluted
chlorhexidine solution, and the administration of oral
cephalexin (1,000 mg per os [PO] bid). The dog was
discharged from the UI-VMTH, and the owner was in-
structed to continue administering cephalexin. It was
given for a total of eight days, but then was replaced with
enrofloxacin (102 mg PO bid) because the skin lesions
continued to enlarge.
The skin problem continued to progress, and the dog
was readmitted to the UI-VMTH. During the two weeks
spent at home, the dog’s signs of systemic illness had
waned, with an improvement in activity level and appe-
tite and a weight gain of 8.2 kg. The skin lesions had,
however, worsened dramatically and now involved the
September/October 1999, Vol. 35
Figure 3—Photomicrograph of haired skin from the dorsum of
case no. 1, showing fragmentation and mineralization of dermal
collagen fibers (Hematoxylin and eosin stain, 40X; bar=165 µm).
entire dorsum from the top of the head to the tail, extend-
ing laterally one-third of the circumference of the trunk.
Most of the dorsum was covered by a thick, moist, yel-
low to cream-colored exudate with cracks, crevices, and
hemorrhage [Figure 1]. The borders of the affected areas
were not covered by exudate and were very well demar-
cated from normal skin by erythema, a very firm texture,
and raised edges [Figure 2]. Similar erythematous, raised,
flat-topped plaques were found nearby, and larger plaques
(up to 4 cm in diameter) were scattered on the neck,
head, axillae, and groin. The skin was malodorous, pain-
ful, and pruritic. Differential diagnoses considered for
the skin lesions included a severe deep pyoderma or
pyotraumatic folliculitis, cutaneous blastomycosis, toxic
epidermal necrolysis, erythema multiforme or other drug
eruption, calcinosis cutis, and cutaneous neoplasia.
Work-up at this time revealed a mild anemia (hemat-
ocrit, 31.4%; reference range, 35% to 52%) as well as a
neutrophilia with a left shift (segmented neutrophils,
24.6 x103/µl; band neutrophils, 0.96 x103/µl; 2+ toxic-
ity), a normal BUN and creatinine, and a urine specific
gravity of 1.034. Since the discontinuation of treatment,
serum ALP and CIALP had decreased substantially to
897 U/L and 164 U/L, respectively, and postprandial bile
acids (which had been elevated to 35.5 µmol/L at initial
presentation) had fallen to 20.6 µmol/L (reference range,
2 to 15 µmol/L). Hyperphosphatemia persisted, and the
corrected serum calcium-phosphorus product was 73.1.
Skin scrapings were negative for ectoparasites, and cyto-
logical examination of the surface exudate showed
degenerate neutrophils with numerous intra- and extracel-
lular bacteria, predominantly Gram-negative rods. A cul-
ture of a skin biopsy, however, yielded an Enterococcus sp.
Multiple 6-mm punch skin biopsies collected for his-
topathology showed severe, multifocal fragmentation and
September/October 1999, Vol. 35
mineralization of dermal collagen fibers, consistent with
calcinosis cutis [Figure 3]. Numerous epithelioid mac-
rophages were present around the mineralized collagen.
In some sections, the epidermis was ulcerated or eroded
with accumulations of neutrophils in the subjacent der-
mis and crusts of blood, fibrin, neutrophils, and Gram-
negative rods on the surface. Intact epidermis tended to
be hyperplastic with areas of parakeratotic hyperkerato-
sis and rete peg formation. Unaffected skin from the
flank was also biopsied and had marked epidermal and
follicular hyperkeratosis with follicular and sebaceous
gland atrophy.
Thoracic radiographs showed a marked improvement
from initial films. A dorsal radio-opaque band of skin
was the only visible focus of mineralization. Abdominal
ultrasonography did not reveal any mineralization of
internal organs; the adrenal glands were within normal
size. A percutaneous liver biopsy was performed to in-
vestigate the decreasing, but still eight-fold normal, ALP
before switching to itraconazole for blastomycosis
therapy. The biopsy showed a marked, nonspecific, dif-
fuse hepatocellular hydropic degeneration with minimal
suppurative inflammation. An adrenocorticotropic hor-
mone (ACTH) stimulation test, performed to rule out
hyperadrenocorticism, was normal. Fractional urinary
excretions of calcium and phosphorus as well as serum
ionized calcium, 25-hydroxyvitamin D, and intact par-
athyroid hormone (PTH) were also within reference
ranges [see Table].
Treatment with amphotericin B was not completed
due to concern that the calcinosis may have been precipi-
tated by the drug. Instead, itraconazole was started at 10
mg/kg PO daily for four days, followed by a mainte-
nance dose of 5 mg/kg body weight daily. Specific treat-
ment of the skin was aimed at reducing the inflammation
which could contribute to calcification as well as lower-
ing the intermittently elevated calcium-phosphorus prod-
uct. The antibiotic was changed to oral amoxicillin/
clavulanic acid at 12.0 mg/kg body weight twice daily
based on culture and in vitro sensitivity results. The
dog’s diet was changed from a mixture of various foods
that the dog found palatable, to the low-phosphorus Hill’s
Prescription Diet Canine k/d b supplemented daily with
four cooked eggs for additional protein. Aluminum hy-
droxide tabletsc were added to the food at 1,200 mg daily
to further reduce phosphorus absorption. The dog was
bathed in a whirlpool of diluted povidone-iodine solu-
tion twice daily for seven days, and aloe vera gel was
applied to the lesions. The dog’s skin improved steadily
over the next month, and at a recheck approximately five
weeks after discharge, the calcinosis cutis had resolved
and only some residual dorsal alopecia remained. A re-
peat complete blood count (CBC) and serum biochemi-
cal profile showed a normal phosphorus level, and
although still elevated, the ALP and CIALP were much
lower than they had been initially. The mild anemia had
Calcinosis Cutis 371
resolved, the dog had gained 19 kg since initial presenta-
tion, and evidence of blastomycosis was no longer noted
on thoracic radiographs. All treatment was stopped, and
the dog was returned to a normal diet. The skin lesions
have not returned two years posttreatment.
Case No. 2
A 16.3-kg, two-year-old, castrated male, mixed-breed
dog was treated for pulmonary, cutaneous, and skeletal
blastomycosis at the UI-VMTH with a cumulative dose
of 12 mg/kg body weight IV amphotericin B lipid
complex d given in 12 fractions over four weeks.3 The
dog had been castrated due to testicular disease two
weeks prior to presentation, and Blastomyces dermatitidis
was found on histopathological examination of the tes-
tes. Multiple skin lesions were present prior to treatment,
and cytology of the surface of these lesions revealed
pyogranulomatous inflammation with fungal organisms.
Osteomyelitis of several digits on both front feet was
also present. The skin lesions improved during therapy,
but approximately two weeks after starting amphotericin
B, a firm, new, plaque-like lesion was found in the groin.
While the initial skin lesions continued to heal, this
plaque enlarged and similar ones appeared on the dor-
sum and shoulders. Biopsies of the lesions that had been
present since admission and were resolving with
treatment, showed granulomatous inflammation with
intralesional Blastomyces. Biopsies of the newly devel-
oped plaques revealed calcified collagen fibers with oc-
casional macrophages (i.e., calcinosis cutis), and neither
pyogranulomatous inflammation nor fungal organisms
were observed. Abdominal radiography showed miner-
alization in external soft tissues (i.e., skin) over the lum-
bar region and possibly in the left kidney. This dog’s
BUN and creatinine remained within reference ranges
throughout therapy [see Table]. The serum calcium con-
centration was slightly elevated in only one of 12 mea-
surements, and the corrected serum calcium was elevated
in two. The calcium-phosphorus product exceeded 70 on
two measurements. Serum 25-hydroxyvitamin D, intact
PTH, and ionized calcium were low. An ACTH stimula-
tion test was normal. Marked elevations in serum ALP
were found, but CIALP was generally within the refer-
ence range. A marked peripheral monocytosis persisted
throughout therapy. Urinary fractional excretions of
electrolytes were measured twice, and the excretion
of calcium was elevated both times [see Table]. The
treatment with amphotericin B was completed, and all
skin lesions resolved without specific therapy after the
dog was discharged.
Case No. 3
A 24.0-kg, six-year-old, intact male golden retriever was
treated at the UI-VMTH for severe pulmonary blastomy-
cosis with a cumulative dose of 15 mg/kg body weight
IV amphotericin B lipid complex given in 11 fractions
372 JOURNAL of the American Animal Hospital Association
over 2.5 weeks. Renal parameters and serum calcium
and phosphorus concentrations remained within refer-
ence ranges throughout therapy [see Table]. Corrected
serum calcium was slightly elevated in one of 11 mea-
surements due to a marked hypoalbuminemia which de-
veloped during and persisted throughout therapy despite
multiple plasma transfusions. The calcium-phosphorus
product did not exceed 70 at any time. Serum ALP rose
mildly during therapy but was almost normal prior to
discharge. The CIALP was within or nearly within refer-
ence range at all times. Monocytosis persisted through-
out therapy [see Table]. A consolidated lung lobe was
removed by thoracotomy after completing the antifungal
treatment. Six weeks after the initiation of treatment, the
dog was presented with numerous, firm, circular papules
and plaques on the lateral thorax, ranging in diameter
from less than 1 mm to 10 mm, scattered around the
thoracotomy incision site. Biopsy confirmed calcinosis
cutis. The dog recovered well, and the lesions regressed
without specific treatment.
Discussion
Calcifying disorders of the skin are uncommon in dogs
and humans.1,4 Calcinosis cutis in dogs is characterized
histologically by variable mineralization of dermal col-
lagen fibers, the accumulation of macrophages and mixed
inflammatory infiltrates, an epidermis that is often se-
verely acanthotic and may be ulcerated or exudative, and
by occasional transepidermal elimination of mineral.5
The marked acanthosis may allow the elimination and
extrusion of the mineral to the surface by the develop-
ment of perforating canals in the epithelium in a process
called catharsis. 6 Calcinosis cutis is classified as
dystrophic, metastatic, idiopathic, or iatrogenic.1 The
terms calcinosis universalis and calcinosis circum-
scripta refer to the generalized and localized forms,
respectively.
The mechanism of mineral deposition in calcinosis
cutis is not known. Local phenomena such as tissue
damage and necrosis may precipitate it, and the lowered
extracellular pH and loss of mineralization inhibitors
that result from tissue damage may be initiating events.4
The transformation of minerals from dissolved ions into
the solid phase may be induced by changes in collagen
fibrils; phosphate ions may initiate the transformation by
forming crystal nuclei on organic matrices.5 On a cellu-
lar level, the mitochondrium can serve as a nidus for
calcification. This organelle has a high affinity for cal-
cium and phosphate and can concentrate them to levels
that allow calcium to crystallize.7
In dystrophic calcification, skin is calcified as the
result of local tissue abnormalities or injury. Damage to
the cytoplasmic membrane from various sources causes
an influx of calcium into cells.7 Generalized dystrophic
calcification in dogs most commonly occurs with spon-
taneous or iatrogenic hypercortisolism; it has also been
September/October 1999, Vol. 35
reported with diabetes mellitus.1 The calcium-phospho-
rus solubility product is normal in these cases. Localized
foci of dystrophic calcification in dogs may be second-
ary to inflammatory lesions such as foreign body
granulomas, interdigital pyoderma and demodicosis, de-
generative lesions such as follicular cysts, or neoplastic
lesions such as pilomatrixomas.1,5 In humans, numerous
processes have been associated with dystrophic calcifi-
cation, most notably connective tissue disorders such as
scleroderma syndrome, dermatomyositis, and systemic
lupus erythematosus. As in dogs, several neoplasms and
cutaneous parasitic infections can manifest calcification.4,7
Metastatic calcification, by contrast, is characterized
by the precipitation of calcium salts in normal tissues as
a result of an underlying defect in calcium or phosphorus
metabolism. Increased extracellular calcium levels are
thought to overcome the cell’s ability to regulate the
intracellular calcium.7 Calcification is usually associated
with demonstrable serum calcium or phosphorus distur-
bances and generally affects other tissues such as blood
vessels, kidneys, lungs, and gastric mucosa.7 A calcium-
phosphorus solubility product in excess of 70 is associ-
ated with calcification of various tissues such as the
gastric mucosa and kidneys, but normal skin is generally
spared. Canine metastatic calcification has only been
reported with chronic renal disease, and the lesions have
usually been limited to the footpads.1,8 In addition to
renal failure, causes of metastatic calcification in hu-
mans include hypervitaminosis D, lymphoma, multiple
myeloma, metastatic carcinomas, and other disorders
which lead to hypercalcemia or hyperphosphatemia.7
Occasionally, humans undergo a form of metastatic cal-
cification in the absence of an elevated calcium-phos-
phorus solubility product. They are thought to do so by
the process of calciphylaxis, a condition of induced sys-
temic hypersensitivity in which tissues respond to cer-
tain systemic or topical challengers with calcium
deposition.9 Calciphylaxis was first produced experi-
mentally by the administration of a sensitizing agent
such as vitamin D or PTH followed by topical or sys-
temic challenge with an agent such as a metallic salt, egg
albumin, corticosteroids, or tissue trauma. Various tis-
sues and organs, including the skin, are selectively calci-
fied by different combinations of sensitizers and
challengers.9 Albumin and blood transfusions, cortico-
steroids, and immunosuppressive drugs are suspected
challenging agents in humans and must be preceded by
sensitizers such as excess PTH levels or an elevated
calcium-phosphorus product.7 A similar process has not
been demonstrated in dogs.
Several forms of cutaneous calcification in dogs, in
which the mechanism and underlying cause are not un-
derstood, are classified as idiopathic. Idiopathic calcino-
sis universalis of young dogs is a disorder clinically and
histologically identical to glucocorticoid-associated cal-
cinosis cutis, except it occurs in otherwise healthy dogs
September/October 1999, Vol. 35
younger than one year. The calcification regresses within
one year.1 Idiopathic calcinosis circumscripta of large-
breed dogs generally affects otherwise normal dogs less
than two years old. Lesions are often located near pres-
sure points and are generally single, although multiple or
bilaterally symmetrical lesions can occur.10–12 Humans
develop a similar disorder, tumoral calcinosis, in which
calcified subcutaneous masses are found around major
joints.7 Occasionally, widespread calcinosis cutis is seen
in puppies as a sequel to severe systemic illness. 5
Iatrogenic calcification has been reported in dogs sec-
ondary to the percutaneous absorption of a calcium-
containing landscaping product13 and has been reported
in humans after the extravasation of a calcium chloride
or calcium gluconate solution.7
Categorizing the calcinosis cutis in these three dogs is
difficult. The common history of amphotericin B admin-
istration suggests an iatrogenic process, but to the au-
thors’ knowledge the drug has not been associated with
similar problems in humans. Cutaneous reactions to am-
photericin B in humans have included exanthemas, pur-
pura, exfoliative dermatitis, flushing, pruritus, and
urticaria.14 Calcification of the psoas muscle following
catheter phlebitis in a patient treated with the drug has
also been reported.15
Several features support the process of metastatic cal-
cification, despite normal or near-normal parameters as-
sociated with renal function in all the patients. All dogs
had a severe granulomatous disease and monocytosis
[see Table], and it is known that granulomatous inflam-
mation may be associated with abnormal calcium me-
tabolism and hypercalcemia in dogs and humans.16–19
Monocytes stimulate the production of prostaglandin E,
which promotes osteoclast-mediated bone resorption.20
Activation of leukocytes in widely disseminated chronic
inflammatory conditions may increase the concentra-
tions of another mediator of bone resorption, osteo
-clastactivating factor (OAF).16 Abnormal vitamin D me-
tabolism in granulomatous disorders is an even more
compelling explanation for the concurrent hypercalce-
mia. Mononuclear cells are capable of metabolizing 25-
hydroxyvitamin D to the active 1,25-dihydroxyvitamin
D (calcitriol).17 The conversion occurring in mononuclear
cells may be regulated differently from the same process
which normally occurs in the kidneys, or it may not be
regulated at all.16,19 For example, stimulation of mono-
nuclear cells by γ-interferon and interleukin-2 is thought
to stimulate 1,25-dihydroxyvitamin D production.19
Overt hypercalcemia has been reported in dogs with
blastomycosis, for these reasons and possibly due to
bone lesions. 16,19 Unlike dogs with primary hyperpara-
thyroidism, dogs with blastomycosis occasionally have
concurrently high serum phosphorus concentrations that
may result from renal insufficiency.16 Calcification of
the subendocardium of the left atrium, the intima of the
left auricle, the colloid of the thyroid gland, the gastric
Calcinosis Cutis 373
mucosa, the kidneys, and the adrenal glands has been
reported in hypercalcemic dogs with blastomycosis, but
the skin has been spared.16 Of the three dogs in the
present report, only one (case no. 2) showed possible
calcification of a tissue other than the skin. All three
dogs had intermittently elevated corrected serum cal-
cium concentrations. These elevations were mild but
resulted in the calcium-phosphorus product exceeding
70 on several measurements in case nos. 1 and 2. In the
two dogs in which they were measured, the ionized
calcium, PTH, and 25-hydroxyvitamin D were normal or
low. These measurements did not, however, include 1,25-
dihydroxyvitamin D, the active hormone expected to
increase with granulomatous inflammation. Negative
feedback from extrarenal overproduction of 1,25-
dihydroxyvitamin D in case no. 2 could have reduced the
levels of the precursor, 25-hydroxyvitamin D, as well as
PTH. The serum levels of PTH in vitro and in rats are
significantly decreased by 1,25-dihydroxyvitamin D.21
The urinary excretion of calcium is increased by 1,25-
dihydroxyvitamin D, possibly explaining the high cal-
cium fractional excretion in case no. 2.21
The authors believe the calcinosis cutis in these cases
shared the features of, but did not conform to, the de-
scriptions of simple dystrophic or metastatic calcifica-
tion as previously reported in dogs. Each dog may have
had foci of cutaneous inflammation which imparted a
susceptibility to dystrophic calcification. Case no. 1 prob-
ably had pyotraumatic folliculitis, case no. 2 had skin
lesions of blastomycosis prior to the development of
calcinosis cutis, and case no. 3 may have been predis-
posed to calcification around the sites of skin sutures and
surgical manipulation. With the exception of case no. 3,
however, the calcinosis cutis lesions were more exten-
sive than (case no. 1) or separate from (case no. 2) the
pre-existing skin lesions. In all three cases, severe sys-
temic inflammation (as demonstrated by the persistent
monocytosis) may also have affected the skin. Case no. 1
showed a positive bacterial blood culture as well as
sloughing of the glossal margins. Sepsis and vasculitis
may have resulted in embolization of the skin and cre-
ated an environment for mineralization. A simple dys-
trophic calcification is unlikely, however, as even
marked inflammatory skin conditions in dogs do not
often spontaneously calcify. Instead, these foci of
inflammation, or possibly plasma transfusions, drugs,
or endogenous corticosteroids, may have acted as
challenging agents to precipitate calciphylaxis in a
system sensitized by 1,25-dihydroxyvitamin D from
activated macrophages or by an elevated calcium-
phosphorus product.
Calcinosis cutis generally resolves gradually follow-
ing removal of the underlying cause. A diet low in cal-
cium and phosphorus combined with oral phosphate
binders such as aluminum hydroxide has been helpful in
some cases.7 In case nos. 2 and 3, the calcinosis resolved
374 JOURNAL of the American Animal Hospital Association September/October 1999, Vol. 35

9. Selye H. Calciphylaxis. Chicago: Univ Chicago Press, 1962.

without specific therapy, suggesting that similar cases
10. Scott DW, Buerger RG. Idiopathic calcinosis circumscripta in the dog: a
may be managed conservatively. retrospective analysis of 130 cases. J Am Anim Hosp Assoc 1988;24:
651–8.
a 11. Roudebush P, Maslin WR, Cooper RC. Canine tumoral calcinosis. Comp
Fungizone; Apothecon, Princeton, NJ Cont Ed Pract Vet 1988;10:1163–5.
b
Hill’s Pet Nutrition, Inc., Topeka, KS 12. Stampley A, Bellah JR. Calcinosis circumscripta of the metacarpal pad in a
c dog. J Am Vet Med Assoc 1990;19–6:113–4.
Amphojel; Wyeth Laboratories, Inc., Philadelphia, PA
d 13. Schick MP, Schick RO, Richardson JA. Calcinosis cutis secondary to
Abelcet; The Liposome Co., Inc., Princeton, NJ
e percutaneous penetration of calcium chloride in dogs. J Am Vet Med Assoc
Acthar Gel; Rhône-Poulenc Rorer Pharmaceuticals, Inc., Collegeville, PA
1987;191:207–11.
14. Litt JZ. Cutaneous drug reaction database, 12/95 (gopher://
gopher.Dartmouth.EDU:70/00/Research/BioSci/CDRD) 31 Dec 1997.
References 15. Karanauskas S, Starshak RJ, Sty JR. Heterotopic Tc-99m MDP uptake
1. Scott DW, Miller Jr WH, Griffin CE. Small animal dermatology. 5th ed. secondary to phlebitis. Clin Nucl Med 1991;16:329–31.
Philadelphia: WB Saunders, 1995:887, 1115–7. 16. Dow SW, Legendre AM, Stiff M, Greene C. Hypercalcemia associated
2. Meuten DJ, Chew DJ, Capen CC, Kociba GJ. Relationship of serum total with blastomycosis in dogs. J Am Vet Med Assoc 1986;188:706–9.
calcium to albumin and total protein in dogs. J Am Vet Med Assoc 17. Lemann Jr J, Gray RW. Calcitriol, calcium, and granulomatous disease.
1982;180:63–7. N Engl J Med 1984;311:1115–7.
3. Krawiec DR, McKiernan BC, Twardock AR, et al. Use of an amphotericin 18. Kozeny GA, Barbato AL, Bansal VK, Vertuno LL, Hano JE. Hypercalce-
B lipid complex for treatment of blastomycosis in dogs. J Am Vet Med mia associated with silicone-induced granulomas. N Engl J Med
Assoc 1996;209:2073–5. 1984;311:1103–5.
4. Kotliar SN, Roth SI. Cutaneous mineralization and ossification. In: 19. Kruger JM, Osborne CA. Canine and feline hypercalcemic nephropathy.
Fitzpatrick TB, Eisen AZ, Wolff K, Freedberg IM, Austen KF, eds. Part 1. Causes and consequences. Comp Cont Ed Pract Vet 1994;15:1299–
Dermatology in general medicine. 4th ed. New York: McGraw-Hill, 315.
1992:1949–9. 20. Dominguez JH, Mundy GH. Monocytes mediate osteoclastic bone
5. Gross TL, Ihrke PJ, Walder EJ. Veterinary dermatopathology. St. Louis: resorption by prostaglandin production. Calcif Tissue Int 1980;31:29–34.
Mosby-Year Book, 1992. 21. Allen TA, Weingand K. The vitamin D (calciferol) endocrine system.
6. Malak JA, Kurban AK. “Catharsis:” an excretory function of the epidermis. Comp Cont Ed Pract Vet 1985;7:482–8.
Br J Dermatol 1971;84:516–22. 22. DiBartola SP. Clinical approach and laboratory evaluation of renal disease.
7. Walsh JS, Fairley JA. Calcifying disorders of the skin. J Am Acad In: Ettinger SJ, Feldman EC, eds. Textbook of veterinary internal medicine.
Dermatol 1995;33:693–706. Philadelphia: WB Saunders, 1995:1707–19.
8. Legendre AM, Dade AW. Calcinosis circumscripta in a dog. J Am Vet Med
Assoc 1974;164:1192–4.
 Clinical Considerations on Canine
Visceral Leishmaniasis in Greece:
A Retrospective Study of
158 Cases (1989–1996)
The medical records of 158 dogs with visceral leishmaniasis confirmed cytologically and/or
serologically were reviewed. Ages of affected dogs varied from nine months to 15 years, with a
male-to-female ratio of 1.3. The most common clinical manifestations of the disease were
variable cutaneous lesions such as exfoliative dermatitis and skin ulcerations, chronic renal
failure, peripheral lymphadenopathy or lymph node hypoplasia, masticatory muscle atrophy
(i.e., chronic myositis), ocular lesions (i.e., conjunctivitis, keratoconjunctivitis sicca, blepharitis,
and uveitis), and poor body condition. Ascites, nephrotic syndrome, epistaxis, polyarthritis, and
ulcerative stomatitis were seen only in a small number of cases. Clinical splenomegaly was not
a common finding. The clinicopathological abnormalities were nonregenerative anemia,
hyperproteinemia, glomerular proteinuria, and symptomatic or asymptomatic azotemia. In this
study, an indirect immunofluorescence assay’s diagnostic sensitivity was found to be higher
than that of lymph node aspiration cytology. J Am Anim Hosp Assoc 1999;35:376–83.

Alexander F. Koutinas, Introduction

DVM, Dr. Med. Vet. Canine visceral leishmaniasis (CVL), caused by a protozoan parasite of
Zoe S. Polizopoulou, the genus Leishmania (order Kinetoplastida, family Trypanosomatidae),
DVM, Dr. Med. Vet. is an infectious disease of zoonotic potential.1–3 In the Mediterranean
countries like Greece as well as in Portugal and West Africa, the causative
Manolis N. Saridomichelakis, agent of the disease is Leishmania infantum (L. infantum).3–7 The same
DVM, Dr. Med. Vet. species is responsible for the human counterpart in these countries.7
Canine isolates from most cases of CVL in the Mediterranean countries
Dimitrios Argyriadis,
DVM belong to zymodeme Montpellier-1 (MON-1).8,9
Leishmania infantum is a diphasic parasite with a promastigote form
Anna Fytianou, mostly found in Phlebotomus spp. sand flies in the Mediterranean coun-
BSc, Dr. Med. Vet. tries and an amastigote form parasitizing several vertebrate species.2,7,10
The main natural reservoir of L. infantum is domesticated dogs, while
Katerina G. Plevraki, humans, rodents, wild canids, and cats can serve as incidental hosts.10–12
DVM
In the Mediterranean countries, several epidemological studies on CVL
have shown that infection rates range from 1.6% up to 40% in the canine
population.12–14 Similar figures (1.6% to 22.6%) have been reported in
RS Greece.5,15 Autochthonous focuses of CVL have been reported in Ohio
and Oklahoma.16–18 Moreover, antileishmanial antibodies were detected

From the Clinic of Companion Animal Medicine (Koutinas, Polizopoulou,

Saridomichelakis, Fytianou, Plevraki), Department of Clinical Studies, Faculty of
Veterinary Medicine, Aristotles University of Thessaloniki, Stavroy Voutyra 11,
54627, Thessaloniki, Greece; and the National Agricultural Research Foundation
(Argyriadis), Institute of Infectious and Parasitic Diseases, 54627, Thessaloniki,
Greece.

Address all correspondence to Dr. Koutinas, P. O. Box 16039, Thessaloniki, 54401,

Greece.

376 JOURNAL of the American Animal Hospital Association

September/October 1999, Vol. 35
in asymptomatic dogs in Michigan, Alabama, and
Texas.19,20 However, in the United States, CVL is most
often diagnosed in dogs returning from Mediterranean
countries where the disease is enzootic.21–23
The promastigotes, inoculated into the skin by female
sand flies while feeding on dogs, are phagocytosed by
cutaneous macrophages and are transformed into the
amastigote form.3,24 Subsequent resistance or suscepti-
bility to leishmaniasis is associated with the stimulation
of T helper-1 (Th-1) or T helper-2 (Th-2) cells, respec-
tively.25 Resistant dogs, which may range from 10% to
more than 50% of the infected dog population, either do
not develop the disease or the disease resolves spontane-
ously.2,6,8,26,27 In the dog, interleukin-2 (IL-2) and tumor
necrosis factor-a (TNF-a) seem to play a protective role
against the development of clinical disease.28 In suscep-
tible dogs, amastigotes disseminate throughout the entire
body and proliferate selectively in organs rich in
lymphoreticular tissue.3 The ensuing excessive immuno-
globin (mainly IgG) production is not protective against
disease but detrimental, leading to the formation of cir-
culating immune complexes, autoantibodies, and cryo-
globulins that are considered responsible for the
subsequent disease pathology.2,27 The two main patho-
physiological mechanisms by which the parasite causes
the various lesions are the production of nonsuppurative
inflammation and circulating immune complexes that
deposit in certain organs.3
Common clinical manifestations of CVL include
decreased or increased appetite, progressive weight
loss, a variety of skin lesions, peripheral lymphaden-
opathy, chronic renal and liver disease, polyarthritis,
epistaxis, and ocular lesions. 3,24,29,30 As the clinical
picture of CVL usually reflects multiple organ dys-
function, any combination of clinical signs is pos-
sible; 2,24,29 however, many dogs are presented with
only a single clinical condition.24
Diagnosis is quite difficult on clinical grounds alone
due to the protean nature of the disease. Therefore, diag-
nosis is based on the demonstration of amastigotes in
lymph nodes, bone marrow, or spleen (i.e., aspiration
cytology); the measurement of specific antileishmanial
antibodies in blood or serum (indirect immunofluores-
cence assay [IFA], enzyme-linked immunosorbent assay
[ELISA], direct antiglobulin test [DAT], Western blot);
and/or the detection of leishmanial deoxyribonucleic acid
(DNA) (i.e., polymerase chain reaction).2,31
Because CVL is manifested with a wide range of
clinical signs similar to any chronic inflammatory dis-
ease, the aim of this retrospective study was to expand
the clinical knowledge of the disease, at least as it ap-
pears in Greece. Other objectives include the evaluation
of historical data, the most crucial clinicopathological
findings, and some of the methods used in the diagnosis
of CVL.
Canine Visceral Leishmaniasis 377
Materials and Methods
The medical records of 158 dogs admitted to the Clinic
of Companion Animal Medicine, Faculty of Veterinary
Medicine, Aristotles University of Thessaloniki, between
1989 and 1996 that were diagnosed as having CVL were
reviewed. The clinical diagnosis was confirmed by the
direct observation of the parasite in Giemsa-stained aspi-
ration smears taken from lymph nodes or bone marrow,
or the detection of antileishmanial antibodies using IFA,
or both. Indirect immunofluoresence assay testing was
done according to the method described by Ambroise-
Thomas, et al.32 and Faure, et al.33 The cut-off titer for
seropositivity to leishmaniasis was established at 1:200
by the authors’ laboratory. 15 The exclusion of other con-
comitant infectious diseases (e.g., babesiosis, erlichiosis)
that are common in Greece was based on parasitological
or serological examinations, or both.
All dogs were subjected to a thorough physical ex-
amination. Complete blood counts (CBC) and total
plasma protein measurements were performed in all the
dogs, while urinalysis was done in 137/158 (86.7%) of
dogs. Serum biochemistries for liver profiles (i.e., ala-
nine aminotransferase [ALT], alkaline phosphatase
[ALP], total bilirubin, albumin, and blood urea nitrogen
[BUN]) were done in 10/158 (6.3%) dogs that were
clinically suspect of having liver disease. Renal profiles
(i.e., BUN, creatinine, calcium, phosphorus) were done
in 63/158 (39.9%) dogs suspected to have renal disease
based on proteinuria and clinical illness. In addition,
cholesterol and albumin were measured in the serum of
the three nephrotic syndrome-suspect animals. Schirmer
tear tests (STT) were done in 30/38 (78.9%) cases which
presented with various ocular lesions. Radiographs of
carpal joints were taken in all five dogs with clinical
evidence of polyarthritis.
Results
The ages of the dogs ranged from nine months to 15
years, with a median of five years. Eighty-nine (56.3%)
were intact males, and 69 (43.7%) were intact females;
109 (69%) were purebreds, 37 (23.4%) were crossbreds,
and 12 (7.6%) were mongrels. The majority of these
animals were residing in various locations of northern
Greece (137/158; 86.7%), whereas a much smaller por-
tion originated from the central part of the country. Fifty-
three (33.5%) dogs were living in urban areas; 55 (34.8%)
were living in suburban areas; and 50 (31.6%) were
living in rural areas.
The main complaints reported by the owners were
skin lesions (80/158; 50.6%), progressive loss of weight
(40/158; 25.3%), decreased appetite (26/158; 16.5%),
and exercise intolerance (17/158; 10.8%). The latter com-
plaint was mostly noticed in hunting dogs. All the other
reasons prompting owners to seek medical advice for
their animals are listed in Table 1. In all of the cases, the
378 JOURNAL of the American Animal Hospital Association September/October 1999, Vol. 35

Table 1 Table 3
Clinical Complaints in 158 Cases of Noncutaneous Clinical Signs, Syndromes,
Canine Visceral Leishmaniasis or Conditions Detected at Physical
Examination in 158 Dogs With
Number of Dogs Canine Visceral Leishmaniasis
Complaint and Percentage
Skin lesions 80 (50.6) Number of Dogs
Weight loss 40 (25.3) Clinical Signs and Percentage
Decreased appetite 26 (16.5) Emaciation 16 (10.1)
Exercise intolerance 17 (10.8) Lymphadenopathy 103 (65.2)
Depression; weakness 13 (8.2) Lymph node hypoplasia 12 (7.6)
Ocular signs 11 (7) Splenomegaly 15 (9.5)
Epistaxis 10 (6.3) Ascites 2 (1.3)
Polyuria-polydipsia 6 (3.8) Nephrotic syndrome 3 (1.9)
Gastrointestinal disease 6 (3.8) Masticatory muscle atrophy 39 (24.7)
Admitted for other reasons 5 (3.2) Polyarthritis 5 (3.2)
Ascites 4 (2.5) Ulcerative stomatitis 9 (5.7)
Respiratory signs 3 (1.9) Epistaxis 6 (3.8)
Lameness 2 (1.3) Blepharitis 19 (12)
Conjunctivitis 38 (24.1)
Keratoconjunctivitis sicca 8 (5.1)
Uveitis 13 (8.2)
Table 2
Types of Skin Lesions Seen in 128 Dogs
With Canine Visceral Leishmaniasis pinnae (n=16), or mucocutaneous junctions (n=14). Sec-
ondary bacterial pyoderma was seen in 31/128 (24.2%)
Number of Dogs of dogs with skin lesions, primarily over the top of the
Types of Skin Lesions and Percentage CVL-associated skin lesions.
Of the noncutaneous conditions or signs observed
Exfoliative dermatitis 82 (64.1)
[Table 3], generalized peripheral lymphadenopathy
Ulcerations 44 (34.4)
(103/158; 65.2%) or lymph node hypoplasia (12/158;
Nodules 3 (2.3)
7.6%), bilateral and symmetrical masticatory muscle at-
Sterile pustular dermatitis 2 (1.6) rophy (39/158; 24.7%), and various ocular conditions
Nasal hyperkeratosis 24 (18.8) were the most common. Ocular conditions were detected
Digital hyperkeratosis 18 (14.1) in 38 (24.1%) dogs, with all demonstrating conjunctivi-
Onychogryposis 39 (30.5) tis. Other opthalmic conditions detected included kerato-
Paronychia 8 (6.3) conjunctivitis sicca (KCS) (n=8) based on decreased tear
Bacterial pyoderma 31 (24.2) production (less than 10 mm) demonstrated on STT,
blepharitis (n=19), and uveitis (n=13). Ascites (possibly
of hepatic origin), nephrotic syndrome, bilateral or uni-
lateral epistaxis, polyarthritis (erosive, 1/5; nonerosive,
onset of clinical signs was insidious and their course 4/5), and ulcerative stomatitis (hard or soft palate) were
progressive. seen in only a small number of animals [Table 3]. The
At physical examination, the most common manifes- number of dogs with splenomegaly, detected by abdomi-
tations of the disease were the skin lesions (128/158; nal palpation following a fast, was 15 (9.5%). Most of
81%). Lesions were symmetric, nonpruritic, alopecic or the animals (16/158; 10.1%), presented in an emaciated
hypotrichotic, and generalized or focal to multifocal. or even cachectic body condition, were suffering from
Exfoliative dermatitis and/or excessively dry seborrhea chronic renal failure.
was the most common skin abnormality seen (82/128; A nonregenerative and often normocytic, normochro-
64.1%). Skin ulcerations, the second most frequent skin mic anemia was noticed in 116/158 (73.4%) dogs. Hy-
abnormality seen (44/128; 34.4%), were either superfi- perproteinemia with values as high as 12.8 g/dl (reference
cial or deep and located over the pressure points (n=22), range, 5.7 to 8 g/dl) was recorded in 115/158 (72.8%)
September/October 1999, Vol. 35
animals. Renal azotemia (BUN, greater than 30 mg/dl;
reference range, 7 to 30 mg/dl; creatinine, greater than
1.4 mg/dl; reference range, 0.5 to 1.5 mg/dl; phosphate,
greater than 5 mg/dl; reference range, 2.5 to 5 mg/dl)
was detected in 24 of the 63 (38.1%) dogs that had
histories and clinical pictures compatible with chronic
renal failure. Increased activities of liver enzymes (ALT,
greater than 34 U/l; reference range, 8 to 34 U/l; ALP,
greater than 210 U/l; reference range, 35 to 210 U/l)
accompanied by low albumin levels (less than 2.5 g/dl;
reference range, 2.5 to 4 g/dl) were noted in the two dogs
with ascites. The three animals with nephrotic syndrome,
manifested with dependent subcutaneous edema, had hy-
percholesterolemia (greater than 300 mg/dl; reference
range, 100 to 300 mg/dl) plus severe hypoalbuminemia
(less than 1.5 g/dl). A mild to severe proteinuria was
detected in 98 of the 137 (71.5%) dogs tested. Hyaline to
fine granular casts in low to moderate numbers were
noted in the urine sediment of most of these dogs.
Leishmania spp. amastigotes were seen in the lymph
nodes of 118 of the 139 (84.9%) dogs tested and in the
bone marrow of five of the seven (71.4%) dogs that had a
bone marrow aspirate done; these seven dogs were Leish-
mania negative when their lymph node aspirates were
evaluated. Positive antileishmania titers were detected in
127/131 (96.9%) dogs that were IFA tested. Negative
lymph node or bone marrow cytology with positive se-
rology was noticed in 16/112 (14.3%) dogs tested with
both methods, where a comparison was made. The oppo-
site was seen only in 4/112 (3.6%) animals.
No treatment of any kind was attempted in all the 158
dogs of this series due to the zoonotic potential. Conse-
quently, most of them either died of complications re-
lated to the disease or were euthanized at their owners’
request.
Discussion
Half of the dogs were over five years of age. Results
from two separate studies on CVL conducted at the
authors’ clinic showed that 25% 4 and 36.4% 30 of the
dogs were older than five years. This could be attributed
to the long incubation period of the disease, extending up
to four years. 1,6 No dog in this series was younger than
nine months of age. In spite of the contradictory observa-
tions regarding male29,34,35 or female predisposition,30 it
is the authors’ belief that CVL is found equally in both
sexes.3,36 The narrow predominance of males (56.3%)
over females (43.7%) may reflect the authors’ general
hospital population. The almost equal distributions be-
tween the dogs living in urban, suburban, or rural areas
are in agreement with the results of other studies on
CVL.5,37 Ciaramella, et al.35 reported that the domestic
lifestyle of dogs is associated with a limited exposure to
infected sand flies, and hence, with a low incidence of
the disease. The incidence of CVL in dogs traveling with
their owners during weekends, holidays, or summer
Canine Visceral Leishmaniasis 379
Table 4
Clinicopathological Findings in 158 Dogs
With Canine Visceral Leishmaniasis
Number of Dogs
Clinicopathological Out of Total Tested;
Findings Percentage
Anemia 116/158 (73.4)
Hyperproteinemia 115/158 (72.8)
Proteinuria 98/137 (71.5)
Azotemia 24/63 (38.1)
months to areas where sand flies flourish probably elimi-
nates the lifestyle effect on the CVL prevalence in the
authors’ canine populations (i.e., Northern Greece).
All the 158 cases reported here had the chronic form
of the disease. The far less common acute form 35 could
be easily misdiagnosed as acute ehrlichiosis (i.e., high
fever) or multicentric lymphoma (i.e., severe peripheral
lymphadenopathy) with which CVL may coexist.24,35
Skin abnormalities are seen in more than half of CVL
cases and can be accompanied5,29,30 or not29,38 by other
characteristic CVL-associated conditions (e.g., glomeru-
lonephritis, uveitis, etc.). In general, the types and rates
of the skin lesions reported in this series [Table 2] are in
agreement with those of other studies. 30,34 Exfoliative
dermatitis and moderate to severe dry seborrhea, usually
starting from the head and pinnae and extending to the
rest of the body, can be misdiagnosed as primary granu-
lomatous sebaceous adenitis, because they share a com-
mon histopathological finding in this type of skin
lesions. 30 Skin ulcerations, mostly located on pressure
points, pinnal margins, or mucocutaneous junctions, are
neither pruritic nor painful.3 The debate over their patho-
genesis as being the direct result of the parasite39 or
immune-complex necrotizing vasculitis 29,40 has not been
resolved. In the authors’ experience, impression smear
cytology of the skin ulcers has mostly failed to demon-
strate the amastigotes. The authors believe that the rarely
reported skin nodules can be seen in various breeds 35 and
not only in the boxer as it has been reported.34 As aspira-
tion cytology or histopathology, or both, of these skin
nodules always reveals a large number of amastigotes,
there is no difficulty differentiating them from the clini-
cally quite-similar skin neoplasms and other infectious
or sterile granulomas. Sterile pustular dermatitis, a quite
uncommon manifestation of CVL,34 was far less seen
(1.6%) in this study than what was reported previously
(13.6%) by some authors.30 Pustules and epidermal
collarettes most often have a ventral distribution, resem-
bling impetigo. However, lymphocytes and macrophages
containing numerous Leishmania amastigotes predomi-
nate in the impression smears.29,34,38 Nasal and digital
380 JOURNAL of the American Animal Hospital Association
hyperkeratosis associated with the disease was seen in a
much larger number of cases than in the past.30 The
chronicity of the disease might be a reasonable explana-
tion, as the possibility of concurrent canine distemper,
which can cause similar lesions, was excluded on his-
torical and clinical grounds. Notably, pedal lesions in-
cluding onychogryposis and paronychia (30.5% and 6.3%
respectively, of the 128 dogs with skin lesions) didn’t
cause lameness or any kind of discomfort. The specula-
tion that severe parasitism of the claw beds is the main-
stay in the pathogenesis of onychogryposis41 is still
pending confirmation. The theory that immunosuppres-
sion induced by CVL is the main underlying pathophysi-
ological mechanism for the development of secondary
pyoderma42 could explain the increased frequency of
superficial and deep bacterial pyoderma noticed in 31 of
the 128 dogs (24.2%) harboring skin lesions. This theory
remains speculative, as the results of previous work are
contradictory.30,34
In CVL, the mononuclear-phagocytic system reaction
to blood-borne leishmania antigens usually results in
hyperplastic lymphadenopathy and/or hepatospleno-
megaly. 2,11,43 Peripheral lymphadenopathy was general-
ized in all the 103/158 (65.2%) dogs where it was seen.
This is a common clinical finding in CVL, with reported
rates of occurrence ranging from 80% to 100%,7,29,30 and
it is mainly detected in the prescapular and popliteal
lymph nodes. In a similar study, Ciaramella, et al.35
reported a localized lymphadenopathy in 32% of their
dogs with either prescapular or popliteal lymph node
involvement. Conversely, lymph node hypoplasia may
be seen in a high proportion of protracted cases, espe-
cially in those with advanced renal failure.24 That was
the case in 12/24 uremic dogs in this series.
Splenomegaly, a hallmark of CVL, was an uncom-
mon clinical finding in the dogs of this study with only
9.5% having a palpable spleen. It is the authors’ clinical
experience that splenomegaly in CVL is generally sub-
clinical, requiring the aid of radiology and ultrasonogra-
phy or postmortem examination for detection. However,
incidences of splenomegaly as high as 32.5% and 53.3%
have been reported by Slappendel29 and Ciaramella,
et al., 35 respectively; in the latter report there is no men-
tion if the splenomegaly was clinical or subclinical. It is
the authors’ opinion that clinical splenomegaly in other
commonly seen endemic diseases, such as ehrlichiosis
and babesiosis, is more severe and of higher prevalence
than in CVL.
Chronic liver failure, the result of chronic active hepa-
titis, may occur in a small percentage of CVL cases.3
Only two of the 10 dogs where the liver serum biochemi-
cal profile was tested demonstrated liver involvement,
which was confirmed both biochemically (with increased
liver enzyme activities) and macroscopically at postmor-
tem (with micronodular cirrhosis). These two animals
had been admitted because of ascites. However, in en-
September/October 1999, Vol. 35
zootic areas it is advisable that all dogs presented with
biochemical or clinical evidence of chronic liver disease,
or both, should be checked for leishmaniasis. In a recent
clinical study on CVL, 24/150 (16%) dogs had increased
serum ALP and ALT activities.35
Renal disease, a common occurrence in CVL, is
mainly due to immune-complex glomerulonephritis,
tubulointerstitial nephritis, and rarely with amyloido-
sis.29,44,45 Histopathologically, glomerulonephritis can be
either membranous, membranoproliferative, mesangio-
proliferative, or a combination thereof.44,45 The renal
lesions may lead to chronic renal failure, the nephrotic
syndrome, or both. In the authors’ experience, the most
common cause of death in CVL is the ensuing end-stage
kidney disease.3,4 Half of the 24 dogs with azotemia in
this study experienced chronic uremia and eventually
died. Increased renal serum biochemical values may be a
sensitive and reliable test for detecting early renal dam-
age in CVL.46 As CVL-associated renal lesions are often
irreversible even with prolonged antileishmanial medi-
cation, quality of life and life expectancy can be in-
creased by instituting the appropriate dietary measures.
The nephrotic syndrome, considered quite uncommon in
CVL,44 was seen in only three (1.9%) dogs of this study.
The clinically detectable masticatory muscle atrophy
which was found in 39/158 (24.7%) dogs in this study
has been attributed to the catabolic nature of the dis-
ease. 7,24 However, the results of a recent research
project47 have demonstrated that a progressive immune-
mediated polymyositis involving the total body muscu-
lature is the underlying pathology of muscle atrophy. The
CVL-associated polymyositis doesn’t seem to cause any
kind of dysphagia or locomotor problems. Locomotor
problems in dogs with CVL are usually associated with
an erosive29,48 or nonerosive49 polyarthritis, as was found
in five of the dogs in this study. The parasite itself, the
circulating immune complexes, or both deposited on the
synovium is the etiology of the polyarthritis.3,29,49 Other
CVL-associated conditions that could result in lameness
include severe onychogryposis and paronychia, footpad
hyperkeratosis, extensive interdigital dermatitis, and bone
lesions.50
Ulcerative stomatitis, noticed in 9/158 (5.7%) dogs in
this study, is quite similar in appearance and location to
that seen in the autoimmune skin diseases of the dog
(e.g., pemphigus vulgaris, systemic lupus erythemato-
sus). The stomatitis in these dogs was subclinical and
consisted of small erosions and ulcerations located on
the hard palate.
Epistaxis, which is usually unilateral and intermittent,
was seen or reported to have occurred in 10/158 (6.3%)
animals. It was the only presenting or recognized sign in
half of these 10 cases. Rarely, epistaxis may present as
an emergency due to severe and massive blood loss. Its
pathogenesis is still unresolved but is usually attributed
to a combination of inflammatory and ulcerative lesions
September/October 1999, Vol. 35
of the nasal mucosa, although a bleeding diathesis (e.g.,
paraproteinemia, thrombocytopenia) could also be in-
criminated in some cases.2,3
Chronic colitis 51 or chronic enteritis are rather un-
common manifestations of CVL. The gastrointestinal
signs reported in six of the 158 dogs in this study were
attributed to the chronic uremic syndrome the dogs were
experiencing.
A wide variety of ocular conditions are associated
with CVL and include blepharitis, conjunctivitis, kerati-
tis, uveitis, and scleritis.3,52,53 These lesions are caused
by ocular parasitism, but immune-mediated mechanisms
may play a pivotal role since cases with clinical opthalmic
problems are more common in animals undergoing
antileishmanial treatment.29 Uveitis, unless treated, may
cause secondary glaucoma or progress to therapy-resis-
tant panophthalmitis with eventual permanent loss of
vision. 35,52 Keratoconjunctivitis sicca, occasionally as-
sociated with CVL,35,54 was diagnosed in eight of 38
(21.1%) dogs in this study with apparent conjunctivitis.
Possibly, KCS is the result of the destructive action of
the parasites on the lacrimal apparatus,54 as histopathol-
ogy of the nictitans glands in CVL dogs with KCS in the
authors’ clinic has not been consistent with that of an
immune-mediated dacryadenitis.
A mild to severe anemia, generally nonregenerative,
normocytic, and normochromic, was a common (73.4%)
finding in this series, seemingly exceeding the frequency
rate (60%) of other studies.3,35 Its underlying patho-
physiological mechanism is mainly the chronic inflam-
matory nature of the disease, although chronic renal
failure, blood loss (i.e., from epistaxis, gastrointestinal
disease), and possibly bone marrow disease may also
contribute.3,24 Though still unclear, positive Coombs’
test and antinuclear antibody (ANA) titers detected in a
substantial number of dogs with CVL3,29,30 could not
exclude the contribution of autoimmune or immune-me-
diated mechanisms to the anemia.
Serum hyperproteinemia, seen in 72.8% of the cases
in this study and having prevalence rates ranging from
70% to 91%, 29,30,35 is generally attributed to polyclonal β
and γ hyperglobulinemia29,55,56 and is almost always as-
sociated with concurrent hypoalbuminemia;35 the latter
is secondary to severe protein-losing nephropathy, liver
disease, prolonged malnutrition, or a combination thereof
and usually equilibrates the hyperglobulinemia, result-
ing in normal serum total protein values.
According to reports originating from the United
States, the typical clinical and clinicopathological find-
ings noticed in CVL cases are fever, anorexia, weight
loss, hematochezia, anemia, neutrophilic leukocytosis,
hypoalbuminemia, and hyperglobulinemia.57
None of the various tests can be considered 100%
specific or sensitive in the diagnosis of CVL.31 The
simplest method is the detection of Leishmania amas-
tigotes in Giemsa or Diff-Quik stained aspiration smears
Canine Visceral Leishmaniasis 381
taken from the peripheral lymph nodes or the bone mar-
row.2,31 Lymph node cytology is easy to perform, but as
nuclear debris shares many similarities with amastigote
morphology, results may be inconclusive. The diagnos-
tic accuracy of lymph node aspirates range from 30%31
to 71.4%;35 in the latter report, bone marrow smears
were also included. Based on the authors’ much higher
figure (84.9%), it is recommended to pursue lymph node
cytology first and perform a bone marrow aspirate only
when lymph node cytology is negative. Bone marrow
smears were Leishmania positive in five out of seven
dogs that had negative lymph node cytology. The num-
ber of amastigotes varies considerably in aspirates, with
only a few to none seen in protracted cases.24 That is also
true in this study, as the 16 dogs that were negative on
cytology but IFA positive presented in an advanced stage
of CVL. Recently, a quantitative scoring system of the
density of Leishmania amastigotes in bone marrow and
lymph node aspiration smears has been instituted but
was not correlated to either the severity of the disease or
the IFA titers.35
Undoubtedly, the results of this study confirmed once
more that serology in general, and IFA in particular, are
more sensitive (96.9%) than lymph node cytology
(84.9%).58 Serological tests are not 100% sensitive, as
four of the dogs in this study were found to be cytologi-
cally positive and serologically negative. It has been
demonstrated that in endemic areas a number of infected
dogs, especially those presented in the early stages of the
disease, remain seronegative or are seronegative at the
time of diagnosis.59 Serology is important for confirming
CVL but should be interpreted in the context of the
clinical picture. The authors’ data is in agreement with
previous studies that demonstrated no correlation be-
tween the severity of the clinical signs and the serologi-
cal titers in treated or untreated animals.6,59,60 Complete
remission of clinical signs but persistence of high anti-
body titers are commonplace in CVL. 31,59 Therefore,
serology cannot be used to monitor the progress of treat-
ment or to confirm a complete cure in the dog. Only
lymph node and bone marrow cytology or the recently
introduced polymerase chain reaction (PCR) on bone
marrow samples61 are considered reliable methods for
the latter. Although serologically positive but asymp-
tomatic dogs are common in endemic areas (e.g.,
Greece15), all 158 dogs in this study showed one or more
CVL-compatible clinical sign.
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 Immune-Mediated Hemolytic Anemia:
70 Cases (1988–1996)
Survival times and mortality rates in dogs with idiopathic immune-mediated hemolytic anemia
(IMHA) have been infrequently reported in the literature. This study evaluates survival and
mortality in a large group of dogs with IMHA. The association of age, sex, and breed with IMHA
was evaluated by comparing affected dogs to control dogs admitted to the hospital during the
same time period. Treatment regimens were reviewed to determine the effects of different
agents upon survival of dogs with IMHA during hospitalization and after discharge. Median
survival times for each treatment group were 57 days (prednisone), 28 days (prednisone,
cyclophosphamide), 974 days (prednisone, azathioprine), 15 days (prednisone,
cyclophosphamide, azathioprine), and one day (no treatment). Overall mortality rate in the
population of dogs studied was 70%. Twenty-nine (41.4%) dogs either died or were euthanized
while hospitalized. Forty-one (59%) dogs were discharged from the hospital. Of the dogs
discharged, 10 died within the first month, another five died within three months, and another
five died within a year of discharge due to assumed complications of therapy or relapses of
IMHA. J Am Anim Hosp Assoc 1999;35:384–91.

Michele E. Reimer, DVM, MS Introduction

Gregory C. Troy, DVM, MS,
Diplomate ACVIM
Lorin D. Warnick, DVM, PhD,
Diplomate ACVPM
RS
From the Department of Small Animal
Clinical Sciences (Reimer, Troy),
Veterinary Teaching Hospital,
Virginia-Maryland Regional College of
Veterinary Medicine,
Blacksburg, Virginia 24061-0442 and the
Department of Population Medicine and
Diagnostic Sciences (Warnick),
Cornell University,
Ithaca, New York 14583-6401.
Doctor Reimer’s current address is
541 Westwood Drive,
Lanoka Harbor, New Jersey 08734.
Immune-mediated hemolytic anemia (IMHA) is a common hematological
disorder in dogs and presents major therapeutic challenges. Red blood
cell (RBC) destruction is the result of a type II immune reaction that
consists of immunoglobulin, complement, or both. Intravascular and ex-
travascular hemolysis may occur, but extravascular hemolysis predomi-
nates, with the spleen and liver being primary organs that participate in
RBC phagocytosis. Etiology of IMHA is classified as primary (i.e., idio-
pathic) and secondary. Sixty percent to 75% of IMHA cases in dogs are
idiopathic.1–4 Secondary IMHA may result from infectious agents, toxins,
drugs, parasites, neoplasia, vaccination, and other disease processes.1,5–8
Clinical signs of IMHA include lethargy, inappetence, pale mucous
membranes, exercise intolerance, tachycardia, tachypnea, and fever. Di-
agnosis is usually based on an acute onset of anemia generally character-
ized by a regenerative response. A nonregenerative form of IMHA has
also been described with the immunological response directed against
erythroid precursors.8–10 Spherocytosis and autoagglutination are consis-
tent laboratory findings in IMHA. Direct antiglobulin test (DAT) is
positive in approximately 60% of cases.3,8,11
Treatment of IMHA is directed at suppression of the immune response.
Glucocorticoids, cyclophosphamide, and azathioprine are the most com-
monly used agents in treatment. Supportive therapy includes fluid therapy,
antibiotic therapy, and blood transfusions. Therapy is often required for
extended periods. Mortality rates with idiopathic IMHA range from ap-
proximately 20% to 80%.3,4,6,7,10,12–18 Survival times have been infre-
quently reported. Dogs surviving for greater than 10 to 14 days after
initiation of treatment or after discharge from the hospital were found to
have longer survival times.4,6,12,18

384 JOURNAL of the American Animal Hospital Association

September/October 1999, Vol. 35
The purposes of this study were to examine the asso-
ciation of age, breed, and sex with IMHA; describe
survival times and mortality for affected dogs; and deter-
mine the relationships of test results and treatment proto-
cols with survival of dogs with IMHA.
Materials and Methods
Medical records of dogs diagnosed with IMHA between
January 1988 and February 1996 at the Virginia-
Maryland Regional College of Veterinary Medicine –
Veterinary Teaching Hospital (VMRCVM-VTH) were
reviewed. Eighty-four records were evaluated, with 14
records being excluded from analysis because of insuffi-
cient clinical information or the presence of an identifi-
able cause for the hemolytic anemia (i.e., tumor,
infectious disease, etc.). Criteria for diagnosis of idio-
pathic IMHA included anemia (packed cell volume
[PCV] less than 30%); a regenerative response
characterized by reticulocytosis or polychromasia;
spherocytosis; presence of macroscopic or microscopic
autoagglutination or a positive DAT a (Immunoglobulin
M [IgM], Immunoglobulin G [IgG], and complement at
4˚ and 37˚ C); and hemolysis characterized by biliru-
binuria, hyperbilirubinemia, or both. The presence of
anemia combined with at least two other inclusive ab-
normalities was used for acceptance into this study. Dogs
were excluded if other potential causes of IMHA such as
drug or toxin exposure, infectious diseases, dis seminated
intravascular coagulation (DIC), or neoplasia were iden-
tified from clinical findings or ancillary diagnostic infor-
mation. Nonimmune-mediated causes of hemolytic
anemias (such as Heinz bodies, hereditary defects, para-
sites, and fragmentation anemias due to DIC) were elimi-
nated with historical information, clinical pathological
review of the blood smears, and appropriate coagulation
profile testing.
Information extracted from records included signal-
ment; vaccination history (substantiated by the referral
veterinarian or the animal’s owner); primary clinical
signs; previous treatments; DAT results; length of hospi-
tal stay; disposition of animal during hospitalization,
after discharge, or both; and date of death or euthanasia
with confirmation by referring veterinarian or owners.
Automated complete blood count (CBC), reticulocyte
count, and serum biochemical profile were performed on
all dogs, as was RBC morphology. Evaluation of macro-
scopic and microscopic agglutination was noted on pe-
ripheral blood smears (saline dilution was not performed
in all cases to rule out rouleaux). Automated platelet
counts were performed in 68 dogs on initial CBCs. An-
cillary diagnostics to rule out secondary disease pro-
cesses were performed in select dogs and included bone
marrow examination, urinalysis, coagulation profiling
(i.e., activated partial thromboplastin time [APTT], one-
step prothrombin time [OSPT], and/or fibrin degradation
products [FDPs]), arthrocentesis, thoracic and abdomi-
Immune-Mediated Hemolytic Anemia 385
nal radiographs, abdominal ultrasonography, heartworm
testing, rickettsial titers, blood smear examination for
hemoprotozoa, and antinuclear antibody (ANA) titer.
Telephone conversations with the referring veterinar-
ian were performed if the animal was discharged from
the teaching hospital. This contact was used to ascertain
information about response of the animal to therapy, the
last known date the animal was examined, and the dispo-
sition of the animal. The date the animal died or was
euthanized after discharge from the hospital was ob-
tained by the referring veterinarian and was used to
calculate mortality and survival rates. If follow-up infor-
mation on the animal was not known by the referring
veterinarian, the last known date the referring veterinar-
ian had contact or knowledge of the animal’s medical
condition was used in analysis. Dogs that were not evalu-
ated by referring veterinarians after discharge from the
hospital were considered lost to follow-up.
In order to provide a comparison group to evaluate
age, gender, and breed characteristics of dogs with
IMHA, two control dogs were chosen from the general
hospital population during the same period in which
each affected dog was admitted to the hospital. The
hospital admission numbers immediately preceding and
following each case were used for selection of the con-
trol dogs. Five control dogs were excluded from the
statistical analyses of the data because of missing ages.
Immunosuppressive treatments administered to dogs
in this study consisted of glucocorticoids, azathioprine,
cyclophosphamide, or combinations of these drugs. Drug
dosages and frequency were not controlled variables.
Prednisone dosage averaged from 1.9 mg/kg body weight
(standard deviation [SD] of 0.5 mg/kg) sid or bid (range,
1 to 2 mg/kg body weight bid to 3 to 4 mg/kg body
weight sid to bid). Dexamethasone, at a comparative
dose of prednisone, and injectable prednisone (Meti-
cortinb) were occasionally used in treatment. Cyclophos-
phamide dosage averaged 1.8 mg/kg body weight, per
day (SD, 2.4 mg/kg body weight, per day; range, 1.6 to
3.3 mg/kg body weight, per day) with different adminis-
tration schedules. Azathioprine dosage averaged 1.7
mg/kg (SD, 1.2 mg/kg body weight; range, 1 to 2 mg/kg
body weight) with a frequency of sid to every other day.
Supportive therapy included fluid therapy, antibiotics,
blood or plasma transfusions, oxygen therapy, and gas-
trointestinal protectants.
Five different treatment groups of dogs were ana-
lyzed: Group I—prednisone only (n=16); Group II—
prednisone and cyclophosphamide (n=28); Group
III—prednisone and azathioprine (n=5); Group IV—
prednisone, cyclophosphamide, and azathioprine (n=16);
and Group V—dogs that died within 24 hours of admis-
sion or were euthanized on request of owner within the
first 24 hours of hospitalization (n=5). Treatment analy-
sis is based on the assumption that correct drug dosages
and frequencies were used in individual animals. Sur-
386 JOURNAL of the American Animal Hospital Association September/October 1999, Vol. 35

Table 1
The Association of Breed, Age, and Sex With the Occurrence of
Immune-Mediated Hemolytic Anemia (based on 70 cases and 135 control dogs
matched with cases by date of admission to the referral hospital)

Odds Ratio* 95% Confidence Interval

Breed
Other purebred 1.0
Mixed 1.1 0.5, 2.8
Cocker spaniel 6.7 1.7, 27.1
English springer spaniel 32.4 2.8, 379
Age
<2 yrs 1.0
2 to <5 yrs 7.8 1.3, 46.7
5 to <8 yrs 11.9 2.1, 68.7
>8 yrs 4.3 0.7, 26.6
Sex
Intact female 1.0
Spayed female 2.2 0.8, 6.1
Intact male 0.7 0.2, 2.2
Neutered male 1.5 0.4, 5.5

* Odds ratios greater than one imply increased risk of IMHA, and those less than one are interpreted as decreased
risk. Groups for which the 95% confidence interval includes one are not statistically different from the baseline
category.

vival and mortality data was calculated based on the last
or final known disposition of each dog obtained from
hospital records or by contacting the referring veterinar-
ian. Survival times were calculated based on the time of
natural death, euthanasia, or the last known date the
animal was alive based on telephone conversations with
referring veterinarians.
Statistical Analysis
Statistical analysis of survival times was performed us-
ing SAS.c Survival time was defined as the period from
initial examination at the veterinary teaching hospital
until death (natural or euthanasia). Dogs lost to follow-
up or alive at the end of data collection were treated as
censored observations, with the date of censoring equal
to the last date the dog was known to be alive. A Kaplan-
Meier method was used to evaluate effect of treatment
on survival. Cox’s proportional hazard model was used
to analyze the association of laboratory test results, age,
and body weight with survival time. The laboratory mea-
surements considered were albumin, total bilirubin, al-
kaline phosphatase (ALP), alanine aminotransferase
(ALT), hematocrit, white blood cell (WBC) count, and
presence of spherocytosis and autoagglutination. Statis-
tically significant factors (p less than 0.05) were selected
by backward elimination.
The case-control data was analyzed using conditional
logistic regression (EGRET) to determine the relation-
ships of age, breed, and sex with the occurrence of
IMHA in hospital patients. This method was also used to
evaluate the risk of death during hospitalization for dogs
with IMHA compared with other dogs admitted to the
hospital. Logistic regression model results were reported
as odds ratios (OR) with 95% confidence intervals. An
odds ratio equal to 1 implies no association between the
factor of interest and the study outcome. Factors with
odds ratios significantly greater than 1 are interpreted
as increasing the risk of the outcome, while factors
with odds ratios less than 1 are associated with de-
creased risk.
Results
Seventy dogs met diagnostic criteria for inclusion into
this study. Ages of affected dogs at admission ranged
from one to 13 years, with a median of six years. Aver-
age ages of dogs that died and survived were 6.1 years
and 4.8 years, respectively. Females (intact and spayed)
comprised 70% of the cases. Age and breed were signifi-
cantly associated with the occurrence of IMHA [Table
1]. Sex of the dog was not a significant factor when
controlling for age and breed. Dogs in the age ranges of
two to four years and five to seven years were at an
September/October 1999, Vol. 35
increased risk of developing disease relative to dogs less
than two years of age (OR, 7.8 and 11.9, respectively).
Sixty-one breeds were represented among the case
and control dogs, but very few occurred with enough
frequency to be analyzed statistically. Breed categories
used for the logistic regression analysis were cocker
spaniel (11 cases, four controls) and English springer
spaniel (five cases, one control), other purebred (42 cases,
98 controls), and mixed-breed (12 cases, 32 controls). In
this referral hospital population, cocker spaniels and En-
glish springer spaniels were at greater risk of IMHA
(OR, 6.7 and 32.7, respectively). Although not included
separately in the statistical analysis, poodle (seven cases;
10%), miniature schnauzer (four cases; 5.7%), and collie
(three cases; 4.3%) were breeds that tended to occur
more frequently as cases than as controls. None of the
IMHA cases were golden retrievers, although this breed
accounted for 7.4% of the control dogs and was the
second most common breed (following mixed-breed
dogs) among the controls.
Clinical signs frequently noted at the time of admis-
sion were anorexia/lethargy (99%), pallor of mucous
membranes (97%), icterus (51.4%), heart murmurs
(47%), weakness (46%), and splenomegaly (43%).
Tachypnea (30%), tachycardia (28%), hepatomegaly
(23%), and hematuria (13%) were less frequently ob-
served clinical signs. Three dogs had a history of being
vaccinated within two weeks of presentation to the
VMRCVM-VTH.
Mean hematocrit of all dogs at admission was 13.7%,
with a range of 5.2% to 30% (reference range, 37% to
55%). The average uncorrected reticulocyte count of all
dogs was 14.3%. Corrected reticulocyte counts (CRC)
were greater than 3% in 40 (57%) dogs, between 1% and
3% for 18 (26%) dogs, and less than 1% in 12 (17%)
dogs. Polychromasia (63 dogs; 90%), spherocytosis (55
dogs; 79%), autoagglutination (46 dogs; 66%), or a com-
bination of the above, were present in 68 (96%) of the 70
dogs. A DAT was performed in 46 dogs, with 17 (37%)
dogs having a positive test result. Leukocytosis was
present in all dogs but one, with a mean WBC count of
42,422/µl (reference range, 5.4 to 15.3 x10 3/µl), a SD of
17.97 x10 3/µl, a median value of 38.7 x10 3/µl, and a
range of 13.6 to 105.7 x103/µl. Mean platelet count for
68 dogs was 206.9 x10 3/µl, with a SD of 133.4 x103/µl, a
median value of 188.5 x103/µl, and a range of 24 to 753
x103/µl. Twenty-nine dogs were considered to have
thrombocytopenia (less than 175 x103/µl; reference range,
200 to 500 x103/µl).
Serum biochemical profile abnormalities were com-
mon. Serum total bilirubin concentrations were abnor-
mal in 48 (68%) dogs, with a range of 0.1 to 59.4 mg/dl
(reference range, less than 0.5 mg/dl). Mean and median
total serum bilirubin concentrations were 6.56 mg/dl and
1.05 mg/dl, respectively. Twenty-two (31%) dogs had
total serum bilirubin concentrations over 3.0 mg/dl, and
Immune-Mediated Hemolytic Anemia 387
21 of these dogs died. Increased total serum bilirubin
concentration was significantly associated with decreased
survival time (p equals 0.0003). Serum ALP was in-
creased in 63 dogs (90%; reference range, 10 to 100 U/L).
Serum ALP values ranged from 40 to 2,570 U/L, with a
median of 318 U/L and a mean of 567 U/L. Increased
values of serum ALP were also significantly associated
with decreased survival (p equals 0.02). Serum ALT was
elevated in 32 (46%) dogs, with a mean of 437 U/L
(reference range, 4 to 91 U/L), a range of 3 to 4,173 U/L,
and a median of 75.5 U/L. Serum ALT was not signifi-
cantly associated with an increased mortality (p equals
0.9). Average hospital stay for dogs in this study was 6.5
days. Thirty-one (44%) dogs received blood transfusions
during hospitalization and 24 (77%) of these dogs died.
Mean and median survival times for each treatment
group were 67.2 and 57 days (prednisone), 215.4 and 28
days (prednisone and cyclophosphamide), 931 and 974
days (prednisone and azathioprine), 779.3 and 15 days
(prednisone, cyclophosphamide, and azathioprine), and
one day each (no treatment). A significant difference in
survival was noted between treatment groups (p equals
0.0001). However, there were not enough dogs in each
group to allow comparison of specific treatment groups
to one another.
Overall mortality in the population of dogs studied
was 70%. Twenty-nine (41.4%) dogs either died or were
euthanized while hospitalized. Forty-one (59%) dogs
were discharged from the hospital. Of the dogs dis-
charged, 10 died within the first month, another five died
within three months, and another five died within a year
of discharge. Most of these dogs were assumed to have
complications of therapy or relapses of IMHA. At the
conclusion of the study, 6/16 (prednisone), 9/28 (pred-
nisone and cyclophosphamide), 1/5 (prednisone and aza-
thioprine), 5/16 (prednisone, cyclophosphamide, and
azathioprine), and 0/5 (no treatment) dogs were alive.
Nineteen (27%) dogs were still alive at the end of the
study. Two dogs were lost to follow-up. Dogs affected
with IMHA were approximately four times more likely
to die in the hospital compared to the general hospital
population (OR, 4.0).
Discussion
This study denotes a guarded prognosis for long-term
survival in dogs affected with IMHA. Mortality rate was
70%, with the majority of dogs dying within three months
after discharge. This differs from earlier references that
indicate a good prognosis and survival for dogs with
IMHA, excluding dogs that experience thromboembolic
events, secondary organ system failure, or fulminate in-
travascular hemolysis.1–3,7,8,19,20 This difference in prog-
nosis and survival is due to methods previous studies
have used to evaluate and report survival times and
mortality rates. Most studies have analyzed these param-
eters for only the period of hospitalization and not the
388 JOURNAL of the American Animal Hospital Association September/October 1999, Vol. 35

Table 2
Survival Times and Mortality Data for Treatment Groups in 70 Dogs
With Immune-Mediated Hemolytic Anemia

Treatment Number of Median and Mean Number of Number of

Group Dogs (days) Dogs Dead Dogs Alive Mortality Rate
I — Prednisone 16 57 10 6 62.5%
67
II — Prednisone and 28 28 19 9 67.8%
cyclophosphamide 215
III — Prednisone and 5 974 4 1 80%
azathioprine 931
IV — Prednisone, 16 15 11 5 68.7%
cyclophosphamide, and 779
azathioprine
V — No treatment 5 1 5 0 100%
1
All dogs 70 21 49 19* 70%
695

* Two dogs were lost to follow-up

period after discharge from the hospital. In six studies
where dogs were followed after discharge from hospital,
mortality rates averaged 48% (range, 38% to 63%).4,6,12,16–18
Survival times and mortality rates from reported stud-
ies are presented in Table 3. These reports consist of 529
dogs with IMHA, with mortality rates ranging from 18%
to approximately 63%.3–7,9,10,12–17,21,22 The average mor-
tality rate for dogs in these investigations is approxi-
mately 41%. Dogs cited in these studies were analyzed
primarily during the period of hospitalization and not
after discharge from the hospital. 3,5,7,10,13,14,17,21 How-
ever, some reports did have follow-up periods that ranged
in duration from less than one week to approximately
156 weeks.4,6,9,18 It was found that of these dogs, those
surviving for more than 10 to 14 days after initiation of
treatment or after discharge from the hospital were found
to have longer survival times.4,6,12,18
Data from this study is biased because the VMRCVM-
VTH is a referral institution, but other investigations
have also been from large referral or university hospi-
tals. Dogs were referred mainly because of the severity
of their disease process or because the level of care that
owners or referring veterinarians desired for the dogs
could not be provided at the primary veterinary hospital.
In some instances, blood products were necessary for
treatment, and a reliable source was not available through
the primary veterinarian.
Breed, age, and sex of dogs affected with IMHA are
similar to the majority of reported investiga-
tions.1,2,5,7,8,12,14,21,23 Cocker spaniels and English springer
spaniels had an increased risk of being affected with
IMHA, and although poodles and collies were over-
represented as breeds, they were not analyzed statisti-
cally. Golden retrievers were found to have a reduced
risk of IMHA that has not been previously identified in
other studies. Middle-aged (five to eight years), spayed
females comprised the majority of dogs with IMHA in
this study, a finding which has been reported previ-
ously.1,2,5,7,8,12,14,21,23 Exact reasons for females to be
more affected with this disease is not fully understood,
but hormonal influences and their effects upon the im-
mune system are suspected.1,5,7,8
Recent association of vaccination with modified live
products and onset of IMHA has been reported.6 Only
three dogs in this study received any type of a modified
live virus vaccine within the immediate two-week period
before IMHA was diagnosed. Sixteen dogs did not have
a current vaccine status (within the past year for distem-
per virus, parvovirus, adenovirus, leptospirosis, and
parainfluenza virus) on initial admission to the hospital.
Duval, et al. demonstrated that 26% of dogs with IMHA
receiving a modified live virus vaccine within the pre-
ceding four-week period had a higher association with
the onset of IMHA. 6 Survival times and mortality rates
between groups were not different in Duval, et al.’s
study, but the majority of deaths occurred during the first
three weeks of treatment.6 Vaccination and exposure to
parvovirus and distemper viruses have been implicated
to increase the incidence of IMHA in dogs.2,24,25
Median survival times for all treatment groups in this
study ranged from one day to 974 days. Median and
mean survival times of 21 days and 695 days were noted
for all dogs, with a range of one day to 2,198 days [Table
2]. Median values are more representative of survival
September/October 1999, Vol. 35 Immune-Mediated Hemolytic Anemia 389

Table 3
Survival Times and Mortality Rates in Dogs With Immune-Mediated Hemolytic Anemia
as Reported in the Literature

Number of Dogs
Author(s) Year Mortality Rate Studied Survival Times
Burgess, et al.12 1997 48% 60 Mean, 14±5 days
50% alive at 10 days
25% alive at 370 days
Jackson, et al.4 1985 44% 29* Mean, 13.2 wks
Range, 0–78 wks
Klag, et al.9 1993 29% 42 Range, 2–130 wks
Klein, et al.13 1989 61% 31 NR†
Hohenhaus5 1992 19% 46 NR
Switzer, et al.7 1981 38% 77 NR
Duval, et al.6 1996 48% 58 Mean, 290 days
Median, 268 days
Range, 92–750 days
Kellerman, et al.14 1995 18% 37 NR
Carr, et al.21 1996 58% 72 NR
Wohl, et al.15 1996 37% 11 NR
Jonas, et al.10 1987 33% 6 NR
Miller16 1997 63% 16 Follow-up period 52 wks
Mason, et al.17 1997 46% 11 Follow-up period 4 wks
Kellerman, et al.18 1997 38% 13‡ Median, 460 days
Range, 120–1,075 days
Cotter, et al.3,22 1990 45% 20 NR

* Study contained 55 dogs, but only 29 were diagnosed with immune-mediated hemolytic anemia (IMHA) or IMHA and
immune-mediated thrombocytopenia (ITP)
†
NR=Not reported
‡
Study contained 37 dogs, but only 13 dogs were treated and reported in analysis

times, since mean values can be skewed by one or two
dogs in treatment groups that survived significantly
longer than other animals. Seventy-five percent of dogs
died within three weeks of diagnosis in one study, while
another retrospective study showed outcome improved
after four weeks of therapy.4,6,12 It appears that treatment
for this disease warrants a guarded to poor prognosis for
long-term survival.
The presence of thromboembolism, low reticulocyto-
sis, thrombocytopenia, icterus, blood transfusion, num-
ber of intravenous catheters, negative Coombs’ test
results, and other organ system involvement are reported
to be significant prognostic factors affecting survival
times in dogs with IMHA.6,7,9,13,21 Thromboembolism is
difficult to diagnose antemortem and was not evaluated
for prognostic information, nor was reticulocytosis,
thrombocytopenia, blood transfusions, number of intra-
venous catheters, or Coombs’ test results in this study.
Hyperbilirubinemia and increased serum ALP values
were correlated with increased mortality in this study.
Increases in serum ALP have not previously been identi-
fied as a predictor of mortality and may be related to the
population of animals studied. Dogs receiving glucocor-
ticoids (which could increase the serum ALP) that did
not respond to treatment may have been more likely to
be referred; however, other studies should have corre-
lated this laboratory abnormality with mortality rates,
because previous reports were also from referral institu-
tions. It could be that the severity of IMHA in dogs has
changed over time, but mortality rates are similar: 44%
after 1990 versus 41% before 1990.
Response of dogs with IMHA to treatment is indi-
cated by an increase in hematocrit, a decrease in hemoly-
sis, agglutination and spherocytosis, and improvement
of clinical manifestations. A variety of treatments are
used for this disease in dogs. Glucocorticoids, cyclo-
phosphamide, azathioprine, danazol, intravenous immu-
noglobulin, and cyclosporine are the most commonly
used agents.7,12,16–19,26 Plasmapheresis and splenectomy
are infrequently used as treatments in veterinary medi-
390 JOURNAL of the American Animal Hospital Association
cine, but splenectomy is an alternate treatment modality
with some reported success. 26
Glucocorticoids are the initial drugs of choice for
treating IMHA in dogs. The 16 dogs in the prednisone
treatment group had a median survival time of 57 days,
with a 62% mortality rate. This mortality rate is higher
than the rate reported in other studies in dogs treated
solely with this agent. More aggressive immunosuppres-
sive therapy has also been suggested by several investi-
gators, if after four to seven days of glucocorticoid
therapy there is no stabilization or increase of the
hematocrit.3,8,18,19
Prednisone and cyclophosphamide have recently been
compared to prednisone therapy in dogs with IMHA and
were not shown to be more efficacious.17 This prospec-
tive study was comprised of 11 dogs with a mortality rate
of 45%, but the dogs were only evaluated for four
weeks.17 Burgess, et al. evaluated 60 dogs treated with
cyclophosphamide and prednisone and found a mortality
rate of 48%, with survival times averaging 14 days.12
Dogs in this study treated with cyclophosphamide and
prednisone had one-half of the median survival times
compared to dogs in the prednisone group, with similar
mortality rates; however, this was not evaluated statisti-
cally. These investigative findings suggest that
cyclophosphamide may not be a safe or useful immuno-
suppressive agent as some authors have suggested for
treatment of IMHA. However, it is likely that cyclophos-
phamide was given to the sicker dogs that were therefore
at higher risk for death, and that cyclophosphamide alone
was not related to the shorter median survival times.
This study did show that dogs treated with prednisone
and azathioprine had longer median and mean survival
times than dogs in the other treatment groups. A small
sample size in this treatment group may have skewed
these results. A double-blind study of 16 dogs with IMHA
treated with prednisone and azathioprine had a reported
mortality rate of 62.5%.16 Prospective studies with these
two agents should be performed to determine whether
this combination is superior to other drugs or combina-
tion of drugs used in treatment of IMHA. This study did
not contain enough dogs in this treatment group to deter-
mine if this trend was a significant factor in survival.
Other authors indicate that intravenous immunoglo-
bulin, danazol, and cyclosporine therapy may be advan-
tageous as sole agents or in combination with other
therapies. Intravenous immunoglobulin therapy has few
reported side effects in dogs when used to stabilize
hemolysis. 18 Median survival time in eight dogs treated
with prednisone and this agent was reported to be 460
days,18 which is the longest median survival time re-
ported in 15 studies of this disease. This mode of therapy
warrants additional clinical trials.
Danazol therapy, in a recent prospective study, did
not improve mortality rates in dogs when compared to
dogs treated with azathioprine, prednisolone, and a pla-
September/October 1999, Vol. 35
cebo.16 Cyclosporine has been used in combination with
other therapy, but in one study of 11 dogs it did not show
efficacy as the sole agent in the treatment of IMHA.15
This study shows that survival times increase after the
first three to six weeks after hospital discharge in dogs
with IMHA. Prognosis for long-term survival is guarded
to poor, with mortality approaching 70% within one year
after discharge. Additional study of dogs treated
with prednisone and azathioprine combination therapy is
warranted.
a
Goat Anti Dog IgM, IgG; Cappel Research, Durham, NC
b
Meticorten; Schering, Kenilworth, NJ
c
SAS Technical Report; SAS/STAT Software, Cary, NC
References
1. Dodds WJ. Autoimmune hemolytic disease and other causes of immune-
mediated anemia: an overview. J Am Anim Hosp Assoc 1977;13:437–42.
2. Dodds WJ. Immune-mediated diseases of blood. Adv Vet Sci Comp Med
1983;27:163–96.
3. Cotter SM. Autoimmune hemolytic anemia in dogs. Comp Cont Educ Pract
Vet 1992;14(1):53–9.
4. Jackson ML, Kruth SA. Immune-mediated hemolytic anemia and
thrombocytopenia in the dog: a retrospective study of 55 cases diagnosed
from 1969 through 1983 at the Western College of Veterinary Medicine.
Can Vet J 1985;26:245–50.
5. Hohenhaus AE. Canine autoimmune hemolytic anemia: predisposing and
prognostic factors. San Diego: Proceed, 10th ACVIM Forum, 1992:146–8.
6. Duval D, Giger U. Vaccine-associated immune-mediated hemolytic anemia
in the dog. J Vet Int Med 1996;10(5):290–5.
7. Switzer JW, Jain NC. Autoimmune hemolytic anemia in dogs and cats.
Vet Clin N Am 1981;11(2):405–20.
8. Bucheler J, Cotter S. Canine immune-mediated hemolytic anemia. In:
Bonagura JD, Kirk RW, eds. Kirk’s current veterinary therapy XII.
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9. Klag A, Giger U, Shofer F. Idiopathic immune-mediated hemolytic anemia
in dogs: 42 cases (1986–1990). J Am Vet Med Assoc 1993;202(5):783–7.
10. Jonas LD, Thrall MA, Weiser WG. Nonregenerative form of immune-
mediated hemolytic anemia in dogs. J Am Anim Hosp Assoc 1987;23:
201–4.
11. Slappendel RJ. The diagnostic significance of the direct antiglobulin test
(DAT) in anemic dogs. Vet Immuno Immunopath 1979;1:49–59.
12. Burgess KE. Immune-mediated hemolytic anemia in dogs: a retrospective
study of 60 cases treated with cyclophophamide. J Vet Int Med
1997;11(2):143–8.
13. Klien MK, Dow S, Rosychuk RA. Pulmonary thromboembolism associated
with immune-mediated hemolytic anemia in dogs: ten cases (1982–1987).
J Am Vet Med Assoc 1989;195(2):246–50.
14. Kellerman DL, Bruyette DS. Canine immune-mediated hemolytic anemia:
a retrospective analysis of 37 cases. Orlando: Proceed, 13th ACVIM
Forum, 1995:189.
15. Wohl JS, Moore AS. Use of single-agent cyclosporine A in dogs with
severe immune-mediated hemolytic anemia. San Antonio: Proceed, 14th
ACVIM Forum, 1996:755.
16. Miller E. Danazol therapy for the treatment of immune-mediated hemolytic
anemia in dogs. J Vet Int Med 1997;11(2):130.
17. Mason NJ, Duval D, Giger U. Evaluation of combined cyclophosphamide
and prednisone versus prednisone alone in the treatment of canine immune
mediated hemolytic anemia. J Vet Int Med 1997;11(2):130.
18. Kellerman DL, Bruyette D. Intravenous human immunoglobulin for the
treatment of immune-mediated hemolytic anemia in 13 dogs. J Vet Int Med
1997;11(6):327–31.
19. Weiser M. Erythrocyte responses and disorders. In: Ettinger SF, Feldman
EC, eds. Textbook of veterinary internal medicine. Philadelphia: WB
Saunders, 1995:1864–91.
20. Werner L. Coombs’ positive anemias in the dog and cat. Comp Cont Ed
Pract Vet 1980;2(2):96–102.
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21. Carr AP, Panciera DL. Immune-mediated hemolytic anemia in dogs: a
retrospective study with emphasis on hemostatic parameters. San Antonio:
Proceed, 14th ACVIM Forum, 1996:754.
22. Cotter SM, Rentko VT, Garlock S. Unpublished data. Department of
Medicine, School of Veterinary Medicine, Tufts University, North Grafton,
MA; 1990.
23. Jacobs RM, Murtaugh RJ, Crocker DB. Use of a microtiter Coombs’ test
for study of age, gender, and breed distributions in immunohemolytic
anemia in the dog. J Am Vet Med Assoc 1984;185:66–8.
24. Dodds WJ. Contributions and future directions of hemostasis research.
J Am Vet Med Assoc 1988;193(9):1157–60.
25. Young N, Mortimer P. Viruses and bone marrow failure. Blood
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26. Feldman BF, Handagama P, Lubberink AAME. Splenectomy as adjunctive
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the dog. J Am Vet Med Assoc 1985;187(6):617–9.
 Cobalamin Deficiency Associated With
Erythroblastic Anemia and Methylmalonic
Aciduria in a Border Collie
Anemia due to cobalamin deficiency is a rare genetic disorder that has been recognized in
dogs only recently. This report concerns a 14-month-old border collie that presented for
chronic, nonregenerative anemia. Cytological examination of a peripheral blood smear showed
the presence of erythroblasts. Serum cobalamin levels were below reference ranges reported
for clinically normal dogs. A methylmalonic aciduria was found on urinalysis. These signs are
consistent with the anemia in Imerslund-Graesbeck syndrome reported in humans. Anemia due
to cobalamin deficiency responds to parenteral vitamin B12 therapy, and affected animals have
a good prognosis for recovery. J Am Anim Hosp Assoc 1999;35:392–5.

Lee W. Morgan, DVM, MS Case Report

James McConnell, DVM
C pertinent history included a urinary tract infection (UTI) one to two
From the Friendship Hospital
for Animals (Morgan),
4105 Brandywine Street, N.W.,
Washington, D.C. 20016 and the
Southpaws Veterinary Referral Center
(McConnell),
6136 Brandon Avenue,
Springfield, Virginia 22150.
This study was supported in part by
NIH grant #02512.
A 14-month-old, spayed female border collie was referred for evaluation
of chronic anemia of six months duration. An anemia (packed cell volume
[PCV], 28.9%; reference range, 36% to 52%) was found incidentally on a
complete blood count (CBC) prior to routine ovariohysterectomy. Other
months prior to presentation, with a positive culture and urinalysis reveal-
ing positive protein, positive white blood cells (WBC), and a specific
gravity of 1.040. The UTI was cleared with antibiotic therapy. The dog
was fed a commercial, meat-based diet and was current on its vaccina-
tions.
Physical examination revealed the dog to be thin, quiet, alert and
responsive, hydrated, normothermic, and slightly pale. Auscultation re-
vealed a I-II/VI systolic flow murmur. Abdominal palpation revealed
mildly increased thickness of bowel loops. The mandibular lymph nodes
were mildly increased in size.
A CBC, reticulocyte count, serum biochemical profile, serum electro-
lytes, and a urinalysis were obtained. Coagulation tests showed a normal
activated clotting time ([ACT], 90 seconds; reference range, 60 to 90
seconds), prothrombin time ([PT], 8.5 seconds; reference range, 6 to 12
seconds), and activated partial thromboplastin time ([APTT], 14.7 sec-
onds; reference range, 10 to 25 seconds). The CBC showed an anemia
with a hematocrit of 29.7%. The anemia was nonregenerative, normocytic,
normochromic, and associated with normal coagulation status. A leuko-
cytosis (17.5 x103/µl; reference range, 6 to 17 x103/µl) with a mature
neutrophilia (14.9 x103/µl; reference range, 3.5 to 14 x103/µl) was found.
Mean corpuscular volume (MCV) was normal (70 fl; reference range, 60
to 77 fl), and the hemoglobin level was low (9.9 g/dl; reference range, 12
to 18 g/dl). The reticulocyte count was 0.1%. A serum biochemical profile
revealed hypoproteinemia (serum total protein, 5.1 g/dl; reference range,
5.4 to 7.8 g/dl), high alkaline phosphatase ([SAP], 97 U/L; reference
range, 1 to 70 U/L), high aspartate aminotransferase ([AST], 288
U/L; reference range, 10 to 100 U/L), and hypocalcemia (serum calcium,
8.3 mg/dl; reference range, 8.5 to 11.5 mg/dl). Serum electrolyte analysis
showed a hyponatremia (serum sodium, 137 mEq/L; reference range, 139

392 JOURNAL of the American Animal Hospital Association

September/October 1999, Vol. 35
to 154 mEq/L) and hypokalemia (serum potassium, 3.2
mEq/L; reference range, 3.5 to 5.5 mEq/L). Urinalysis
revealed a mild proteinuria (30 mg/dl) and a urine spe-
cific gravity of 1.042.
Additional diagnostic evaluation consisted of radiog-
raphy, abdominal ultrasonography, serum iron determi-
nation, fecal occult blood test (i.e., guaiac method), and
bone-marrow aspirate. Radiographs revealed decreased
abdominal contrast secondary to the thin body condition
of the dog, moderately decreased hepatic mass, and in-
creased amounts of stool within the descending colon.
The kidneys, spleen, and bladder were within normal
limits. Abdominal ultrasonography revealed no abnor-
malities in the liver, biliary tract, kidneys, spleen, uri-
nary bladder, or stump of the uterus. No free fluid or
abdominal masses were seen. Serum iron was not de-
creased. A trace positive blood in the stool was found
and considered most likely to be dietary in origin.
The bone-marrow aspirate cytology revealed dramatic
erythroid hyperplasia with erythrophagocytosis. The
myeloid:erythroid (M:E) ratio was decreased. Erythroid
precursors were seen in high numbers, and there was a
moderate shift toward immaturity. Granulocyte numbers
were relatively decreased. Megakaryocytes were seen in
adequate numbers. Macrocytes with a high degree of
erythrophagocytosis and iron pigmentation were ob-
served. This severe erythroid hyperplasia showed that
the bone marrow was capable of erythroid production.
Further evaluations were performed to investigate im-
mune-mediated disease (e.g., reticulocyte-negative
hemolytic anemia) and congenital disorders including
metabolic anomalies, hemoglobinopathies, and red blood
cell (RBC) membrane abnormalities. Diagnostic tests
included direct Coombs’ test (immunoglobulin G [IgG],
immunoglobulin M [IgM], and complement [C 3]),
hemoparasite screen, canine erythrocyte osmotic fragil-
ity test, serum cobalamin and folate, evaluation of urine
for organic acid abnormalities, and repeat CBC and
reticulocyte count. Coombs’ test for IgG, IgM, and C3
was negative. No RBC parasites were seen on direct
examination of the blood smear. The erythrocyte os-
motic fragility test showed a slightly increased fragility.
Serum folate levels were normal; however, serum cobal-
amin levels were very low (20 pg/ml; reference range,
175 to 550 pg/ml). A repeat CBC showed an anemia
(PCV, 29.1%), a low hemoglobin content (8.0 g/dl; ref-
erence range, 12 to 18 g/dl), and a high MCV (83 fl;
reference range, 60 to 70 fl). A neutrophilia (53.4 x103/µl;
reference range, 3.5 to 14.5 x103/µl) with a left shift
(bands, 1,602/µl; reference range, 0 to 300/µl) and mild
lymphocytosis (5,874/µl; reference range, 1,000 to
5,000/µl) was found. The reticulocyte count was 2.6%.
Cytology of a peripheral blood smear showed marked
erythroblastemia. No spherocytes were noted.
Methylmalonic acid (MMA), an organic acid not
present in clinically normal dog urine, was found in the
Cobalamin Deficiency in a Border Collie 393
dog described in this report. Detailed evaluation of the
MMA in the dog’s urine indicated 3,643 mg MMA/g
creatinine. Normal dogs have been reported to excrete
less than 10 mg MMA/g creatinine.1 Urine amino acids
and carbohydrates were found to be present in normal
amounts. Test results were compatible with the anemia
of cobalamin deficiency.
Parenteral vitamin B12 therapy was initiated at 1 mg
divided over seven days, then 1 mg every one to two
months. Parenteral administration was chosen because
the cobalamin deficiency was assumed to be due to mal-
absorption. On recheck at 18 months of age, the dog was
clinically better. The dog was bright and alert. Pink
mucous membranes, adequate hydration, and significant
weight gain were noted on physical examination. The
anemia had resolved (PCV, 39.9%). The leukocytosis
had resolved (10.2 x103/µl; reference range, 3.5 to 14.5
x103/µl). A serum biochemical profile showed a high
SAP (146 U/L; reference range, 1 to 70 U/L) and AST
(506 U/L; reference range, 10 to 100 U/L). All other
parameters were within normal limits. In addition, uri-
nalysis showed resolution of the methylmalonic aciduria;
however, the proteinuria (30 mg/dl) persisted.
Discussion
Imerslund-Graesbeck syndrome is a megaloblastic ane-
mia of humans associated with methylmalonic aciduria,
proteinuria, and decreased serum cobalamin levels. It
was described independently as an autosomal recessive
trait seen in children by Imerslund and Grasbeck in
1960.2,3 Since then, cobalamin deficiencies have been
reported in dogs1,4,5 and a domestic cat.6
For carnivores and omnivores, the nutritional require-
ment of cobalamin is met through the ingestion of animal
protein. In the gastric mucosa, cobalamin binds to a
transport protein, intrinsic factor (IF). The cobalamin-
protein complex is absorbed via specific receptors lo-
cated in microvillus pits of enterocytes in the distal
ileum.7 Once absorbed, the IF-cobalamin complex is
dissociated, with the IF then becoming available at the
luminal surface to bind more cobalamin,8 and cobalamin
exits the cell across the basilateral membrane. The co-
balamin is found in the portal circulation bound to an-
other protein, transcobalamin II (TC-II), for transport
into tissues.9,10
Cobalamin deficiency can develop as a result of di-
etary insufficiency of vitamin B12, utilization of cobal-
amin by intestinal microorganisms, intestinal disease,
pancreatitis, immune-mediated mechanisms, or selective
malabsorption of cobalamin. There are several inherited
defects which result in cobalamin malabsorption, in-
cluding IF insufficiency, 11–13 TC-II deficiency, 14 and
deficiency of cobalamin receptors in the distal il-
eum.2,3 The term Imerslund-Graesbeck syndrome gen-
erally is reserved for cobalamin deficiency due to
malabsorption.
394 JOURNAL of the American Animal Hospital Association
In humans with Imerslund-Graesbeck syndrome, clini-
cal signs usually develop between one and four years of
age, after exhaustion of the supplies of cobalamin stored
during the intrauterine period.15 Rarely, the condition is
first recognized in the patient’s teenage years.16–18 Pa-
tients exhibit weakness, gastrointestinal symptoms, and
failure to thrive.19,20 Less commonly, neurological symp-
toms, including spasticity, ataxia, and cerebral atrophy
have been described.21,22 The most common physical
examination findings include pallor, glossitis, growth
retardation, weight loss, hepatomegaly, and spleno-
megaly. 22 Concurrent skin hyperpigmentation has been
reported.2,23–25 In addition to the megaloblastic anemia,
one of the hallmark signs of Imerslund-Graesbeck syn-
drome is proteinuria. Proteinuria in Imerslund-Graesbeck
syndrome is thought to be glomerular in origin,26–28 with
possible transmembranal translocation of protein mol-
ecules in the kidney. 29 The proteinuria is often persis-
tent even after parenteral vitamin B 12 therapy is
initiated. 26,28
Cobalamin deficiencies due to dietary insufficiency,
transport defects, or malabsorption result in impairment
of the hemopoietic system and subsequent anemia and
metabolic changes, resulting in methylmalonic aciduria.
Methylmalonic acid is excreted when there is a defect in
the catabolic pathway of certain amino acids and fatty
acids. The methyl derivative of B12 is required for the
conversion of homocysteine to methionine, and the
5-deoxyadenosyl derivative is required for the conver-
sion of methylmalonyl coenzyme A (CoA) to succinyl
CoA, which is in turn required for the catabolism of
methionine, threonine, valine, and isoleucine.
L-methylmalonyl-CoA mutase requires vitamin B12 for
the conversion of L-methylmalonyl to succinyl CoA. In
cobalamin deficiency, L-methylmalonyl is not converted
to succinyl CoA, and thus it accumulates in the system.
Excess methylmalonic acid is excreted in the urine, re-
sulting in methylmalonic aciduria.
Megaloblastic anemia is thought to be due to a defect
in the metabolism of folate.30 The vitamin B12-dependent
conversion of homocysteine to methionine in turn con-
verts N 5-methyl H4 folate to H4 folate. A deficiency in
vitamin B12 thus results in an accumulation of N5-methyl
H4 folate and a deficiency in the active form of folate.
One effect of folate deficiency is inhibition of deoxyri-
bonucleic acid (DNA) synthesis, arresting cells in the S
phase of cellular growth. In rapidly dividing cells, such
as those involved in hematopoiesis, this effect is espe-
cially pronounced. The block of RBCs results in retarda-
tion in the maturation of erythrocytes, and the release of
immature cells.
Studies with humans have shown a simple autosomal
recessive inheritance of Imerslund-Graesbeck syn-
drome. 2,3,15,25,27,31 One pedigree analysis of a Bedouin
family was suggestive of an X-linked mode of inheri-
tance.32 A case report by Celep, et al. found an associa-
September/October 1999, Vol. 35
tion of Imerslund-Graesbeck with a chromosome de-
letion at 46, XX, del (21)(q22). 33 A higher incidence
of the disease has been reported in Scandinavian coun-
tries, Israel, and Turkey.22,34 Altay, et al. attributed
the higher incidence in Turkey to an increased fre-
quency of consanguineous marriages occurring in that
region.22
The preferred therapy for the anemia is parenteral
administration of vitamin B12, although high doses (1,000
µg/dl) of orally administered cobamide have been re-
ported to be effective.35
Fife, et al. described a condition in giant schnauzers
that was similar to Imerslund-Graesbeck syndrome in
humans. 1 Two related giant schnauzers developed
chronic inappetence, lethargy, cachexia, and failure to
thrive at 12 weeks of age. Dermatological abnormalities
that are sometimes seen in humans with Imerslund-
Graesbeck syndrome were not reported in either
schnauzer. Abnormal laboratory findings included a
megaloblastic anemia, neutropenia, and low serum co-
balamin concentrations. Bone-marrow aspirates yielded
a low M:E ratio. Serial routine urinalysis revealed a
proteinuria (2+) in each of the dogs and transient keton-
uria (1+) in one of the dogs. As in the dog presented here,
the giant schnauzers had extremely high methylmalonic
acid (5,970 and 4,252 mg MMA/g creatinine; reference
range, less than 10 mg MMA/g creatinine) in the urine.
The diagnosis of cobalamin malabsorption was supported
by failure of the authors to detect radiolabeled cobalamin
in the serum or urine of the affected dogs after a subse-
quent dietary challenge with a physiological dose (1 µg)
of radiolabeled cobalamin. The dogs responded to 1 mg
of vitamin B12 given intramuscularly once a day for
seven days, then maintained on 1 mg vitamin B12 intra-
muscularly every four or five months. As with human
patients, the methylmalonic aciduria resolved; however,
the proteinuria persisted. A controlled clinical familial
study and breeding experiment demonstrated a simple
autosomal recessive inheritance of the disease in giant
schnauzers.4 Immunoelectron microscopy of the ileum
from affected dogs has shown a deficiency in the cobal-
amin receptors on the brush border.4 Recently, a heredi-
tary cobalamin deficiency has also been described in
border collies.5
Administration of parenteral vitamin B12 resolved the
anemia in the dog described in this report. The diagnosis
of cobalamin deficiency should be considered in young
dogs with chronic, nonregenerative anemias. The diag-
nosis is supported by erythroblastemia, methylmalonic
aciduria, and low serum cobalamin levels. Parenteral
administration of vitamin B12 should be instituted in
suspected cases. Generally this therapy is effective at
resolving clinical signs associated with cobalamin defi-
ciency. Overall prognosis is good, and normal life ex-
pectancy can be achieved with ongoing vitamin B12
therapy.
September/October 1999, Vol. 35 Cobalamin Deficiency in a Border Collie 395

Acknowledgment 23. Watson-Williams EJ, Fleming AF. Isolated malabsorption of vitamin B 12

deficiency causing megaloblastic anemia and hyperpigmentation in a
The authors would like to acknowledge the valuable Nigerian. Blood 1966;28:770–5.
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Screening Laboratory at the University of Pennsylvania 25. Lin SH, Sourial NA, Lu KC, Hsueh EJ. Imerslund-Graesbeck syndrome in
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 Azathioprine Therapy for Acquired
Myasthenia Gravis in Five Dogs
Five dogs with acquired myasthenia gravis (MG), verified via positive serum acetylcholine
(ACh) receptor antibody concentrations, were treated with a drug protocol including
azathioprine (AZA). Four of the five dogs were concurrently treated with pyridostigmine.
Azathioprine was used as the sole immunosuppressive agent in four dogs. One dog was
temporarily treated with a combination of an immunosuppressive dose of prednisone and AZA,
then maintained on AZA as the sole immunosuppressive drug. Three patients experienced
complete remission of clinical signs within three months of therapy. In the four dogs for which
follow-up serum ACh receptor antibody concentrations were available, initial versus final
concentrations decreased substantially (81%), coincident with clinical improvement. One dog
died suddenly due to a suspected myasthenic crisis before attaining the target dose of AZA.
Two of the four surviving dogs were euthanized approximately one and seven years after
diagnosis. One of these two dogs was euthanized because of a rib osteosarcoma, and the
other dog was euthanized because of paraparesis of undetermined cause. The remaining two
dogs were alive and doing well at the time of final follow-up evaluation, approximately six
months and one year after diagnosis. The use of AZA as a therapeutic agent for acquired
canine MG has not been investigated. The cases presented in this report suggest a potentially
important role for AZA in the treatment of acquired MG in dogs.
J Am Anim Hosp Assoc 1999;35:396–402.

C.W. Dewey, DVM, MS, Introduction

Diplomate ACVIM, Diplomate ACVS Acquired myasthenia gravis (MG) is a well-characterized, immune-medi-
J.R. Coates, DVM, MS, ated disease in which autoantibodies are produced against nicotinic ace-
Diplomate ACVIM tylcholine (ACh) receptors of skeletal muscle neuromuscular junctions.
Through a number of proposed mechanisms, the immune response against
J.M. Ducoté, DVM ACh receptors results in failure of neuromuscular transmission. The
resultant impairment of neuromuscular transmission is manifested clini-
J.C. Meeks, DVM,
cally as muscle weakness. Focal, generalized, and acute fulminating
Diplomate ACVIM
forms of the disease have been described in dogs.1–4
J.M. Fradkin, DVM In almost every aspect, acquired canine MG is remarkably similar to
the analogous disease of human beings. A distinguishing feature of canine
MG is the propensity of afflicted dogs to develop megaesophagus, often
O with associated aspiration pneumonia. In contrast to the human esopha-
gus, the canine esophagus contains a large proportion of skeletal versus
smooth muscle, making it susceptible to the immune response against
nicotinic ACh receptors.1–3 The tendency for canine myasthenics to de-
velop megaesophagus and aspiration pneumonia represents an important

From the Department of Small Animal Medicine and Surgery (Dewey, Coates,
Ducoté, Fradkin), College of Veterinary Medicine, Texas A&M University,
College Station, Texas 77843-4474 and Gulf Coast Veterinary Surgery (Meeks),
11 West Loop South, Suite 160, Houston, Texas 77027.

Address all correspondence and reprint requests to Dr. Dewey.

396 JOURNAL of the American Animal Hospital Association

September/October 1999, Vol. 35
difference from human MG patients, as aspiration pneu-
monia is the main reason for death or euthanasia in dogs
with acquired MG.2,5 In a recent report, the one-year
mortality rate for canine myasthenics was found to be
approximately 60%; deaths were attributed to respira-
tory complications.2 By comparison, mortality rates for
human MG patients are typically 5% or less.6
Anticholinesterase agents, such as pyridostigmine, of-
ten provide symptomatic relief in myasthenic humans by
providing additional ACh molecules at neuromuscular
junctions. However, these drugs are often ineffective as
a sole therapy in controlling clinical signs of disease.7,8
Since anticholinesterase drugs have no effect on the
immune response in acquired MG, the efficacy of these
agents in a given patient may reflect the availability of
ACh receptors in that individual. In canine myasthenics,
esophageal muscle appears to be less responsive than
appendicular muscle to anticholinesterase agents. Immu-
nosuppressive agents are commonly and successfully
used in myasthenic humans in combination with anticho-
linesterase therapy. 5–8 Unlike anticholinesterase agents,
immunosuppressive drugs combat the underlying autoim-
mune process of acquired MG. Prednisone and the cyto-
toxic antimetabolite agent, azathioprine (AZA), are the
most widely used immunosuppressive drugs in treating
human MG, either as single agents or in combination.
Although side effects occur with prednisone and AZA
use in humans, they are rarely serious and are usually
outweighed by the benefits that these agents provide in
controlling myasthenic symptoms.6–10
Limited evidence of efficacy exists for prednisone
therapy for acquired MG in dogs.5,11,12 Although AZA
has been suggested as a potential adjunctive therapy for
canine myasthenics,13 there is virtually no information
evaluating the efficacy of AZA as a treatment for ac-
quired canine MG. Commonly encountered undesirable
side effects of prednisone at immunosuppressive doses
include polyuria/polydipsia (PU/PD), polyphagia with
attendant weight gain, and gastrointestinal irrita-
tion.5,10,14–16 Polyphagia and PU/PD are particularly un-
desirable side effects in canine myasthenics, as they may
increase the likelihood of aspiration pneumonia. Immu-
nosuppressive doses of prednisone also may exert a nega-
tive effect on neuromuscular transmission in the early
treatment phase of acquired MG.5,7–10,17 The clinical sig-
nificance of this latter side effect increases in magnitude
with increasing severity of disease.5,7,8,15 Serious side
effects due to AZA are uncommon in dogs and humans;
the side effects that do occur are usually correctable with
dose adjustment or discontinuation of AZA.5,6,10,14,18–21
The purposes of this case series are to report the use
of AZA for the treatment of acquired MG in five dogs
and to discuss the potential role of AZA as a therapeutic
agent in acquired canine MG.
Azathioprine Therapy for Acquired Myasthenia Gravis 397
Materials and Methods
The dogs of this report include one patient whose case
record was evaluated retrospectively and four patients
that were prospectively evaluated. The retrospective case
was included in a previous publication.2 Inclusion crite-
ria consisted of dogs with serologically confirmed (ACh
receptor antibody concentration greater than 0.60
nM/L 22) acquired MG that had received AZA (Imurana)
as the sole immunosuppressive therapy at some point
during their treatment. A minimum database consisting
of complete blood cell count (CBC), serum biochemical
profile, urinalysis, and resting thyroid hormone (T4) level
was performed for each dog. In prospective cases, dogs
with clinical evidence of aspiration pneumonia were
treated accordingly (e.g., antibiotic therapy, supplemen-
tal oxygen) prior to instituting AZA therapy. Each dog
was initially placed on 2.0 mg/kg body weight of AZA
per day, either orally or through a gastrostomy tube. The
AZA dose was tapered to every other day (eod) when
clinical remission of disease and normalization of serum
ACh receptor antibody concentrations were achieved.
Azathioprine dosage was decreased or discontinued if
side effects occurred, depending on the severity of those
side effects. A CBC was evaluated every one to two
weeks for each patient for the first month of AZA therapy,
then at least monthly thereafter. Serum ACh receptor
antibody concentrations were scheduled to be rechecked
every four to six weeks. For each patient, the following
information was recorded: signalment, historical/clinical
findings, clinical form of MG, serial serum ACh receptor
antibody concentrations, concurrent treatment(s), clini-
cal response to therapy, outcome, and side effects attrib-
uted to AZA therapy. Clinical responses to therapy were
evaluated via recheck examinations and telephone con-
versations with owners and referring veterinarians. The
clinical response categories were divided as follows:
clinical remission, improvement, no improvement, wors-
ening, and death. Clinical improvement was judged as an
increase in ambulatory ability for the generalized
myasthenics and a decrease in the frequency of regurgi-
tation for both the generalized myasthenics and the focal
myasthenic dog.
Results
Signalment, Historical/Clinical Findings, Clinical
Form of MG
Data for the five dogs is summarized in the accompany-
ing Table. Information was incomplete from the retro-
spective case, but none of the five dogs were lost to
follow-up. The mean age of the five dogs was 5.4 years
(range, two to eight years). There were two castrated
males and three spayed females. All five dogs had radio-
graphic evidence of megaesophagus. One dog (case no.
398 JOURNAL of the American Animal Hospital Association September/October 1999, Vol. 35

Table
Summary of Signalment, Clinical Form of Myasthenia Gravis (MG), Initial and
Final ACh Receptor Antibody Concentration, Side Effects, and Clinical Response in
Five Myasthenic Dogs Treated With Azathioprine

ACh Receptor
Signalment Clinical Antibody
Case Age Form Concentrations (nM/l) Side Clinical
No. Breed (yrs) Sex* of MG Initial Final Effects Response
1 Boxer 7 MC Generalized 9.05 1.45 Leukopenia Remission
2 Pointer mix† 8 FS Generalized 2.68 0.61 Thrombocytopenia Remission
3 German 5 FS Generalized 2.26 0.23 Leukopenia, Remission
shepherd dog‡ thrombocytopenia
4 Shetland 2 MC Focal 5.90 1.49 None Improved
sheepdog
5 German 5 FS Generalized 0.81 NA§ Vomiting Died
shepherd dog

* MC=male castrated; FS=female spayed

†
Treated temporarily with an immunosuppressive prednisone dose
‡
Retrospective case
§
NA=not available

weeks while on AZA treatment. In case no. 1, there was

a total of five serum ACh receptor concentrations per-
formed over an approximate 10-month period. In each of
these four dogs, a sequential decline in serum ACh re-
ceptor antibody concentration was demonstrated over
time [Figure 1] while receiving AZA therapy. Mean final
serum ACh receptor antibody concentration for these
four dogs was 0.95 nM/L (range, 0.61 to 1.49 nM/L), a
decrease of 81%.

Figure 1—Sequential serum ACh receptor antibody concentra-
tions in four myasthenic dogs receiving azathioprine therapy.
Recheck number is defined as when the serum ACh antibody
concentrations were determined at four- to six-week intervals.
4) exhibited regurgitation and facial muscle weakness,
with no evidence of appendicular muscle weakness; this
dog was considered a focal myasthenic. The remaining
four dogs had evidence of appendicular muscle weak-
ness and were designated as generalized myasthenics.
Mean initial serum ACh receptor antibody concentra-
tions of the four dogs for which a final concentration was
available was 4.97 nM/L (range, 2.26 to 9.05 nM/L;
reference range, less than 0.6 nM/L). For all but one of
the four dogs (case no. 1), a recheck serum ACh receptor
antibody concentration was available every four to six
Concurrent Treatment(s)
Four of the five dogs had received pyridostigmine
(Mestinonb) therapy for variable periods (mean, 3.6
weeks; range, one to 8.5 weeks) prior to adding AZA
therapy. The pyridostigmine therapy overlapped during
the initial AZA therapy; the dose was gradually tapered
in two dogs. Case no. 3 did not receive concurrent
pyridostigmine. One dog (case no. 2) was treated tempo-
rarily (approximately one month) with an immunosup-
pressive dose of prednisone,c concurrently with AZA
therapy. After the first month of therapy, the prednisone
was reduced to an anti-inflammatory dose due to the
development of an apparent cellulitis over the neck,
shoulder, and mandibular areas. The prednisone was
tapered over the ensuing two to three weeks, then dis-
continued. The dog remained on AZA as a sole immuno-
suppressive drug for an additional six to seven weeks.
One dog (case no. 3) was switched to oral prednisone
September/October 1999, Vol. 35
due to persistent mild leukopenia and thrombocytopenia
as well as owner reluctance to pursue the frequent blood
work rechecks necessary with a patient on AZA therapy.
Four dogs (case nos. 1 through 4) were treated concur-
rently with thyroid supplementation because of suspected
hypothyroidism (based on low serum T 4 levels). Two
dogs (case nos. 1 and 4) were fed and medicated through
gastrostomy tubes. Three dogs (case nos. 1, 3, and 4) had
clinical and radiographic evidence of aspiration pneu-
monia; these dogs responded favorably to antibiotics and
supplemental oxygen administration.
Clinical Response to Therapy
Three dogs with generalized MG (case nos. 1, 2, and 3)
experienced remission of clinical signs of disease within
three months of AZA therapy. It was not possible to
ascertain from the retrospective case (case no. 3) exactly
when, during that three-month period, clinical remission
occurred. However, the serum ACh receptor antibody
concentration was normal (0.46 nM/L) after one month
of AZA therapy in this dog. Clinical remission occurred
in case nos. 1 and 2 approximately 3.5 weeks and nine
weeks, respectively, after initiating AZA therapy. Ra-
diographic resolution of megaesophagus was demon-
strated in two of these three dogs. The third dog (case no.
3) was not returned for follow-up thoracic radiographs
due to financial constraints of the owners. The AZA
protocol was changed to eod in case no. 3 after one
month and eventually discontinued at some point two to
six weeks after switching to eod AZA therapy; this dog
was placed on an immunosuppressive prednisone regi-
men at the time of discontinuing the AZA. Based upon a
telephone conversation with the dog’s owner, case no. 3
had achieved remission of clinical signs prior to switch-
ing from AZA to prednisone. The prednisone was ta-
pered to an eod dosage between anti-inflammatory and
immunosuppressive levels (1.4 mg/kg body weight per
day). The dog was maintained on that therapy until she
was euthanized for an unrelated disorder seven years
after initial diagnosis. In one dog (case no. 1), the
pyridostigmine dose was reduced by half, and in another
(case no. 2) it was discontinued. This latter dog was
switched to eod AZA administration after three months
of therapy; approximately three weeks later, AZA was
discontinued and the dog remained in clinical remission.
This dog attained clinical remission while on AZA as the
sole immunosuppressive drug. The dog with focal MG
(case no. 4) had been regurgitating food three to four
times a day initially. Within three months of AZA
therapy, this dog was regurgitating a small amount of
saliva approximately once a week. Radiographic evi-
dence of megaesophagus persisted in the dog with focal
MG six months after initial radiographic evaluation (time
of last follow-up).
Azathioprine Therapy for Acquired Myasthenia Gravis 399
Side Effects Attributed to AZA Therapy
Mild leukopenia (white blood cell [WBC] count, 5.3
x103/µl; reference range, 6.3 to 17 x103/µl) developed in
case nos. 1 and 3 while on AZA therapy. The neutrophil
counts and WBC distributions were normal in both dogs.
The leukopenia resolved without adjusting the AZA dose
in case no. 1, and a follow-up CBC after AZA dose
adjustment was not available for case no. 3. Two dogs
(case nos. 2 and 3) experienced mild thrombocytopenia
(platelet count, 90 x103/µl and 126 x103/µl, respectively;
reference range, 200 to 400 x103/µl) during AZA therapy.
The owners of case no. 2 had inadvertently been admin-
istering twice the daily AZA dose. The platelet count
returned to normal in this dog shortly after correcting the
dosing error. A follow-up CBC was not available for this
dog. One of the generalized MG patients (case no. 5)
experienced recurrent vomiting when placed on a daily
AZA dose of 2.0 mg/kg body weight. The daily dosage
was reduced by half and then gradually increased over
the ensuing several weeks. The vomiting resolved subse-
quent to adjusting the AZA dose schedule.
Outcome
Survival periods from the time of diagnosis of acquired
MG ranged from 1.5 months (the dog that died suddenly)
to seven years, with a mean of 23 months. During the
AZA dose adjustment period for case no. 5, the patient
died suddenly after a brief period of respiratory distress.
No necropsy was performed, and the reason for respira-
tory distress was undetermined. No follow-up serum
ACh receptor antibody concentration was available for
this dog. One dog with generalized MG (case no. 1)
developed a rib osteosarcoma and was euthanized for
that reason approximately one year after the diagnosis of
acquired MG. No necropsy was performed. One dog
(case no. 3) was euthanized for paraparesis of recent
onset approximately seven years after the diagnosis of
acquired MG. A necropsy performed on this patient failed
to discern a reason for the pelvic limb weakness. The
dog’s esophagus appeared grossly normal at necropsy.
The remaining two dogs were alive and doing well at the
time this manuscript was written, approximately six
months and one year after diagnosis.
Discussion
Similar to acquired human MG, anticholinesterase drugs
form the cornerstone of therapy for acquired MG in
dogs. 2,5 Immunosuppressive drugs have greatly improved
the outcome of acquired human MG and are therefore
widely used for treating the disease. Serum ACh receptor
antibody concentrations tend to decrease coincident with
clinical improvement in human myasthenics treated with
immunosuppressive agents. 7,8,10 Numerous immunosup-
400 JOURNAL of the American Animal Hospital Association
pressive drugs have been used to treat acquired MG in
humans, but prednisone and azathioprine remain the stan-
dard agents.6–8,18 In the United States, AZA is generally
considered to be a useful adjunctive therapy for patients
who are either poorly controlled with prednisone alone
or are experiencing unacceptable side effects of immu-
nosuppressive prednisone therapy. In Europe, however,
AZA is often employed as the sole maintenance immu-
nosuppressive drug for acquired human MG.7,9,10,15,18,19,23–26
Azathioprine is a cytotoxic antimetabolite drug; the
biologically active form is 6-mercaptopurine. Azathio-
prine is converted to 6-mercaptopurine in the liver. Once
within the cell, 6-mercaptopurine binds to ribose-
triphosphate and is converted into thioinosinic acid.
Thioinosinic acid is incorporated into nucleotides, inter-
fering with the synthesis of ribonucleic and deoxyribo-
nucleic acid (RNA and DNA). The net result is a decrease
in lymphocyte proliferation, with a subsequent decrease
in immunoglobulin production. Azathioprine is most ef-
fective on rapidly proliferating cells and may be rela-
tively specific for T lymphocytes.5,7,10,14,15,18,20,26–31
Because acquired MG is a T cell-dependent disease,1,7,18
the use of a relatively T cell-specific agent such as AZA
as a sole or adjunctive treatment may be a more logical
choice than using a more globally immunosuppressive
agent like prednisone as the sole immunosuppressive
therapy.
Azathioprine is a particularly attractive immunosup-
pressive agent for the treatment of acquired MG for a
number of reasons. In comparison with prednisone, AZA
has relatively few serious side effects. Both humans and
dogs tend to tolerate AZA therapy very well. Bone mar-
row suppression, with resultant hematological abnor-
malities (e.g., leukopenia, thrombocytopenia), is most
commonly encountered with AZA use, but gastrointesti-
nal irritation and hepatotoxicity are also possible side
effects.5,8–10,14,18–20,23,26,27,31 Side effects of AZA therapy
typically resolve with dose reduction or temporary dis-
continuation of the drug.6,10,15,18,20,23,25,31 It is generally
recommended to discontinue AZA therapy if the WBC
count falls to less than 4,000 cells/µl or the neutrophil
count drops below 1,000 cells/µl.14,29,31
The major disadvantage of AZA therapy in acquired
human MG is the time delay between institution of treat-
ment and appreciation of a clinical response. This time
delay is variable but may be two to eight months or
longer.7,8,10,15,18,20,26,27 Because of the delayed clinical
benefit of AZA in myasthenic humans, concurrent ad-
ministration of an immunosuppressive dose of prednisone
and AZA is sometimes utilized. The clinical response to
prednisone is usually evident within two weeks of therapy
at immunosuppressive levels. After two to four months
of combination therapy, the prednisone is tapered to a
minimum dosage or eliminated. The patient is then main-
September/October 1999, Vol. 35
tained on AZA as a sole immunosuppressive agent.10
There is some evidence that the clinical response of
human myasthenics to AZA may be more rapid than
generally believed, with the majority of patients showing
some benefit within three months of treatment initia-
tion.19 For immune-mediated diseases other than acquired
MG, dogs seem to respond to AZA therapy within sev-
eral weeks, rather than months.31 One study found that
lymphocytes from dogs treated with AZA for only one
week had a significantly diminished in vitro response to
T-cell mitogens.30 The four dogs of this report that sur-
vived acquired MG exhibited both dramatic clinical im-
provement and reduction of serum ACh receptor antibody
concentrations within the initial three months of AZA
treatment. Only one of these four dogs was concurrently
treated with an immunosuppressive regimen of pred-
nisone during the initial period of immunosuppression.
The clinical response of myasthenic dogs to AZA therapy
may be more rapid than that experienced by myasthenic
humans.
Two areas of continuing controversy concerning ac-
quired MG in dogs are the prognosis and appropriate
treatment of the disease. The prognosis for long-term
survival in acquired human MG is excellent. 6,7,10,16,21,23,25
Little information is available concerning survival of
myasthenic dogs, but the prognosis appears to be sub-
stantially worse in comparison with human myasthenics.
The use of immunosuppressive drugs for acquired ca-
nine MG is controversial. The controversy arises from
the susceptibility of dogs to develop aspiration pneumo-
nia. Immunosuppressive therapy may potentially lead to
severe bacterial pneumonia in dogs predisposed to aspi-
ration pneumonia.2,5 However, the persistence of esoph-
ageal, pharyngeal, and/or laryngeal muscle weakness
due to an unattenuated immune response may also place
a canine MG patient at constant risk of developing life-
threatening aspiration pneumonia.5 Thus, there are po-
tential risks associated with both administering and
withholding immunosuppressive therapy in acquired ca-
nine MG patients. In a recent retrospective study, more
than half of the myasthenic dogs died or were euthanized
due to severe aspiration pneumonia within one year of
diagnosis. A statistically significant, positive effect of
immunosuppressive therapy on survival was found in
that study.2 In another retrospective study, 10 of the 25
(40%) dogs for which follow-up information was avail-
able had died or had been euthanized due to pneumonia.32
The improvement in clinical status of the four surviv-
ing dogs in this report cannot definitively be ascribed to
AZA therapy. Since myasthenic dogs can experience
spontaneous clinical remission,5 the possibility exists
that the three dogs that experienced remission and the
one dog that improved would have done so despite
therapy. Considering previous data concerning the clini-
September/October 1999, Vol. 35
cal course of acquired canine MG, it is unlikely that the
four surviving dogs improved due to the natural course
of the disease process rather than due to AZA therapy.
Two dogs of this report also received immunosup-
pressive doses of prednisone. However, one of these
dogs (case no. 3) had attained improvement or resolution
of clinical signs of disease, as well as normalization of
serum ACh receptor antibody concentrations, prior to
switching to prednisone therapy. The other dog (case no.
2) had not achieved clinical remission of disease or
normalization of serum ACh receptor antibody concen-
trations until after immunosuppressive prednisone was
discontinued. Clinical remission and normalization of
serum ACh receptor antibody concentrations occurred in
this dog while receiving AZA as the sole immunosup-
pressive agent. In a recent double-blinded clinical trial
involving human myasthenics, the combination of pred-
nisone and AZA resulted in significantly fewer treatment
failures, fewer side effects of therapy, and longer remis-
sion times when compared to treatment with prednisone
and a placebo.33
The limited number of dogs in this case series prohib-
its formulation of a recommendation concerning AZA
therapy for acquired MG in dogs. However, four of five
dogs appeared to exhibit a positive clinical response to
AZA treatment, with minimal side effects. The dog that
did not survive acquired MG had not reached the target
dose of AZA and apparently died due to a myasthenic
crisis. This patient may not have had the opportunity to
experience a clinical benefit from AZA therapy. The dog
that was euthanized seven years after diagnosis of ac-
quired MG may have experienced a recurrence of the
disease. Acquired MG in dogs often causes pelvic limb
weakness,2 which was the reason the dog was eventually
euthanized. Unfortunately, a serum ACh receptor anti-
body concentration was not rechecked at the time of this
dog’s final hospital admission.
The results of this report support further investigation
of AZA as a therapy for acquired canine MG. A double-
blinded, prospective clinical investigation, comparing
myasthenic dogs treated with pyridostigmine alone to
those treated with pyridostigmine and AZA, would be
the ideal statistical method of ascertaining the efficacy/
inefficacy of AZA therapy for acquired canine MG. How-
ever, the known clinical efficacy of AZA in acquired
human MG and the apparent efficacy suggested by this
case series raises an ethical dilemma when considering
such an investigation. Hopefully, future clinical experi-
ence with AZA as a therapeutic agent for acquired ca-
nine MG will better define its role in the treatment of this
disease.
a Assoc 1984;184(7):845–8.
Imuran; Glaxo Wellcome, Inc., Research Triangle Park, NC
b
Mestinon; Roche Laboratories, Nutley, NJ
c
Prednisone; Schein Pharmaceutical, Florham Park, NJ
Azathioprine Therapy for Acquired Myasthenia Gravis 401
Addendum
Since this manuscript was written, the authors have ob-
tained additional follow-up information from case nos. 2
and 4, as well as clinical data from three additional
myasthenic dogs treated with AZA as a sole immunosup-
pressive agent. Case nos. 2 and 4 are alive and doing well
clinically approximately 25 and 20 months from the time
of the diagnosis, respectively. Both dogs have achieved
serological remission of acquired MG (ACh receptor
antibody concentration, less than 0.6 nM/L) and are cur-
rently not receiving any drug therapy. Case no. 2 contin-
ues to exhibit no clinical signs of acquired MG. Case no.
4 retains radiological evidence of megaesophagus but is
virtually free from signs of clinical disease; this latter
dog continues to be fed through a gastrostomy tube. A
mean follow-up period of nine months is available for
the three additional myasthenic dogs. All three dogs
have improved clinically subsequent to instituting AZA
therapy, and their mean serum ACh receptor antibody
concentrations have decreased (pre-AZA treatment:
mean, 31.46 nM/L; range, 2.90 to 25.3 nM/L; with AZA
treatment: mean, 6.77 nM/L; range, 1.03 to 4.16 nM/L),
coincident with their improvement.
Acknowledgments
The authors wish to thank the following individuals for
their generous contributions to this manuscript: Dr. K.
Fassino, Dr. D. Hertel, Dr. A. Kivney, Dr. G. Kortz, Dr.
R. LeCouteur, Ms. C. Nieuwsma, and Dr. K. Ullmann.
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In: Rolak RA, Harati Y, eds. Neuroimmunology for the clinician. Boston:
response. Vet Immunol Immunopathol 1988;18:119–27.
Butterworth-Heinemann, 1997:263–99.
31. Beale KM. Azathioprine for treatment of immune-mediated diseases of
19. Cosi V, Lombardi M, Erbetta A, Piccolo G. Azathioprine as a single
dogs and cats. J Am Vet Med Assoc 1988;192(9):1316–8.
immunosuppressive drug in the treatment of myasthenia gravis.
Acta Neurol 1993;15:123–31. 32. Bartges JW, Hansen D, Hardy RM. Outcome of 30 cases of acquired
myasthenia gravis in dogs (1982–1992). J Vet Int Med (abs)
20. Matell G. Immunosuppressive drugs: azathioprine in the treatment of
1997;11(2):144.
myasthenia gravis. Ann NY Acad Sci 1987;505:588–94.
33. Palace J, Newsom-Davis J, Lecky B, et al. A randomized double-blind trial
21. Sommer N, Sigg B, Melms A, et al. Ocular myasthenia gravis: response to
of prednisolone alone or with azathioprine in myasthenia gravis.
long term immunosuppressive treatment. J Neurol Neurosurg Psychiatry
Neurol 1998;50:1778–83.
1997;62:156–62.
22. Shelton GD, Cardinet GH, Lindstrom JM. Canine and human myasthenia
gravis autoantibodies recognize similar regions of the acetylcholine
receptor. Neurol 1988;38:1417–23.
W. B. Saunders Company
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page 403
 Cryptosporidiosis, Coccidiosis, and
Total Colonic Mucosal Collapse in an
Immunosuppressed Puppy
An eight-week-old puppy with chronic diarrhea was diagnosed with simultaneous opportunistic
pathogens (i.e., cryptosporidiosis, coccidiosis) and total colonic mucosal collapse. Lack of
lymphoid follicles in the spleen and lymph nodes suggested a primary underlying
immunosuppression that most likely permitted infection with these pathogens. Intensive
antibiotic therapy was most likely responsible for the severe colonic lesion, and bismuth
subsalicylate administration in this severely dehydrated puppy may have contributed to renal
failure as the ultimate cause of death. J Am Anim Hosp Assoc 1999;35:405–9.

Michael D. Willard, DVM, MS, Case Report

Diplomate ACVIM
Donna Bouley, DVM, PhD,
Diplomate ACVP
C vaccine against distemper, adenovirus, parvovirus, and leptospirosis.a
From the Departments of Small Animal
Medicine and Surgery (Willard) and
Pathobiology (Bouley),
College of Veterinary Medicine,
Texas A&M University,
College Station, Texas 77843.
Doctor Bouley’s current address is the
Department of Comparative Medicine,
Stanford University,
Stanford, California 94305-5410.
An eight-week-old, male miniature pinscher was referred to the Texas
A&M University College of Veterinary Medicine (TAMU-CVM) be-
cause of persistent vomiting and diarrhea. The puppy was obtained by the
owners two weeks before admission to the TAMU-CVM. The puppy had
normal stools the first day after he was obtained and brought to the
owners’ home. The next day he was vaccinated with a modified live
Afterward, the puppy became tired and unwilling to play. Later that day,
he developed diarrhea. Twenty-four hours after developing diarrhea (i.e.,
the third day at home), he started vomiting. Initially the diarrhea was
without form or blood, and it occurred at least once daily. Stool varied in
color from brownish green to clear fluid. One week later, red blood was
noted (intermittently) in the stool. Vomiting occurred intermittently and
contained bile, food, and occasionally mucus. Appetite varied but gener-
ally lessened over the two weeks prior to referral to TAMU-CVM. Before
referral, the puppy was treated at the veterinarian’s office for three days
with praziquantel, pyrantel, subcutaneous (SC) fluids (lactated Ringer’s
solution with 5% dextrose), metronidazole, sulfadimethoxine plus
ormethoprim, amoxicillin plus clavulanic acid, metoclopramide,
lactobacillus, b and sucralfate. During this time, the puppy was also force-
fed a commercial soft diet.c A test for parvoviral antigen in the feces was
negative; one coccidian oocyst was found on a fecal flotation examina-
tion; and a barium contrast abdominal series did not reveal any obvious
alimentary tract lesions (e.g., intussusception). Also during this time, a
complete blood count (CBC) and serum biochemistry profile revealed
various abnormalities (i.e., total carbon dioxide [TCO2], 13 mmol/L;
reference range, 17 to 27 mmol/L; aspartate transaminase [AST], 126 U/L;
reference range, 5 to 100 U/L) but did not help determine the cause of the
animal’s gastrointestinal disease. A fecal culture grew a large number of
Proteus vulgaris which were resistant to sulfa drugs but sensitive to
amoxicillin plus clavulanic acid.
On admission to the TAMU-CVM, the puppy was depressed and
emaciated (1.05 lbs). In the examination room, he had repeated bowel
movements consisting of clear fluid that appeared to be mucus. Initial
testing consisted of direct and flotation fecal examination (six oocysts
were seen after using sodium chloride flotation solution and allowing the

JOURNAL of the American Animal Hospital Association 405

406 JOURNAL of the American Animal Hospital Association
Figure 1—Section of duodenum from an eight-week-old puppy
with chronic diarrhea. In this section of duodenum, the villous
epithelium is stippled with intracellular, extracytoplasmic oocysts
of Cryptosporidium parvum (arrows), ranging in diameter from 2
to 5 µ (Hematoxylin and eosin stain, 100X; bar=30 µ).
oocysts to passively float to the surface); enzyme-linked
immunosorbent assay (ELISA) on feces for parvovirusd
(results were negative); and abdominal ultrasound ex-
amination (no evidence of intussusception or other le-
sions was found). A CBC and serum biochemistry profile
revealed anemia (packed cell volume [PCV], 31%; refer-
ence range, 37% to 55%); thrombocytopenia (188 x103
platelets/µl; reference range, 200 to 500 x10 3/µl); mild
neutrophilia (15.81 x103/µl; reference range, 3.0 to 11.5
x103/µl); a moderate number of mildly toxic neutrophils;
hyponatremia (136 mEq/L; reference range, 138 to 148
mEq/L); decreased TCO2 (18 mmol/L; reference range,
21 to 28 mmol/L); and hypoalbuminemia (1.8 gm/dl;
reference range, 2.4 to 3.6 gm/dl). Blood urea nitrogen
(BUN) and serum creatinine concentrations were within
reference ranges. Urine could not be obtained at the time
because the bladder was small on abdominal palpation
and could not be sampled by cystocentesis.
The authors’ assessment was that the puppy had a
protein-losing enteropathy not caused by nematodes or
intussusception. The main differential diagnosis at that
time included other intestinal parasites (e.g., coccidi-
osis), gastrointestinal ulceration/erosion, and bacterial
or viral enteritis. Over the next 48 hours, therapy con-
sisted of multiple (i.e., every one to four hours) volun-
tary or forced feedings of turkey baby foode (90 to 120
kcal per day); oral bismuth subsalicylate (0.5 to 1.5 ml,
bid to tid, orally);f sulfadimethoxine (25 mg initially,
decreasing to 12 mg sid orally);g parenteral B-complex
vitamins (0.1 ml initially, decreasing to 0.05 ml sid SC);h
parenteral cobalamin (100 µg initially, then decreasing
to 50 µg sid SC);i the same lactobacillus preparation
previously dispensed by the referring veterinarian (2 ml
bid orally); and parenterally administered lactated
Ringer’s solution (10 ml bid SC). Approximately 48
hours after admission (i.e., the third day at TAMU-CVM),
the puppy became noticeably depressed. A repeat serum
biochemistry panel at that time revealed severe azotemia
(BUN, 151 mg/dl; reference range, 8 to 29 mg/dl; creati-
September/October 1999, Vol. 35
Figure 2—Section of ileum from the same puppy as in Figure 1,
with various sexual and asexual stages of coccidia within
epithelial cells and the lamina propria (arrows). Note the
accumulation of inflammatory cells, mucus strands, and shed
organisms overlying the mucosal surface (arrowhead) (Hema-
toxylin and eosin stain, 50X; bar=60 µ).
nine, 4.3 mg/dl; reference range, 0.3 to 2.0 mg/dl; phos-
phorous, 14.9 mg/dl; reference range, 2.9 to 6.2 mg/dl);
hyponatremia (111 mEq/L); and hyperkalemia (9.3
mEq/L; reference range, 3.5 to 5.0 mEq/L). Urine could
not be obtained at that time because there was none in the
bladder. There had been no previous indication that renal
disease was likely, and hence an indwelling urinary cath-
eter had not been used. The puppy died, and the owners
requested a postmortem examination. The owners fur-
ther stated that they were told that at least one of the
puppy’s littermates died of gastrointestinal disease, but
they had no other details about this or any of the other
puppies.
A postmortem examination performed within 30 min-
utes of death did not reveal obvious gross abnormalities.
Histopathology detected several lesions. Within the
duodenum, rare villi were mildly blunted and fused, and
scattered, dilated crypts contained inflammatory cells
(crypt abscesses). In several areas of the duodenum there
was a moderate number of small, basophilic, round or-
ganisms within intracellular, extracytoplasmic vacuoles
(i.e., lying just beneath the luminal enterocyte mem-
brane) in the brush border of the villus tips, consistent
with Cryptosporidium parvum (C. parvum) [Figure 1].
Sections of jejunum appeared normal except for rare C.
parvum. The ileum had regional blunting and fusion of
villi; branching, tortuous, and occasionally dilated crypts;
and a moderate number of inflammatory cells composed
of lymphocytes, plasma cells, and neutrophils within the
lamina propria and submucosa. Numerous villi contained
a large number of sexual and asexual stages of coccidia
within epithelial and lamina propria cells, the various
forms ranging from approximately 20 to 50 µm in diam-
eter [Figure 2]. No lymphoid follicles were noted in the
four sections of ileum examined. The colon showed com-
plete collapse of the lamina propria with loss of colonic
glands, scattered regenerating glands, and marked mu-
September/October 1999, Vol. 35
Figure 3—Section of colon from the same puppy as in Figures
1 and 2. Complete collapse of the colonic lamina propria is
accompanied by a mixed inflammatory infiltrate and rare
regenerating glands (Hematoxylin and eosin stain, 50X;
bar=100 µ).
cosal and mild submucosal inflammation consisting of
neutrophils, lymphocytes, and plasma cells [Figure 3].
The spleen was virtually devoid of white pulp, lacking
formed lymphoid splenic nodules, periarteriolar lym-
phatic sheaths, and germinal centers [Figure 4A]. In
addition, sections of anterior mediastinal and mesenteric
lymph node [Figure 4B] were also lacking lymphoid
follicles and germinal centers, and medullary sinuses
contained a low number of histiocytes. Low cellularity
of the thymus was considered consistent with involution.
There were no discernible light microscopic lesions in
the kidney, liver, pancreas, or lungs. Electron micros-
copy of intestinal contents failed to reveal any viral
particles, and fluorescent antibody testsj on tissue samples
of lung were negative for canine distemper virus.
Discussion
Three separate, clinically important lesions (i.e., duode-
nal cryptosporidiosis, ileal coccidiosis, and colonic mu-
cosal collapse) affecting different areas of the intestines,
plus marked lymphoid depletion of spleen and lymph
nodes were found in this eight-week-old miniature pin-
scher. The marked lymphoid depletion of the spleen and
lymph nodes, with negative results for canine distemper
virus and parvovirus, suggests a primary underlying im-
munosuppression. Immunosuppression is consistent with
finding both C. parvum and Isospora spp., which, al-
though capable of infecting animals and producing clini-
cal signs of diarrhea, are often considered opportunistic
pathogens and may be associated with immunodeficiency
states.
Finding three distinct and potentially significant in-
testinal lesions in three different areas of the alimentary
tract is clinically important. If only the jejunum had been
sampled, some causes of this animal’s intestinal disease
would have been underestimated and others undiagnosed.
It is a common practice of many clinicians to only sample
one or two areas of the intestines at surgery, endoscopy,
Systemic Illness in an Immunosuppressed Puppy 407
Figure 4A
Figures 4A, 4B—(A) Section of spleen demonstrating complete
lack of organized white pulp; and (B) section of mesenteric lymph
node demonstrating lack of primary and secondary lymphoid
follicles from the same puppy as in Figures 1, 2, and 3 (Hema-
toxylin and eosin stain, 10X; bar=313 µ).
Figure 4B
or necropsy, ostensibly because of the assumption that
one or two areas of the intestines should be affected with
whatever is affecting the rest of the intestines. Although
clinical signs can often allow localization of intestinal
lesions to the small or large intestine (or both), biopsying
multiple areas of both the small and large intestines is
more reliable and recommended.
Exactly which pathogen(s) or condition(s) was re-
sponsible for the diarrhea and weight loss in this puppy
is unclear. The duodenal cryptosporidiosis in this puppy
may have been sufficient to cause the diarrhea by itself.
While cryptosporidiosis is seldom diagnosed in dogs,
individual case reports have included very young ani-
mals,1–3 an immunosuppressed puppy,4 an adult animal,5
and clinically normal dogs. 6 Canine cryptosporidiosis
appears to be relatively rare in the United States, as seen
by the paucity of case reports and a survey which found
that only four out of 200 stray dogs (which included 30
puppies) in San Bernardino County, California, were
shedding oocysts at the time of examination.6 Another
report from Czechoslovakia found that 21 of 458 dogs
408 JOURNAL of the American Animal Hospital Association
shed C. parvum oocysts in their feces;7 but it is not clear
how many, if any, were showing signs of alimentary
tract disease. Therefore, finding plentiful C. parvum with
associated villus blunting (while there was no such blunt-
ing in the jejunum) suggests that this parasite was clini-
cally significant in this animal. Failing to find C. parvum
oocysts on routine fecal examination is expected; the
oocysts are so small that they are routinely missed unless
one is specifically looking for them. If cryptosporidiosis
is suspected, feces should be submitted to a laboratory
familiar with techniques necessary to demonstrate it.
Coccidiosis can be an important disease in young
puppies,8–12 and this puppy had an intense ileal infection
despite treatment with a potentiated sulfa drug before
coming to TAMU-CVM. Only six oocysts were seen on
an entire fecal flotation examination at TAMU-CVM,
and only one oocyst was seen on a fecal flotation at the
referring veterinarian’s office, which could give the er-
roneous impression that coccidia were only present in
low numbers and therefore clinically unimportant.13 It is
possible that the profuse diarrhea at the time of the fecal
examination diluted the concentration of oocysts or that
there was periodic shedding of the oocysts. Sulfa drugs
are coccidiostatic, not cidal; therefore, such drugs
may be inadequate to cure an infection in an immuno-
compromised patient.
Histopathologically, the colonic lesion was the most
dramatic of the intestinal lesions and probably contrib-
uted significantly to the severity of the diarrhea. The
absence of colonic mucosa implies markedly impaired
absorptive function in this most aborad portion of the
alimentary tract. The authors speculate that this dramatic
colonic mucosal destruction may have been due to over-
growth of a particular species of bacteria (i.e., antibiotic-
associated colitis). Certain drugs can directly cause
colonic disease,14 but none of the drugs administered to
this puppy should have had such an effect. The antibac-
terial drugs (i.e., metronidazole, amoxicillin plus
clavulanic acid, potentiated sulfa drug) used prior to
admission could have allowed proliferation of a particu-
lar bacteria (e.g., Clostridium difficile [C. difficile]), as
has been reported in humans.15–19 Antibiotic-associated
colitis in humans can be extremely severe, even fatal.
Only two other dogs with such dramatic colonic destruc-
tion have been reported, and in both of them bacteria
were speculated to be the underlying cause.20,21 In this
case, analysis for C. difficile toxin and culture for aero-
bic and anaerobic bacteria may have been useful.
Cryptosporidiosis and coccidiosis are common op-
portunistic pathogens found in immunosuppressed hu-
mans infected with human immunodeficiency virus
(HIV).22–25 The authors speculate that an underlying im-
munodeficiency was most likely responsible for simulta-
neous infections with C. parvum and coccidia, plus the
lack of expected numbers of lymphocytes in the spleen
and lymph nodes. While lymphoid depletion may occur
September/October 1999, Vol. 35
secondary to various diseases (e.g., distemper virus,
parvovirus), no evidence for either disease was found in
this puppy. Furthermore, the degree of lymphocyte deple-
tion was marked and near complete, suggesting a
primary problem instead of a secondary one. Immuno-
globulin concentrations were not measured in this ani-
mal, because the authors did not foresee the need for
such analysis, and the blood samples taken antemortem
were, by necessity of the animal’s size, of minimal vol-
ume to avoid worsening the anemia. Therefore, there
was no serum left over after death for such an analysis.
The acute and major increases in BUN, creatinine,
phosphorous, and potassium argue strongly for severe
acute renal failure. The serum creatinine was increased
tenfold over values obtained 48 hours before, despite the
puppy being emaciated and having little muscle to pro-
duce the creatinine (a factor that makes serum creatinine
underestimate the severity of the azotemia in this case).
Unfortunately, the authors were unable to obtain urine at
admission or prior to death; however, the fact that the
puppy was receiving parenteral fluid therapy makes
prerenal azotemia very unlikely as a cause of azotemia of
this severity. Various intestinal diseases can also cause
similar serum electrolyte changes and azotemia;26 how-
ever, there was no evidence of such changes on the first
chemistry panel. Furthermore, the electrolyte changes in
the dogs in that report were resolved when they were
treated with fluids, mineralocorticoids, or both, and the
puppy of this report was receiving fluids at the time this
occurred.
The cause of the acute renal failure is unknown. Bis-
muth subsalicylate was used therapeutically in this puppy
because the authors believed that if bacteria were re-
sponsible for the diarrhea, it would be better to avoid
drugs causing intestinal stasis (e.g., loperamide). Fur-
thermore, bismuth subsalicylate has some antibacterial
properties that might have been beneficial.27 Bismuth
subsalicylate is considered safe in diarrheic children,
and renal failure has not been reported in humans treated
with this drug.27 However, salicylate is absorbed from
the intestinal tract of dogs after ingesting bismuth
subsalicylate,28 and nonsteroidal anti-inflammatory drugs
(NSAID) are recognized as nephrotoxic in humans29 and
dogs.30 Severe intestinal and colonic lesions could have
allowed excessive salicylate absorption. There are at
least three syndromes of renal failure associated with
NSAIDs in humans: renal papillary necrosis seen with
analgesic nephropathy and chronic renal failure; intersti-
tial nephritis plus glomerulonephritis; and acute vaso-
motor renal failure.31 The latter syndrome is usually
oliguric and begins within days of starting therapy with
an NSAID. Hyperkalemia out of proportion relative to
the decrease in renal function is also reported.31 This
puppy might have been oliguric (the authors could not
obtain urine at the time and were unable to discern which
wet spots on the cage diaper were urine and which were
September/October 1999, Vol. 35
watery feces; plus, there had been no previous indication 9.
to monitor urine production with an indwelling catheter), 10.
was markedly hyperkalemic, and had renal failure occur
within 48 hours of beginning therapy with the NSAID. 11.
There were no obvious light microscopic renal lesions
12.
which could explain the acute renal failure seen in the
puppy. Such a lack of light microscopic renal lesions has 13.
been noted in other syndromes of acute vasomotor renal
failure, such as hepatorenal syndrome.32,33 Therefore, it 14.
seems possible that the NSAID was at least partly re-
sponsible for the renal failure seen in this puppy. Al- 15.
though bismuth subsalicylate is an excellent antidiarrheal
16.
drug, caution may be warranted when repeatedly admin-
istering it to small patients with severe intestinal disease 17.
that may allow excessive absorption of the NSAID moiety.
18.
Conclusion
In summary, veterinarians must sample multiple areas of 19.
the intestinal tract in order to find all clinically pertinent
lesions. Finding more than one infectious lesion, particu- 20.
larly C. parvum, in the intestinal tract suggests that either
immunosuppression or excessive environmental expo- 21.
sure to infectious agents may be responsible. Coccidia 22.
cannot be eliminated as an important problem in a diar-
rheic pet simply because only a few oocysts have been
23.
found. Finally, severe colitis may exist even though there
is little or no blood in the stool at the time of examination.
24.
a ficiency syndrome. N Engl J Med 1986;315:87.
Fort Dodge Laboratories, Dallas, TX
b 25.
Bene-Bac Pet Gel; Pet Ag Inc., Hampshire, IL
c ciency syndrome. Gastroenterology 1993;105:1238.
Prescription diet a/d; Hill’s Pet Nutrition, Inc., Topeka, KS
d 26.
Canine Parvovirus Antigen Test Kit; IDEXX, Westbrook, ME
e
Turkey baby food; Gerber Products Co., Fremont, MI
f
Gastro-Cote; Butler Company, Columbus, OH 27.
g 1990;99:863.
Albon; Pfizer Co., New York, NY
h 28.
Vito-jec B-complex; RXVeterinary Products, Porteville, CA
i antidiarrheal preparation in dogs and cats. J Am Anim Hosp Assoc
Vito-jec Vitamin B12; Western Veterinary Supply, Inc., Porteville, CA
j
Texas Veterinary Medical Diagnostic Laboratory, College Station, TX 29.
30.
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 Primary Hyperaldosteronism in Two Cats
A condition of primary hyperaldosteronism resulting from an adrenal tumor in two cats is
presented and was characterized by hypertension, hypokalemia, inappropriate kaliuresis, low
normal plasma renin activity, and markedly increased serum aldosterone concentration. One of
the two cats underwent a laparotomy, and in this case hypertension and hypokalemia resolved
following the removal of an adrenal tumor. J Am Anim Hosp Assoc 1999;35:411–6.

Shannon M. Flood, DVM Case Reports

John F. Randolph, DVM,
Diplomate ACVIM
Anna R.M. Gelzer, Dr. Med. Vet.,
Diplomate ACVIM
Kent Refsal, DVM, PhD
C tion revealed an alert, responsive cat of thin body condition with bilaterally
From the Companion Animal Hospital,
Department of Clinical Sciences
(Flood, Randolph, Gelzer),
College of Veterinary Medicine,
Cornell University,
Ithaca, New York 14853 and the
Endocrinology Section of the Animal Health
Diagnostic Laboratory (Refsal),
Michigan State University,
East Lansing, Michigan 48824.
Doctor Flood’s current address is
Garden State Veterinary Specialists,
Tinton Falls, New Jersey 07753.
Case No. 1
A 20-year-old, 3.1-kg, spayed female domestic shorthair presented to the
Companion Animal Hospital with a two-month history of vision loss and
a three-week history of nocturia and polydipsia. At the time of presenta-
tion, the cat was being medicated weekly with aspirin (81 mg per os [PO])
to alleviate clinical signs attributed to arthritis. Diet consisted of commer-
cial cat fooda that had a sodium level of 0.44% on a dry-matter basis.
Referring serum biochemical analyses were within reference ranges, al-
though electrolyte determinations were not included. Physical examina-
detached retinas and a Grade III/VI systolic murmur with maximal inten-
sity over the mitral valve. Repeated indirectb measurements of systolic
blood pressure were 230 mmHg. Echocardiography revealed mild to
moderate hypertrophic cardiomyopathy with mild left atrial dilatation.
The electrocardiogram (EKG) demonstrated left anterior fascicular bundle
branch block. Serum thyroxine (T4) concentration was 2.6 µg/dl (refer-
ence range, 1.5 to 4.0 µg/dl). The cat was released on diltiazemc (2.4 mg/kg
body weight, PO, q 12 hrs) and aspirin (81 mg, PO, q three days).
On day eight, the cat was unchanged from the previous evaluation,
with the exception of mild bilateral retinal reattachment and a systolic
blood pressure of 158 mmHg. Atenolold (2 mg/kg body weight, PO, q 24
hrs) and furosemidee (0.8 mg/kg body weight, PO, q 12 hrs) were added to
the therapeutic regimen.
On day 43, the cat returned with a complaint of poor appetite for the
preceding 14 days. Physical examination was unchanged. Systolic blood
pressure was 230 mmHg. Serum biochemical analyses revealed mild
hypernatremia (164 mEq/L; reference range, 148 to 161 mEq/L), marked
hypokalemia (2.4 mEq/L; reference range, 3.3 to 5.2 mEq/L), and a mild
increase in blood urea nitrogen ([BUN], 38 mg/dl; reference range, 17 to
35 mg/dl). Furosemide and atenolol treatments were discontinued, but
diltiazem was continued and potassium gluconatef (2 mEq) was added to
food twice daily.
By day 70, the owner had not noted substantial improvement in the
cat’s clinical signs. Fundic examination revealed bilateral retinal hemor-
rhages with partial reattachment of the left retina and complete reattach-
ment of the right. Unfortunately, systolic blood pressure was not evaluated.
Urine specific gravity was 1.015. Serum biochemical analyses revealed
persistence of the hypokalemia (3.0 mEq/L) and mild azotemia (BUN, 36
mg/dl), resolution of the hypernatremia, and a mild increase in both serum
alanine aminotransferase ([ALT], 176 U/L; reference range, 27 to 127 U/L)

JOURNAL of the American Animal Hospital Association 411

412 JOURNAL of the American Animal Hospital Association
and aspartate aminotransferase ([AST], 72 U/L; refer-
ence range, 12 to 48 U/L) concentrations. Urinary frac-
tional excretion of potassium (FE K) was markedly
increased at 53% (reference range for potassium-defi-
cient animals, less than 6%1). Serum aldosterone con-
centration also was markedly increased (2,319 pg/ml;
reference range, 194 to 388 pg/mlg). The cat was contin-
ued on the treatment regimen implemented during the
previous visit.
On day 93, the cat was admitted for anorexia and
weight loss of 0.2 kg. Physical examination revealed
small kidneys and mild hypothermia (36.7˚ C [98˚ F]).
Systolic blood pressure was 165 mmHg. A complete
blood count (CBC) was normal, but serum biochemical
analyses revealed persistence of hypokalemia (2.6
mEq/L), resolution of the azotemia, and mildly increased
transaminase activities (ALT, 142 U/L; AST, 69 U/L).
Baseline serum cortisol concentration (4.95 µg/dl; refer-
ence range, 1.0 to 3.0 µg/dl) was mildly increased, and
serum aldosterone concentration continued to be mark-
edly increased (greater than 3,329 pg/ml). Plasma renin
activity was 0.5 ng/L per sec (reference range, 0.2 to 1.4
ng/L per secg). Abdominal ultrasound demonstrated a 1-
cm hyperechoic mass associated with the left adrenal
gland and bilaterally small kidneys. Fine-needle aspirate
cytology of the left adrenal mass was consistent with an
endocrine or neuroendocrine tumor. A left adrenalec-
tomy was performed successfully and without complica-
tion the day after admission. All antihypertensive therapy
was discontinued the day of surgery. Postoperative
therapy consisted of intravenous (IV) fluid therapy (lac-
tated Ringer’s solution [LRS] with 40 mEq potassium
chloride [KCL]/L at 7.5 ml/hr). The IV fluid therapy was
gradually tapered, and oral potassium supplementation
was reinitiated. The cat was discharged five days follow-
ing surgery with an improved attitude and appetite. On
the day of discharge, systolic blood pressure was 150
mmHg, and serum biochemical analyses documented
normokalemia, mild azotemia (39 mg/dl), and mild in-
crease in serum ALT activity (135 U/L). The owner was
instructed to continue oral potassium supplementation.
The cat was reevaluated on postoperative day 13 and
had continued to improve in attitude, appetite, and activ-
ity level at home. The serum potassium concentration
was normal (4.0 mEq/L), and the BUN was increased at
62 mg/dl. The urinary FEK was still increased at 32%.
Histopathological findings on the adrenal mass revealed
a partially encapsulated, expansile proliferation of epi-
thelial cells which compressed the adrenal medullary
and cortical cells to the periphery. Multifocal areas in
which the cells were mildly pleomorphic were arranged
in tubules surrounding proteinaceous material; a mitotic
rate of up to two mitotic figures per high-power field
(hpf) was noted. An adrenocortical tumor, a probable
carcinoma, was diagnosed. Oral potassium supplementa-
tion was discontinued.
September/October 1999, Vol. 35
By postoperative day 41, the cat continued to do well.
Physical examination revealed a 0.44-kg weight gain,
bilateral retinal detachment and hemorrhage, and persis-
tence of a Grade III/VI systolic murmur. Serum bio-
chemical analyses were normal, with the exception of an
increased BUN (55 mg/dl). Repeat serum thyroxine con-
centration was normal at 2.13 µg/dl. Serum aldosterone
concentration was normal (136 pg/ml). Echocardio-
graphic findings were unchanged from the previous
evaluation. Systolic blood pressure was 140 mmHg. Un-
fortunately, urinary FEK was not repeated. No medica-
tion was prescribed following this visit. The cat did well
for one year postoperatively but died at 22 years of age.
No necropsy was performed.
Case No. 2
A 10-year-old, 7.1-kg, castrated male domestic shorthair
presented to the Companion Animal Hospital with a
four-week history of weight loss, polyuria/polydipsia,
and a pendulous abdomen. Additionally, the cat had
been azotemic and mildly hypokalemic for one year. The
cat was not being medicated at the time of presentation.
Diet consisted of prescription dry and canned high-fiber
foodsh with 0.27% and 0.49% sodium on a dry-matter
basis, respectively. Physical examination revealed an
alert and responsive cat with dry, flaky skin; marked,
diffuse muscle atrophy; multifocal, bullous retinal de-
tachments bilaterally; and a pendulous abdomen. Re-
peated indirect measurements of systolic blood pressure
were 250 mmHg. A CBC showed a stress leukogram,
and serum biochemical analyses revealed marked hy-
pokalemia (2.4 mEq/L; reference range, 3.3 to 5.2 mEq/L);
increased serum bicarbonate (26 mEq/L; reference range,
13 to 24 mEq/L); increased BUN (52 mg/dl; reference
range, 17 to 35 mg/dl); and repeatable hyperglycemia
(350 to 517 mg/dl; reference range, 63 to 140 mg/dl).
Urine obtained by cystocentesis showed a specific grav-
ity of 1.022, a pH of 6.5, moderate glucosuria (greater
than 500 mg/dl), 1+ proteinuria on sulfosalicylic acid
(SSA) determination, and 5 to 20 red blood cells
(RBC)/hpf. Baseline T4 concentration was normal (1.8
µg/dl; reference range, 1.5 to 4.0 µg/dl). Baseline serum
insulin concentration was 14.95 µIU/ml (reference range,
4 to 15 µIU/ml). Urinary FEK was increased at 58.3%. A
0.1-mg/kg dexamethasone suppression test disclosed a
normal baseline serum cortisol concentration (2.42 µg/dl;
reference range, 1.0 to 3.0 µg/dl), and the six- and eight-
hour postdexamethasone serum cortisol concentrations
were suppressed at 0.71 µg/dl and 0.83 µg/dl,
respectively.2 Thoracic and abdominal radiographs dem-
onstrated a rounded cardiac silhouette; small, irregular
kidneys with mineralization of the pelves; and an area of
ill-defined mineralization in the region of the right adre-
nal gland. Abdominal ultrasound detected irregular kid-
neys, with the right kidney being smaller than the left,
and a 3-cm mass in the region of the right adrenal gland.
September/October 1999, Vol. 35
The mass had a complex echogenic appearance and min-
eralization of the capsule. Cytological evaluation of a
fine-needle aspirate of the adrenal mass yielded a certain
diagnosis of endocrine neoplasia. The cat was discharged
with instructions to continue neutral protamine Hagedorn
(NPH) insulini (6 U, subcutaneously [SC], q 12 hrs),
potassium gluconatef (2 mEq) with each meal, and
enalaprilj (0.25 mg/kg, PO, q 12 hrs). Serum aldosterone
concentration and plasma renin activity were pending at
the time of discharge.
By day eight after the initiation of treatment, the cat’s
physical examination was unchanged, and hypokalemia
(3.0 mEq/L) and hyperglycemia (greater than 250 mg/dl
during 24 hrs) persisted. Systolic blood pressure was 200
mmHg. The serum aldosterone concentration from the
previous visit was markedly increased (3,329 pmol/L;
reference range, 194 to 388 pg/ml), whereas the plasma
renin activity was 0.2 ng/L per sec (reference range, 0.2
to 1.4 ng/L per sec). At this time, the owner chose to treat
the cat medically. The cat was released on potassium
gluconate (4 mEq) with each feeding and spirono-
lactonek (2.5 mg/kg body weight, PO, q 12 hrs). Enalapril
was discontinued. Instructions were given to gradually
increase the insulin dose based on serial blood glucose
profiles.
Three months after the initial presentation, the cat re-
presented for surgical removal of the right adrenal mass.
Physical examination revealed a slightly depressed but
responsive cat with an unkempt hair coat; diffuse, severe
muscle atrophy; detectable thyroid nodules; systolic car-
diac murmur; and small kidneys. Systolic blood pressure
was 190 mmHg. A CBC showed a stress leukogram, and
serum biochemical analyses disclosed normokalemia (4.1
mEq/L), continued increase in the serum bicarbonate
concentration (28 mEq/L), and increased BUN (46 mg/dl).
The blood glucose concentration remained greater than
250 mg/dl throughout the day, despite a current NPH
insulin dose of 9 U, SC, q 12 hrs. Echocardiography
detected left ventricular hypertrophy. Electrocardiog-
raphy revealed a left anterior fascicular bundle branch
block. Abdominal ultrasound demonstrated a 1.7-cm in-
crease in the length of the right adrenal mass with inva-
sion of the caudal vena cava. A large thrombus also was
noted within the lumen of the caudal vena cava, extend-
ing from the caudal border of the liver to the cranial pole
of the right adrenal gland and occluding 30% to 50% of
the lumen of the caudal vena cava. Due to the invasion of
the caudal vena cava by the adrenal mass, the cat was
determined to be a poor surgical candidate and further
evaluation was not performed. The cat was continued on
the treatment regimen implemented at the last visit, with
the addition of aspirin (81 mg, PO, q 3 days) and
amlodipine l (0.18 mg/kg body weight, PO, q 24 hrs). The
owner was instructed to have the cat’s serum electrolyte
concentrations and systolic blood pressure reevaluated
frequently. The serum potassium concentration remained
Hyperaldosteronism 413
within normal limits on the prescribed treatment regi-
men; however, the cat remained mildly hypertensive
despite spironolactone and amlodipine therapy. The in-
sulin dose was gradually increased to 12 U, SC, q 12 hrs.
Seven months after being diagnosed with an aldoster-
one-secreting adrenal tumor, the cat was euthanized fol-
lowing a thromboembolic episode. A necropsy was not
performed.
Endocrinological Studies
Serum thyroxine and aldosterone concentrations were
quantified by use of validated radioimmunoassay tech-
niques.3,4 For T4 measurements in cats, serial dilutions of
three samples of sera generated inhibition curves that
were parallel with the standard curve.m Serum cortisol
concentration was quantified by use of the Immuliten
chemiluminescent immunoassay system validated for use
in cats.5 Plasma renin activity was determined with an
assay method essentially the same as previously
described.6
Discussion
The two cats of this report were diagnosed with primary
hyperaldosteronism on the basis of markedly increased
serum aldosterone concentrations in conjunction with
hypertension, hypokalemia, inappropriate kaliuresis, ab-
sence of increase in plasma renin activity, ultrasono-
graphic confirmation of an adrenal mass, and cytological
and/or histopathological diagnosis of adrenal cortical
neoplasia. To the authors’ knowledge, there is only one
previously reported cat with an adrenal cortical tumor
causing hyperaldosteronism. 7 The cat of that report dem-
onstrated many of the clinical and laboratory abnormali-
ties described herein.
Aldosterone is the principal mineralocorticoid pro-
duced and secreted by the cells of the zona glomerulosa
of the adrenal cortex. Secretion of aldosterone is mainly
controlled by the serum potassium concentration and
stimulation by the renin-angiotensin system. An increase
in either the serum potassium concentration or the renin
concentration will cause an increased release of aldoster-
one by the adrenal cortex. In contrast, increased adreno-
corticotropic hormone (ACTH) concentration and low
serum sodium concentration have minimal stimulatory
effects on aldosterone secretion.8 The primary function
of aldosterone is sodium and potassium regulation and
maintenance of normal intravascular fluid volume. Al-
dosterone conserves sodium while promoting potassium
excretion. With sodium conservation, there is concurrent
water conservation, thereby increasing the intravascular
fluid volume. Aldosterone exerts its effects by binding to
mineralocorticoid receptors of the distal convoluted tu-
bules and collecting ducts of the kidney, resulting in
increased production of Na+/K + ATPase, an increased
number of sodium pumps within the nephron, and facili-
tated potassium excretion at the luminal membrane.9
414 JOURNAL of the American Animal Hospital Association
Aldosterone also promotes the excretion of magnesium,
hydrogen, and ammonia.9 Interestingly, case no. 2 ex-
hibited persistent increase in serum bicarbonate concen-
tration, possibly reflecting aldosterone-facilitated renal
excretion of hydrogen ions.
Excess production of aldosterone may develop from
primary or secondary causes. Primary hyperaldoster-
onism results from either an adrenal tumor or adrenal
hyperplasia affecting the mineralocorticoid-producing
zona glomerulosa of the adrenal cortex. Secondary hy-
peraldosteronism, on the other hand, develops in re-
sponse to activation of the renin-angiotensin system by
conditions such as heart failure or kidney failure.
Primary hyperaldosteronism in humans is character-
ized by aldosterone excess, renin suppression, spontane-
ous or readily inducible hypokalemia, inappropriate
kaliuresis, and hypertension. 10–12 However, 12.5% of hu-
mans diagnosed with primary hyperaldosteronism have
normal renin determinations.13 The cats of this report
had dramatically increased aldosterone concentrations,
with endogenous renin activities at the low end of the
reference range. Similarly, the previously reported cat
with primary hyperaldosteronism also had a normal re-
nin determination.7 Dietary intake of sodium has tradi-
tionally been thought to affect plasma renin activity and
aldosterone concentration. However, recent work ques-
tions whether dietary sodium content has a major
influence on plasma renin activity or aldosterone con-
centration in hypertensive cats.6 Nevertheless, diets con-
sumed by the two cats of this report were comparable in
sodium content on a dry-matter basis to diets fed control
cats in establishing published reference ranges for plasma
renin activity (0.3 to 0.9 ng/L per sec)6 and aldosterone
concentration (upper value as defined by 95th percentile
was 252 pg/ml).3
In humans, primary hyperaldosteronism is commonly
associated with moderate to severe hypokalemia caused
by a profound kaliuresis.9–12,14,15 Similarly, the cats of
this report had severe hypokalemia and urinary FEK
exceeding 50% (reference range for potassium-deficient
animals, less than 6%1). Recent work questions the reli-
ability of using random urine samples for “spot”
determination of FEK as compared to 72-hour FEK deter-
minations in normokalemic cats.16 Nevertheless, “spot”
urinary FEK values (mean±2SD [standard deviation]) in
those normal cats never exceeded 50%.16 Other potential
reasons for hypokalemia caused by increased urinary
loss of potassium are diet-induced hypokalemic nephrop-
athy; renal tubular acidosis; postobstructive diuresis;
mineralocorticoid excess associated with hyperadreno-
corticism; drugs such as loop and thiazide diuretics; and
chronic renal disease. 1,17 With the exception of chronic
renal disease, these conditions seemed unlikely in the
cats of this report. Their diets were not low in potassium;
laboratory data failed to document metabolic acidosis;
and historical features of urethral obstruction were not
September/October 1999, Vol. 35
present. Case no. 1 did receive furosemide, but the drug
was discontinued four weeks before demonstration of
increased FEK and persistent hypokalemia. Hyperadreno-
corticism (Cushing’s syndrome) due to an adrenal tumor
was ruled out in case no. 2 based on suppression of
cortisol concentrations following dexamethasone (0.1
mg/kg) administration. Glucocorticoid-secreting capa-
bility of the adrenal tumor in case no. 1 was not evalu-
ated; however, this cat had neither clinical signs nor
laboratory abnormalities commonly encountered in cats
with Cushing’s syndrome.18
Chronic renal disease is the most commonly diag-
nosed cause of spontaneous hypokalemia in the cat19 and
could have contributed to the hypokalemia in the cats of
this report. Both cats had ultrasonographically-confirmed
small kidneys and recurrent azotemia. It is unknown if
these cats had concurrent primary renal disease or renal
disease secondary to the persistent hypertension and hy-
pokalemia. Although the blood pressure, serum aldoster-
one, and serum potassium normalized in case no. 1
following adrenalectomy, the FEK remained increased
and the azotemia worsened. The persistent increase in
FEK in this cat may suggest underlying renal disease
with potassium wasting or may reflect variability in the
“spot” determination of FEK. 16 The increase in BUN
might result from a return to normal intravascular fluid
volume once serum aldosterone declined in a cat with
underlying renal disease. Theoretically, the low-normal
plasma renin activities in both cats would argue against
stimulation of the renin-angiotensin system as the main
reason for hyperaldosteronism. However, in some cats
with chronic renal failure, kidney renin synthesis may be
decreased.20 In fact, recent work suggests that cats with
hypertension associated with chronic renal disease have
increased aldosterone concentrations despite variable ac-
tivation of the renin-angiotensin system.6 Nevertheless,
the aldosterone concentrations in those cats were mod-
estly increased (highest value was 518 pg/ml),6 in
contrast to the profoundly increased aldosterone concen-
trations (greater than 3,000 pg/ml) in the cats of this
report.
In humans, primary hyperaldosteronism is associated
with moderate to severe hypertension.11,12,15 Similarly,
the cats of this report had hypertension; hypertension
was defined as a systolic blood pressure that repeatedly
exceeded 180 mmHg, taken by indirect means in an
awake, untrained cat.21 Minimal manual restraint was
used, and measurements were repeated over a five- to
10-minute period until three consecutive readings had
less than 10 mmHg variation. Determinations of blood
pressure were repeated over hours in most instances; but,
for some of the recheck examinations, repeated indirect
blood pressure measurements were, by necessity, per-
formed over a shorter time frame. Hyperaldosteronism
causes hypertension by increasing the intravascular fluid
volume as a result of sodium and water conservation.
September/October 1999, Vol. 35
However, after several days of mineralocorticoid excess
in humans, a pressure diuresis develops in an effort to
reduce the expanded intravascular fluid volume.8 Never-
theless, these humans remain hypertensive.8 The persis-
tent hypertension is thought to be caused in part by an
increase in vascular smooth-muscle sodium concentra-
tion which causes vasoconstriction and increased periph-
eral vascular resistance. 22 Attempts to lower systemic
blood pressure in case no. 1 with a calcium channel
blocker and in case no. 2 with angiotensin-converting
enzyme inhibitor were only moderately successful,
whereas treatment with spironolactone yielded more suc-
cess in lowering systolic blood pressure of case no. 2.
Other causes of feline hypertension are hyperthyroidism,
hyperadrenocorticism, pheochromocytoma, chronic in-
terstitial nephritis, pyelonephritis, glomerulonephritis,
renovascular disorders, anemia, and essential/idiopathic
hypertension. 21 The authors cannot discount that renal
dysfunction may have contributed to the hypertension in
the cats of this study.
Glucose intolerance is noted in 25% to 50% of
humans with hyperaldosteronism and is attributed to
decreased insulin production secondary to profound
and persistent hypokalemia. 11,12,15 Although case no.
2 had a baseline insulin concentration within the nor-
mal range, it was inappropriately low for the marked
hyperglycemia. To what degree the hypokalemia con-
tributed to decreased insulin secretion in that cat is
not known; however, despite resolution of the hy-
pokalemia, diabetes mellitus persisted, suggesting
unrelated beta cell pathology. The sustained hyper-
glycemia despite insulin doses greater than 3 U/kg
per day in this cat supports insulin resistance possibly
associated with the neoplastic process.
Although both cats were hypokalemic at the time of
presentation, none exhibited electrocardiographic abnor-
malities commonly associated with hypokalemia. Both
cats did have evidence of left ventricular hypertrophy
that probably developed secondary to persistent systemic
hypertension. Increased serum ALT and AST activities
in case no. 1 are most likely a result of rhabdomyolysis
and muscle cell membrane damage secondary to persis-
tent hypokalemia,23 although concurrent hepatic disease
is possible.
Human patients diagnosed with primary hyperaldos-
teronism report nonspecific clinical signs such as noc-
turia, polyuria/polydipsia, dizziness, headaches, muscle
weakness, and/or visual impairment.11,12,15,22,24 These
clinical symptoms may wax and wane with variation in
the degree of hypokalemia and hypertension.12 Of the
cats described herein, none exhibited substantial muscle
weakness despite moderate to severe hypokalemia. Chief
complaints included nocturia, polyuria/polydipsia, and
visual impairment.
Adrenal imaging is helpful in the diagnosis of pri-
mary hyperaldosteronism. Approximately 66% of
Hyperaldosteronism 415
humans with this condition have an aldosterone-produc-
ing adrenal cortical adenoma, whereas the remaining
33% are diagnosed with idiopathic adrenocortical hyper-
plasia.10–12,22 Adrenocortical carcinomas rarely cause
hyperaldosteronism in humans.22 The two cats of this
study and the previously reported cat7 all were diagnosed
with adrenal tumors. Although there is one dog reported
with hyperaldosteronism from idiopathic adrenocortical
hyperplasia,25 this form of aldosterone excess has not yet
been reported in cats. Computed tomography is the adre-
nal imaging modality of choice in human medicine;10,11,13,15
however, the authors found abdominal ultrasound to be
diagnostic in both cats of this report.
Adrenalectomy is the preferred treatment in humans
with an aldosterone-producing adrenocortical tumor,11,15
as it permanently cures the hypokalemia in all
cases.10,12,13,15,26 Hypertension is resolved in 70% of the
humans in the immediate postoperative period and con-
tinues to be resolved in greater than 50% of the remain-
ing humans five years postoperatively. 10,12 The patients
that remained hypertensive following adrenalectomy
were generally older at the time of surgery 24 and had
been hypertensive for a longer duration prior to sur-
gery.24,26 Case no. 1 was normotensive and normokalemic
postoperatively. However, the recurrence of retinal
detachments and hemorrhage noted at case no. 1’s last
visit, despite a normal blood pressure, might suggest
intermittent hypertension as a sequela of the primary
hyperaldosteronism or a consequence of renal dysfunc-
tion. Mineralocorticoid supplementation is rarely
necessary postoperatively in humans10,15 and was not
administered to case no. 1.
In humans with primary hyperaldosteronism, medical
management is recommended for four to six weeks pre-
operatively and is palliative for those patients who are
not surgical candidates.10,11,15,22 Medical management
primarily consists of sodium restriction, oral potassium
supplementation, and spironolactone therapy. 9,11,15
Spironolactone is an aldosterone antagonist which binds
the cytoplasmic receptor proteins in aldosterone-respon-
sive cells of the distal convoluted tubules and collecting
ducts, resulting in potassium sparing and sodium excre-
tion.27 The recommended dose of spironolactone for the
cat is 2 to 4 mg/kg body weight per day.9 The recom-
mended dose of oral potassium supplementation for the
cat is 2 to 6 mEq potassium gluconate daily.9 Serial
electrolyte monitoring is recommended following the
induction of therapy. The human literature discourages
the use of oral potassium supplementation in conjunc-
tion with spironolactone treatment, due to the risk of
hyperkalemia.11 Case no. 2 was treated for several months
with both spironolactone therapy and oral potassium
supplementation without the development of hyperkale-
mia. Amiloride and triamterene can be used in place of
or in addition to spironolactone treatment.9 These drugs
block the sodium channels of the distal convoluted tu-
416 JOURNAL of the American Animal Hospital Association September/October 1999, Vol. 35

bules, thereby decreasing sodium availability for the
Na+/K+ pumps and decreasing kaliuresis.27 If the patient
remains hypertensive following spironolactone therapy,
additional antihypertensive therapy may be
attempted.9,11,15,28 Calcium channel blockers are being
used more frequently in human medicine because of
their propensity to decrease aldosterone biosynthe-
sis.11,15,22,28
Conclusion
Hyperaldosteronism is a rare condition in both humans
and cats, in which excessive endogenous secretion of
aldosterone causes systemic hypertension, hypokalemia,
pathological kaliuresis, and variable renin suppression.
Both the hypertension and hypokalemia may be
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m
Endocrinology Section, New York State Diagnostic Laboratory, College of 646–50.
Veterinary Medicine, Cornell University, Ithaca, NY 25. Breitschwerdt EB, Meuten DJ, Greenfield CL, Anson LW, Cook CS,
n
DPC; Diagnostic Products Corporation, Los Angeles, CA Fulghum RE. Idiopathic hyperaldosteronism in a dog. J Am Vet Med Assoc
1985;187:841–5.
26. Lo CY, Tam PC, Kung AW, Lam KS, Wong J. Primary aldosteronism:
Acknowledgment results of surgical treatment. Annals Surg 1996;224:125–30.
The authors would like to thank Dr. Cathy Moore, Turco 27. Fox PR. Current uses and hazards of diuretic therapy. In: Kirk RW,
Bonagura J, eds. Current veterinary therapy XI. Philadelphia: WB
Animal Hospital, Westerly, Rhode Island, for her invalu- Saunders, 1992:668–76.
able assistance with the management of case no. 2. 28. Steigerwalt SP. Unraveling the causes of hypertension and hypokalemia.
Hosp Prac 1995;30:67–79.

References
1. De Morias HS. Disorders of potassium: hypokalemia and hyperkalemia. In:
DiBartola SP, ed. Fluid therapy in small animal practice. Philadelphia: WB
Saunders, 1992:89–115.
2. Feldman EC, Nelson RW. Canine and feline endocrinology and
reproduction. 2nd ed. Philadelphia: WB Saunders, 1996:256–65.
3. Yu S, Morris JG. Plasma aldosterone concentration of cats. Vet J
1998;155:63–8.
4. Hickey G, Jacks T, Judith F, et al. Efficacy and specificity of L-692, 429, a
novel nonpeptidyl growth hormone secretagogue, in beagles. Endocrinol
1994;134:695–701.
5. Reimers TJ, Salerno VJ, Lamb SV. Validation and application of solid-
phase chemiluminescent immunoassays for diagnosis of endocrine diseases
in animals. Comp Haematol Int 1996;6:170–5.
 Streptococcal Meningoencephalitis
in a Dog
A 5.5-year-old French bulldog was presented with acute neck pain and a short history of central
vestibular syndrome. A marked neutrophilic pleocytosis and numerous gram-positive cocci
were evident on cerebrospinal fluid (CSF) cytology. Streptococcus pneumoniae, a pathogen of
humans, was isolated upon CSF microbiological culture. Treatment consisted of intravenous
antibiotics, supportive care, and anticonvulsants for the generalized seizures which developed
shortly after admission. The dog responded to therapy and two years later exhibited only a
mild, residual head tilt. The pathogenesis and treatment of bacterial meningoencephalitis in
dogs are reviewed. J Am Anim Hosp Assoc 1999;35:417–22.

Peter J. Irwin, BVetMed, Case Report

PhD, FACVSc A 5.5-year-old, 10-kg, male French bulldog was referred to the Melbourne
Bruce W. Parry, BVSc, PhD, University Veterinary Clinic and Hospital with an eight-day history of
Diplomate ACVP progressive neurological signs. The owners had originally noticed a right-
sided head tilt and ataxia, and a vertical nystagmus was observed by the
referring veterinarian. Treatment had consisted of tranexamic acid,a but
when the dog’s condition deteriorated, dexamethasone (30 mg) was given
on three occasions at 12-hour intervals. A hemogram taken by the veteri-
C narian revealed a mild leukocytosis (18.5 x109/L; reference range, 6.0 to
17 x109/L) with a mature neutrophilia (16.3 x109/L; reference range, 3.0
to 11 x109/L). The dog had become progressively more lethargic,
inappetent, and began vocalizing when handled.
Physical examination was within normal limits. Rectal temperature
was 37˚ C. Small amounts of wax were observed bilaterally in the hori-
zontal ear canals, but the tympanic membranes appeared to be normal.
The dog was depressed, reluctant to move, and stood with his neck held in
a stiff and extended position. On neurological assessment, cranial nerve
(CN) examination revealed anisocoria (i.e., left pupil smaller than the
right) and slow, consensual and direct pupillary light reflexes in both
eyes. No strabismus was noted, and the nystagmus and head tilt reported
by the first veterinarian were no longer present. A mild, bilateral papille-
dema was observed on fundic examination. The dog resented any stimula-
tion of the face, suggesting a facial or neck hyperesthesia; but there was
no facial or masticatory muscle paresis. The dog resisted any manipula-
tion of the head, neck, and limbs. This cervical rigidity and hyperesthesia
precluded a thorough neurological examination, but the patient exhibited
both conscious (i.e., knuckling) and unconscious (i.e., ataxia) propriocep-
tive deficits in all four limbs when encouraged to ambulate.
On the basis of these findings, the patient was considered to have
diffuse or multifocal brain disease, predominantly involving the brain
stem. Involvement of the oculomotor (CN III) and trigeminal (CN V)
nerves was apparent, and the history of head tilt and nystagmus suggested
earlier disturbance of the vestibular system. Brain stem lesions involving
From the Department of the midbrain through medulla may lead to dysfunction of cranial nerves
Veterinary Clinic and Hospital,
University of Melbourne,
III to XII, and the depression was consistent with inhibition of the reticu-
250 Princes Highway, lar-activating system, anatomically located from the diencephalon through
Werribee, Victoria, 3030, Australia. the myelencephalon. The differential diagnoses for these multifocal signs

JOURNAL of the American Animal Hospital Association 417

418 JOURNAL of the American Animal Hospital Association
Figure 1—Direct smears made from the cerebrospinal fluid on
day one in a dog with streptococcal meningoencephalitis. Note
moderately karyolytic neutrophils and cocci (Wright’s stain,
1,000X; bar=10 µm).
of neck pain and neurological dysfunction included vari-
ous infectious meningoencephalitides (i.e., bacterial,
mycotic, viral, rickettsial, and parasitic), granulomatous
meningoencephalitis (GME), other noninfectious me-
ningoencephalitides, and multifocal neoplasia. Other
causes of neck pain (e.g., cervical disk disease, cervical
fracture or instability, discospondylitis, and vertebral
neoplasia) were considered less likely due to the appar-
ent brain stem involvement.
The dog was anesthetized using thiopentone sodium
and halothane. No abnormalities were detected on plain
lateral and ventrodorsal radiographs of the neck. A cere-
brospinal fluid (CSF) sample from the cerebellomedul-
lary cistern was turbid and pale cream in color. A large
number of neutrophils and bacterial cocci were observed
in direct smears, fixed, and stained with a Wright’s stain
[Figure 1]. Full laboratory facilities were not immedi-
ately available, so the sample was aliquotted; half was
preserved in ethanol,1 and half was refrigerated at 4˚ C
without preservative until examination could be com-
pleted the next day. Blood cultures were not performed.
The dog made an uneventful postanesthetic recovery,
and the neurological status remained unchanged. Intra-
venous (IV) fluid therapy was commenced using lactated
Ringer’s solution,b and cefoxitinc was given IV (40 mg/kg
body weight, qid). Meperidined (4 mg/kg body weight,
intramuscularly [IM]) or buprenorphinee (10 µg/kg body
weight, IV) were given as required for pain control.
Cytological evaluation of the CSF confirmed a marked
neutrophilic pleocytosis together with many gram-posi-
tive cocci, usually located in pairs or in short chains
[Figure 2]. Encapsulated yeast cells were not observed in
a nigrosin wet preparation of the CSF. The CSF was
characterized by hypoglycorrhachia (i.e., abnormally low
sugar content in the CSF), increased protein, and a posi-
tive Pándy’s test [Table 1]. An electrophoretic analysis
was not performed. Microbiological culture of the CSF
on blood agar plates produced a heavy, pure growth of
Streptococcus spp. that was sensitive to penicillin, tetra-
September/October 1999, Vol. 35
Figure 2—Cerebrospinal fluid on day one from the dog in Figure
1, showing Streptococcus pneumoniae organisms (Gram stain,
1,000X; bar=10 µm).
cycline, erythromycin, sulphafurazole, and trimethoprim.
The isolate was confirmed to be Streptococcus pneu-
moniae (S. pneumoniae) by Optochin sensitivity2 and
was identified as serotype 4 by exposure to type-specific
antisera in the Neufeld quellung reaction.3 A diagnosis
of streptococcal meningoencephalitis was made. Cul-
tures of swabs taken from the pharynx and tonsillar crypts
grew a Mycoplasma spp. and an anaerobic gram-positive
rod after 72 hours, but streptococci were not isolated.
Twenty-four hours after admission, the dog devel-
oped generalized seizures. Diazepam (1 mg/kg body
weight, IV, repeated three times) was not effective, so
the treatment was changed to pentobarbitalf (5 to 15 mg/kg
body weight, IV, to effect). Once anesthetized, the dog
was intubated and an intensive care nursing protocol was
followed (airway suction and humidification; applica-
tion of ocular lubricating ointment;g frequent turning;
and a closed urine collection system). The antibiotic was
changed to amoxicillin (50 mg/kg body weight, IV, qid),
and fluid therapy was continued but was modified to
saline (0.45%) with potassium supplementation (17.8
mmol/L) to provide a more physiologically appropriate
solution for maintenance. Anesthesia was maintained
with phenobarbital sodiumh (2 to 4 mg/kg body weight,
IV, to effect) for 24 hours.
A second CSF sample collected (on day three) was
clear with slight xanthochromia. Analysis revealed a
lower white blood cell (WBC) count than the previous
sample and an increased protein concentration [Table 1].
No bacteria were observed or cultured. The dog still
demonstrated intermittent seizures, but there was no ap-
parent cervical rigidity or pain. Due to the ongoing sei-
zure activity, anesthesia was reinstated for a further 24
hours. On day four, the dog recovered normally from
anesthesia, showed an interest in food, and had a consid-
erably improved demeanor. A neurological examination
demonstrated a right-sided head tilt and marked ataxia.
The pupils were of normal size and responsiveness, and
the facial hyperesthesia and neck pain had resolved. The
IV medication was stopped, and amoxicillini (8 mg/kg
body weight, qid) and phenobarbitalj (4.5 mg/kg body
September/October 1999, Vol. 35 Streptococcal Meningoencephalitis 419

Table 1
Results of Cerebrospinal Fluid (CSF) Analysis on Days Zero, Three, and Five Postadmission
in a Dog With Streptococcal Meningoencephalitis

Parameter Day 0 Day 3 Day 5 Reference Range

Red blood cell count (/µL) 433 5,029 1,629 None
Nucleated cell count (/µL) 62,741 1,916 339 <10
Total protein (g/L) 1.27 6.40 1.13 <0.40
Glucose (mmol/L) 0.60* 4.3 4.0 60%-80% of
blood value
Creatinine kinase (units/L) 1 35 0 <10
Pándy’s test Positive-mild Positive-marked Positive-moderate Negative (-)
(+) (+++) (++) or trace
Microbiological culture Heavy, pure No organisms seen No organisms seen Negative
growth of Negative culture Negative culture culture
Streptococcus
pneumoniae
Cytology >95% neutrophils 64% neutrophils 4% neutrophils Occasional
<5% macrophages 2% lymphocytes 24% lymphocytes “monocytic”
Phagocytosed cocci 34% large 58% large cells
“monocytic” cells “monocytic” cells

* Blood glucose at the time of CSF collection=6.1 mmol/L

weight, bid) were started by oral administration (PO).
No more seizures were observed, and the dog’s vestibu-
lar disturbance improved. Another CSF sample (day five)
indicated further improvement in cytological and bio-
chemical parameters [Table 1].
The dog was discharged six days after admission with
a right-sided head tilt and mild ataxia, but was otherwise
responsive and alert. Amoxicillin was continued for a
further two weeks, and trimethoprim-sulphadiazinek (15
mg/kg body weight, bid) was added for four weeks. The
dog remains on anticonvulsant therapy indefinitely, and
serum phenobarbitone levels are periodically evaluated.
Two years after admission, the dog has not had any
further seizures and is normal except for a mild, residual,
right-sided head tilt.
Discussion
Central nervous system (CNS) infections as a cause of
meningitis and meningoencephalitis in dogs are rarely
reported. It has been suggested that meningoencephalitis
of noninfectious origin is the predominant form of CNS
inflammatory disease encountered in small animal prac-
tice,4 and this is certainly reflected by the admissions to
the authors’ hospital where a steroid-responsive, aseptic,
suppurative meningitis-arteritis, and the multifocal form
of GME predominate (unpublished observations). A
number of noninfectious inflammatory disorders of the
CNS have been reported in certain breeds including pugs,
Maltese, and Yorkshire terriers.5–7 The etiopathogenesis
of these disorders is unclear.
There are a few reports of bacterial meningitis and
meningoencephalitis in dogs [Table 2]. Staphylococcus
spp., Escherichia coli, and various anerobes are usually
implicated.8–14 Despite its importance as a human patho-
gen, there are no reports of S. pneumoniae (pneumococ-
cus) isolated from the CNS of dogs. In contrast, this
organism is a frequent cause of bacterial infection of the
CNS in children,15 and 80% to 90% of bacterial meningi-
tis cases in adult humans are caused by Haemophilus
influenzae (H. influenzae), Neisseria meningitides, or S.
pneumoniae.
In general, brain tissue is relatively resistant to infec-
tion, and it is difficult for organisms to gain access to the
CNS in the presence of an intact blood-brain barrier or
dura mater.16 However, it is generally assumed that bac-
terial invasion may occur in one of three ways: from
direct access, by local spread, or by the hematogenous
route. Bacteria may gain access to the cranial vault or
vertebral canal as a result of trauma, contamination from
surgery or CSF collection, and local spread from adja-
cent structures such as the paranasal sinuses, middle ear,
or rarely from discospondylitis lesions.17 In the case
described here, the route of infection was unknown, but
the early occurrence of a head tilt and vestibular signs
would suggest that the middle ear may have been the
original source, although no evidence for this was found
during the authors’ examination. The hematogenous route
is usually incriminated in animals and humans. It has
been reported that bacteremia following mucosal inva-
sion usually permits a single type of virulent organism to
420 JOURNAL of the American Animal Hospital Association
Table 2
Published Reports of Bacteria Isolated
From Cases of Canine Meningitis or
Meningoencephalitis
Organism Reference
Aerobes:
Staphylococcus spp. 13
Staphylococcus epidermidis 10
Staphylococcus aureus 9,11
Staphylococcus albus 12
Pasteurella spp. 10
Pasteurella multocida 14
Escherichia coli 8,13
Anaerobes:
Bacteroides spp. 13
Peptostreptococcus anaerobius 13
Escherichia coli 13
Fusobacterium spp. 13
Eubacterium spp. 13
Propionibacterium spp. 8 The most consistent signs of CNS inflammation are
gain entry to the cranial cavity. This is in contrast to the
development of septic cerebral emboli from distant pyo-
genic foci such as abscesses or osteomyelitis lesions,
which more usually cause a “mixed infection” with mul-
tiple organisms.18 There was no evidence of infection
elsewhere in the case reported herein. In humans, mu-
cosal attachment and subsequent invasion of the blood
stream are mediated by certain microbial virulence fac-
tors such as the bacterial cell surface components or the
presence of a precipitating insult such as a viral infection
of the respiratory tract. Furthermore, several studies re-
ported in the human medical literature have shown that
there is a close correlation between the serotype of pneu-
mococcus and the development of meningitis.19,20 How-
ever, the serotype reported here (type 4) is more often
associated with otitis media and bacteremia in children
than the development of meningitis.19 Neither of the
adult owners of this dog had recently been sick, and the
source of the bacterium remains unknown.
Hematogenous infections most commonly localize in
the regions supplied by the middle cerebral artery21 which
include the choroid plexus of the lateral ventricle and the
capillaries of the cerebral cortex. Although the mecha-
nisms underlying bacterial traversal of the intact blood-
brain barrier are largely unknown, recent reports suggest
that endothelial cells within these structures may possess
specific receptors for adherence of bacteria, which may
facilitate entrance to the subarachnoid space.22,23 Since
this space is continuous with the surface of the brain and
September/October 1999, Vol. 35
bathed in CSF, organisms may then easily spread
throughout the neuraxis.
The clinical signs of CNS inflammation are variable
and are related to anatomical location and severity, but
the mechanisms by which the infectious agents elicit
meningeal inflammation are not fully elucidated. Bacte-
rial multiplication initially proceeds unchecked due to
the absence of effective host defense mechanisms within
the CSF in the early stages of infection. It is thought that
bacterial cell wall components stimulate the release of
inflammatory cytokines from the vascular endothelial
cells, and that interleukin-1 (IL-1), tumor necrosis fac-
tor, and prostaglandins act as powerful chemotactants.
The ensuing inflammatory reaction and release of toxic
agents injure structures within the subarachnoid space
(such as the cranial nerves and spinal nerve roots) or
those adjacent to it (such as the pial vasculature, brain
parenchyma, and subpial white matter of the spinal cord).
In humans, bacterial meningitis exerts profound effects
on the blood vessels that course through the subarach-
noid space, producing a vasculitis that results in luminal
narrowing and thrombus formation, with the potential
for ischemia or infarction of the brain parenchyma.24
ataxia and pain. Neck and limb rigidity, paresis, fever,
seizures, and cranial nerve dysfunction may also occur.
Hyperesthesia is thought to result from stimulation of the
dense sensory innervation of meningeal tissue,21 in com-
bination with the relative mobility of the cranial nerve
roots. Cranial nerves are affected secondary to meningeal
inflammation as they traverse the subdural space. Blind-
ness (CN II), anisocoria (CN II and III), facial hyperes-
thesia (CN V) or paralysis (CN VII), and vestibular
disturbances (CN VIII) have been reported.21 Occasion-
ally animals may present with focal neurological signs
associated with brain abscessation and subdural or epi-
dural empyema.8,13 The occurrence of seizures, as in the
case reported here, is consistent with forebrain involve-
ment. The development of seizures in animals with bac-
terial infection of the CNS may result from progressive
inflammation, edema, fever, or hypoglycemia.21 Further
progression of the inflammation may cause secondary
hydrocephalus and tentorial herniation and the develop-
ment of more serious signs including opisthotonus,
bradycardia, pupillary dilatation, and coma.
The diagnosis of bacterial meningitis requires a suspi-
cion from the history and clinical signs, together with
evaluation of the CSF. Additional laboratory analyses such
as the detection of specific antibodies in the CSF or serum,
or electroencephalography, computerized tomography, and
magnetic resonance imaging may also be of benefit.25
The choice of antibacterial agent for the treatment of
bacterial meningitis depends principally on the drug’s
ability to penetrate into the CSF. This is determined by
the drug’s lipid solubility, ionization, and protein-bind-
ing properties. Antimicrobials such as trimethoprim, me-
September/October 1999, Vol. 35 Streptococcal Meningoencephalitis 421

h
tronidazole, ampicillin, chloramphenicol, and potenti- Phenobarbitone injection, 200 mg/ml; Fawns & McAllen Pty Ltd, Clayton,
Australia
ated sulfonamides have been used traditionally in veteri- i
Betamox palatable tablets; Heriot Agvet Pty Ltd, Rowville, Australia
nary and human medicine. In recent years there has been j
Phenobarbitone, 30 mg tablets; Sigma Co. Ltd, Clayton, Australia
an alarming increase in the frequency of resistance to k
Tribrissen 20; Pitman-Moore Australia Ltd, North Ryde, Australia
many of these drugs in children, which limits their use-
fulness.26 This has necessitated greater use of second- Acknowledgments
and third-generation cephalosporins, such as cefoxitin The authors acknowledge the help of Dr. Kevin Whithear
and ceftriaxone respectively.27 Since meningeal inflam- and Ms. Angela Irving in microbiological analysis, and
mation enhances the ability of many antibiotics to cross Dr. David Hansman, Adelaide Children’s Hospital, for
the blood-brain barrier, the β-lactam compounds and the serotyping the Streptococcus pneumoniae.
macrolides are often used in early cases before the re-
sults of microbiological culture are known. In the present
case, a second-generation cephalosporin (i.e., cefoxitin) References
was chosen initially but was changed to amoxicillin once 1. Coles EH. Cerebrospinal fluid. In: Kaneko JJ, ed. Clinical biochemistry of
domestic animals. Academic Press, 1980:719–48.
the organism was identified. Furthermore, a potentiated
2. Bowers EF, Jeffries LR. Optochin in the identification of Str. pneumoniae.
sulfonamide was introduced to the treatment protocol J Clin Pathol 1955;8:58–60.
once the signs of meningitis had resolved, on the as- 3. Lund E. Polyvalent, diagnostic pneumococcus sera. Acta Pathol Microbiol
sumption that amoxicillin would no longer reach the Scand 1963;59:533–6.
4. Meric SM. Canine meningitis, a changing emphasis. J Vet Int Med
CSF with the same efficiency as when meningeal inflam- 1988;2:26–35.
mation was present. 5. Cordy DR, Holliday TA. A necrotizing meningoencephalitis of pug dogs.
Corticosteroids have been used for the treatment of Vet Path 1989;26:191–4.
bacterial meningitis in dogs,12 but their benefits have not 6. Stalis IH, Chadwick B, Dayrell-Hart B, et al. Necrotizing meningoencepha-
litis of Maltese dogs. Vet Path 1995;32:230–5.
been clearly demonstrated in veterinary medicine, and
7. Tipold A, Fatzer R, Jaggy A, et al. Necrotizing encephalitis in Yorkshire
their use in CNS infections remains controversial.25 Dex- terriers. J Sm Anim Pract 1993;34:623–8.
amethasone has found renewed favor in the treatment of 8. Bruyette DS, Tomlinson JL. Canine cerebral abscess: a case report and
discussion. Vet Med 1983;78:1706–11.
H. influenzae and pneumococcal meningitis in humans
9. Hudson MD. Bacterial meningitis; a case study and review. J Am Anim
due to its ability to dampen the degree of cytokine- Hosp Assoc 1976;12:88–91.
induced injury generated during bacteriolysis as a result 10. Heavner JE. Cardiac arrhythmia with meningitis in a dog. Mod Vet Pract
of microbial therapy.28 Subarachnoid inflammation is a 1977;58:149–50.
major factor contributing to the morbidity and mortality 11. Kornegay JN, Lorenz MD, Zenoble RD. Bacterial meningitis in two dogs.
J Am Vet Med Assoc 1978;173:1334–6.
of human patients with meningitis, and the same may 12. Bullmore CC, Sevedge JP. Canine meningoencephalitis. J Am Anim Hosp
well be true in animals. However, although meningitis Assoc 1978;14:387–94.
caused by the common pathogens in children is rarely 13. Dow SW, LeCouteur RA, Henik RA, Jones RL, Poss ML. Central nervous
system infection associated with anerobic bacteria in two dogs and two
fatal, corticosteroids have been shown to be of value in cats. J Vet Int Med 1988;2:171–6.
reducing the frequency of postmeningitis deafness and 14. Rogers RJ, Elder JK. Purulent leptomeningitis in a dog associated with an
minor neurological deficits. It has been suggested that aerogenic Pasteurella multocida. Aust Vet J 1967;43:81–2.
these potential benefits are of limited value in canine 15. Austrian R. Pneumococcal infections. In: Wilson JD, Bauwald E,
Isselbacher KJ, et al., eds. Harrison’s principles of internal medicine.
patients where the pathogenesis may be different from New York: McGraw-Hill, 1991:553–7.
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Comp Cont Ed 1994;16:45–53.
mg/kg body weight) was initially used in the absence of
17. Lobetti RG. Subarachnoid abscess as a complication of discospondylitis in
an etiological diagnosis. Although corticosteroids, to- a dog. J Sm Anim Pract 1994;35:480–3.
gether with antibiotics, are now recommended in the 18. Harter DH, Petersdorf RG. Bacterial meningitis and brain abscess. In:
therapy of childhood meningitis, extreme caution should Wilson JD, Bauwald E, Isselbacher KJ, et al., eds. Harrison’s principles of
internal medicine. New York: McGraw-Hill, 1991:2023–31.
be exercised when using them in dogs with infectious
19. Gray BM, Converse GM, Dillon HC. Serotypes of Streptococcus
meningoencephalitis; and anti-inflammatory, not immu- pneumoniae causing disease. J Inf Dis 1979;140:979–83.
nosuppressive, doses should be used. 20. Broome CV, Facklam RR, Allen JR, et al. Epidemiology of pneumococcal
serotypes in the United States, 1978–1979. J Inf Dis 1980;141:119–23.
21. Greene CE. Infections of the central nervous system. In: Greene CE, ed.
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Hartmanns; Baxter Healthcare Pty Ltd, Old Toongabbie, Australia
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 Potential Central Nervous System
Complications of
Von Willebrand’s Disease
Three Doberman pinschers were presented on emergency referral for progressive neurological
deficits. All three dogs had a similar onset of clinical signs associated with an apparently minor
traumatic event. Each dog progressed to significant neurological dysfunction including
paraplegia, tetraplegia, and/or loss of deep pain sensation. None of the animals was apparently
affected by cervical vertebral instability (“Wobbler’s Syndrome”). All were confirmed to have von
Willebrand’s disease. In all cases, significant epidural hemorrhage was identified. The etiology
of each hemorrhage, however, was different for each animal. The cases presented here
demonstrate a potential relationship between neurological deficits and the patient’s ability to
effectively coagulate blood. Hemostatic abnormalities, such as von Willebrand’s disease,
should be included as possible differential diagnoses or contributing factors in animals
demonstrating neurological deficits. These abnormalities should especially be considered
following trauma, intervertebral disk extrusion, or spinal surgery.
J Am Anim Hosp Assoc 1999;35:423–9.

Aric A. Applewhite, DVM Introduction

Brent E. Wilkens, DVM,
Diplomate ACVS
Darryl E. McDonald, DVM, MS,
Diplomate ACVS
Robert M. Radasch, DVM, MS,
Diplomate ACVS
Robert D. Barstad, DVM, MS
C FVIII’s half-life in plasma. Von Willebrand’s factor plays a critical role
From the Dallas Veterinary Surgical Center,
14075 Waterfall Way,
Dallas, Texas 75240.
Doctor Applewhite’s current address is the
Department of Small Animal Medicine,
Veterinary Teaching Hospital,
College of Veterinary Medicine,
The University of Georgia,
Athens, Georgia 30602-7390.
Von Willebrand’s disease (vWD) is the most common inherited bleeding
disorder of humans and dogs.1–3 The disease is manifested as a deficiency
of von Willebrand’s factor (vWF). Von Willebrand’s factor is a glycopro-
tein produced and stored predominantly by vascular endothelial cells, but
it is also present in platelets, megakaryocytes, and intact subendothelium.
In the canine species, in contrast to other species, circulating platelets
store only a small amount of vWF.3 Von Willebrand’s factor is released
into the plasma and circulates as a complex with coagulation factor VIII
(FVIII), and it is frequently referred to as factor VIII-related antigen
(FVIIIR:Ag). Factor VIII is an essential cofactor in the intrinsic coagula-
tion pathway. Von Willebrand’s factor acts to transport FVIII to sites of
vessel injury and protect it from proteolytic digestion, therefore extending
in primary hemostasis as it is responsible for instituting platelet plug
formation and promoting platelet adherence.4
Von Willebrand’s factor is composed of a variable number of identical
(0.27 million dalton) glycoprotein subunits. It exists as small, medium,
and large multimers. The larger multimers are more hemostatically active
in the plasma because of an increased number of platelet-binding sites.4
The different-sized multimers are distributed in the plasma and may be
quantitated consistently using electroimmunoassay (Laurell rocket immu-
noelectrophoresis) or enzyme-linked immunosorbent assay (ELISA).4 Di-
agnosis of vWD in dogs has traditionally relied upon the quantification of
vWF in the plasma or by assays that measure vWF-dependent platelet
agglutination. For the latter, botrocetin cofactor assays are used most
commonly in dogs.5 Deoxyribonucleic acid (DNA) testinga for vWF
genes is now available to clearly identify Doberman pinschers as affected
(i.e., homozygous positive), carriers (i.e., heterozygous), or unaffected

JOURNAL of the American Animal Hospital Association 423

424 JOURNAL of the American Animal Hospital Association
Figure 1—Lateral thoracolumbar myelogram of case no. 1.
There is diffuse dorsal compression of the spinal cord from the
caudal aspect of the tenth thoracic (T10 ) vertebra to the caudal
aspect of the third lumbar (L3) vertebra. The narrow black arrow
demarcates the dorsal border of the spinal canal, while the
arrowhead points to the dorsal border of the spinal cord.
(i.e., homozygous negative) for vWD. 6 Screening tests
are available for rapid evaluation of platelet function and
estimation of platelet number. These tests are, however,
not sensitive for abnormalities or deficiencies of vWF.
The most reliable of these screening tests is buccal
mucosal bleeding time (BMBT).1 When performed prop-
erly, BMBT reliably identifies potential surgical hemor-
rhagic risks.
Abnormalities of the vWF can be acquired or inher-
ited. Acquired vWD has been associated with hypothy-
roidism, lymphoproliferative diseases, neoplasia, and
autoimmune disease in humans.7 The correlation of hy-
pothyroidism and vWD in dogs is controversial.7 No
other acquired forms of vWD have been described in
dogs. There are three classifications of inherited vWD in
dogs. These are classified depending on the quantity and
function of vWF in the plasma. In Type-1 vWD, all of
the multimeric forms of vWF are present in the plasma,
but there is an overall decrease in the quantity of circu-
lating factor. Type-1 vWD is the most common form in
both dogs and humans, having been identified in a large
number of dog breeds.3,4 The Doberman pinscher has a
high prevalence (up to 70% in one study)7 of Type-1
vWD. Type-2 vWD exists in animals and is manifested
by a deficiency of specifically the large multimers of
vWF. Type-2 vWD has been described in German short-
haired and German wirehaired pointers.1 Type-3 vWD is
the most severe type and is characterized by almost no
detectable vWF in circulation. Type-3 vWD has been
identified in Scottish terriers and Chesapeake Bay re-
trievers1 as well as in one reported Himalayan cat.8
Complications of vWD in affected dogs are generally
manifested as hemorrhage from mucosal surfaces, pro-
longed bleeding times, or bleeding excessively during
surgery or following other trauma. Frequently, abnormal
bleeding is noted early in life with elective neutering,
September/October 1999, Vol. 35
cosmetic otoplasty, or tail docking. In some affected
animals, however, complications are not noticed or docu-
mented by owners or veterinarians until later in the
animal’s life. The variation in severity of signs and de-
gree of affliction are largely dependent on the amount of
functional vWF in circulation at any one time. This
amount of vWF is variable in Type-1 vWD secondary to
the exact genetic mutation present.6
This paper presents three cases of central nervous
system (CNS) complications in Doberman pinschers with
documented vWD. None of the animals were diagnosed
previously, had evidence of other coagulation abnor-
malities, or had any other significant medical problems
that would predispose them to excessive hemorrhage.
The clinical presentation of each dog is similar, but the
underlying etiology of the hemorrhagic complication in
each case is somewhat different.
Case Reports
Case No. 1
A two-year-old, castrated male Doberman pinscher was
referred for acute onset of paraplegia. Forty-eight hours
prior to presentation, the owner had noted that the dog
yelped and was unwilling to jump into the owner’s ve-
hicle. Twenty-four hours before presentation, the dog
was ambulatory but reluctant to come to the owner. The
day of presentation, the dog was unable to walk or move
his hind limbs. There was no previous history of pain,
neurological deficits, or other medical problems.
The dog presented on emergency referral in left
lateral recumbency. Neurological examination re-
vealed upper motor neuron reflexes of the hind limbs.
The dog was negative for deep pain sensation in both
rear limbs. Forelimb reflexes were within normal lim-
its, and superficial sensation was present in both of
the forelimbs.
Survey thoracolumbar radiographs demonstrated no
significant abnormality. Myelography [Figure 1] revealed
diffuse dorsal compression of the spinal cord beginning
cranially at the tenth thoracic (T10) vertebra and extend-
ing caudally to the third lumbar (L3) vertebra. Blood was
submitted to a national laboratoryb for analysis of serum
free-thyroxine (fT4) and vWF evaluation. Genetic test-
ing for vWD was not available at the time of this dog’s
admission to the hospital. A poor prognosis was given to
the owner due to the loss of deep pain bilaterally in the
hind limbs. The owner elected to have the dog euthanized.
Necropsy revealed an epidural hematoma within the
spinal canal extending from T10 to L3, apparently caus-
ing diffuse compression of the spinal cord [Figure 2]. No
obvious trauma was noted. Results of blood tests showed
a normal fT4 concentration (1.57 ng/dl; reference range,
1.0 to 4.0 ng/dl). Results of the vWF assay (ELISA)
revealed a vWF concentration of 50% (reference range,
70% to 180%).
September/October 1999, Vol. 35
Figure 2—Necropsy specimen of case no. 1 following standard
right hemilaminectomy performed at postmortem. There is an
epidural hematoma (black arrows) causing compression of the
spinal cord (white arrow) within the spinal canal.
Case No. 2
A seven-year-old, spayed female Doberman pinscher
was referred for acute paraplegia. Thirty-six hours prior
to presentation, the dog experienced a painful episode
while playing with another dog. Twenty-four hours prior
to presentation, the dog was reluctant to move but was
ambulatory. In the 12 hours prior to presentation, the dog
became nonambulatory and experienced pain when
handled. There was no previous history of neurological
deficits. The dog was currently being treated with dieth-
ylstilbestrol (1 mg every other day) for urinary inconti-
nence. A cutaneous “cyst” had previously been removed
surgically from her right stifle. No other abnormal his-
torical findings were noted.
Neurological examination revealed paraplegia with
upper motor neuron reflexes in the rear limbs. The fore-
limbs were noted to be in extensor rigidity. Sensation
was diminished bilaterally in the rear limbs but was
considered normal in the forelimbs. Survey thoracolum-
bar radiographs revealed no significant abnormal find-
ings. Myelography [Figure 3] demonstrated diffuse dorsal
compression of the spinal cord from the ninth thoracic
(T9) vertebra to L 3. Complete blood count (CBC), serum
biochemical analysis, and fT4 assay were submitted to a
national laboratory.b Based on the breed of the dog, the
appearance of the myelogram, and the findings at sur-
gery, samples were submitted the following day for DNA
analysis to determine if the dog was affected by vWD.
A standard right dorsal hemilaminectomy was per-
formed from T9 to L3. A diffuse hematoma was noted in
the spinal canal from T 9 to L3, apparently causing com-
pression of the spinal cord. Intervertebral disk material
was identified within the spinal canal at the first to
second lumbar (L1 to L2) disk space. The disk material
and blood were removed from the spinal canal, and
fenestration of the intervertebral disks from the thir-
teenth thoracic (T13) to L 3 vertebrae was performed.
Nervous System Complications of Von Willebrand’s Disease 425
Figure 3—Lateral thoracolumbar myelogram of case no. 2.
There is diffuse dorsal spinal cord compression extending from
the cranial aspect of the ninth thoracic (T9) vertebra (black arrow
with narrow head) to the caudal aspect of the third lumbar (L3)
vertebra (black arrow with wide arrowhead).
Hemostasis was established within the tissues surround-
ing the spine by direct pressure and judicious use of
electrocautery. Hemostasis was verified within the spi-
nal canal following hemilaminectomy by direct observa-
tion. No excessive ongoing hemorrhage was noted within
the spinal canal once the hematoma was removed. The
incision was closed routinely. The dog recovered un-
eventfully from anesthesia and was weakly ambulatory
48 hours postoperatively.
Complete blood count, serum biochemical analysis,
and fT4 were essentially within reference ranges. Creati-
nine phosphokinase (CPK) was 5,022 IU/L (reference
range, 20 to 400 IU/L). This value was attributed to
severe neuromuscular damage secondary to spinal cord
trauma. Free-T 4 was 1.16 ng/dl (reference range, 1.0 to
4.0 ng/dl).b Deoxyribonucleic acid analysisa demon-
strated that the dog was homozygous-positive for vWD.
Postoperatively the dog improved initially, was ambula-
tory, and was discharged from the hospital within seven
days of surgery. The dog was, however, euthanized by
the referring veterinarian within one month of discharge
for reported intractable pain.
Case No. 3
A six-year-old, spayed female Doberman pinscher was
referred for evaluation of tetraplegia. Forty-eight hours
prior to presentation, the dog experienced pain while
jumping out of a vehicle. She was treated by the refer-
ring veterinarian with steroids (unknown dose or exact
formulation) and cage confinement. The dog experienced
pain upon manipulation of her neck. Over the next 24
hours, she gradually became tetraplegic. No previous
episodes of cervical pain or neurological deficits had
been noted. No other significant medical problem was
noted.
426 JOURNAL of the American Animal Hospital Association
Figure 4—Lateral cervical myelogram of case no. 3 five days
postoperatively for a ventral slot at the fifth to sixth cervical (C5 to
C6) intervertebral space (white arrowhead). There is compression
of the spinal cord ventrally from the caudal aspect of C5 to the
cranial aspect of the seventh cervical (C7) vertebra (between the
narrow white arrows). The compression is centered over the
surgical site.
Neurological examination revealed tetraplegia with
normal sensation in all limbs. Survey radiography of the
cervical spine revealed no abnormal findings. Myelogra-
phy revealed ventral compression of the spinal cord at
the intervertebral disk space between the fifth and sixth
cervical (C5 to C6) vertebrae. No evidence of cervical
vertebral instability (“Wobbler’s Syndrome”) was noted.
A standard ventral slot was performed at C5 to C6, and a
large amount of intervertebral disk material was removed
from the spinal canal. Intervertebral disk fenestration
was performed from the second cervical (C2) vertebra to
C 5, and between C6 and the seventh cervical (C7) verte-
brae. The incision was closed routinely.
The dog did not improve as expected. She was
nonpainful but remained tetraplegic. Five days postop-
eratively, a cervical myelogram was repeated [Figure 4].
Myelography at that time revealed diffuse spinal cord
compression between C5 and C 7. Exploration of the pre-
vious ventral slot revealed a large hematoma at the sur-
gery site, extending into the spinal canal and apparently
causing moderate compression of the spinal cord. The
blood clot was removed. No ongoing hemorrhage was
noted within the spinal canal. Hemostasis was accom-
plished in surrounding tissues with direct pressure and
electrocautery. Hemostasis was verified by direct visual-
ization by the surgeon. The incision was closed rou-
tinely. Blood was drawn and submitted to a national
laboratoryb for a vWF assay (ELISA). Financial con-
straints prevented the submission of a DNA analysis for
vWD in this patient. The dog recovered uneventfully and
was discharged from the hospital 72 hours after the
second surgery. She was tetraparetic but ambulatory at
September/October 1999, Vol. 35
discharge. Result of the vWF assay was 24% (reference
range, 70% to 180%).
Discussion
The Doberman pinscher breed is known to be genetically
predisposed to vWD.9,10 The breed is also considered to
be at risk for certain CNS diseases, namely cervical
vertebral instability (“Wobbler’s Syndrome”) with or
without intervertebral disk disease (IVDD).11 Differen-
tial diagnoses on initial presentation for all of the cases
in this report included IVDD; cervical vertebral instabil-
ity; spinal trauma; infection or inflammation of the CNS
or support structures (i.e., meningitis or discospondy-
litis); vascular compromise (i.e., fibrocartilaginous
embolism); or potentially a neoplasm that caused com-
pression of the spinal cord (i.e., lymphoma, nerve sheath
tumor).
Case no. 1, unlike case nos. 2 and 3, had no evidence
of intervertebral disk extrusion, other trauma, or abnor-
mality within the spinal canal that could have instigated
hemorrhage. The injury to the spinal cord in case no. 1
was suspected to arise from the direct compressive force
of hemorrhage into the spinal canal. Progression of the
neurological deficits that followed the initial injury was
then attributed to ongoing compression of the spinal cord
by the expansion of the epidural hematoma. Myelogra-
phy demonstrated diffuse dorsal compression of the spi-
nal cord beginning at T10 and extending caudally to L3.
At necropsy, there was no identifiable etiology or source
of the hemorrhage. Testing of serum collected antemor-
tem demonstrated a low vWF concentration (ELISA)b
but no other obvious abnormalities. Other coagulation
tests were not performed on admission to the hospital.
Activated partial thromboplastin time (APTT) testing of
the intrinsic coagulation pathway, prothrombin time (PT)
testing of the extrinsic coagulation pathway, a platelet
count, and measurement of fibrinogen in circulation
would help to identify or rule out any other coagulo-
pathies. These tests were not performed on this or the
other patients in this study because of the lack of avail-
ability of these tests on an emergency basis at the au-
thors’ hospital. Complete blood work (CBC, serum
biochemical profile, and coagulation tests) and urinaly-
sis would be helpful in identifying any underlying abnor-
malities that could predispose to abnormal coagulation.
Nontraumatic spinal cord hemorrhage has been reported
in veterinary medicine.12–14 Spontaneous hematomas do
occur in animals afflicted with vWD, although they are
frequently reported in the subcutaneous tissues on the
body surface.2 Occurrence of nontraumatic spinal cord
hematomas in a dog affected with vWD, however, has
not been identified in the veterinary literature. One re-
port of a Doberman pinscher puppy with spontaneous
intracranial hemorrhage thought to be associated with
concurrent low levels of vWF and thrombocytopenia has
September/October 1999, Vol. 35
been documented. 15 There was reportedly no significant
trauma that would have instigated hemorrhage in that
case. Other reports in the veterinary literature describe
nontraumatic hemorrhage into the spinal canal and re-
sultant hematomas in association with suspected vascu-
lar anomalies (i.e., arteriovenous fistulas or aneurysms)
or neoplasm (i.e., hemangioma, hemangiosarcoma, lym-
phosarcoma). For most of the cases, however, the exact
etiologies of the hemorrhages were not identified.12,13
Spontaneous epidural hemorrhage and hematomas are
reported rarely in human medicine. These cases typically
present with the patients complaining of back pain or
referred abdominal pain that either slowly or rapidly
progresses to neurological deficits in their legs. These
cases are considered surgical emergencies with the prog-
nosis being directly proportional to the length of time
from the onset of clinical signs to surgical decompres-
sion. 16 The most common etiologies for these hemor-
rhages include coagulation disorders (acquired or
congenital), vascular anomalies, anticoagulant therapy,
pregnancy, hypertension, and neoplasia.16–18 A report
has been made of acquired platelet abnormalities (e.g.,
excessive garlic ingestion) that lead to a spontaneous
spinal epidural hematoma. 18 This would lend credence to
the ability of a spontaneous spinal epidural hemorrhage
to occur in a vWD-positive dog because of the defect in
primary hemostasis and the inability of an affected dog
to adequately form a platelet plug.
Case no. 2 showed a similar onset and progression of
neurological deficits as case no. 1. Both animals experi-
enced pain following an apparently minimal traumatic
incident. However, a Hansen Type I disk extrusion was
identified surgically in case no. 2. The severity of the
signs as well as the progression of the neurological defi-
cits were suspected to be related to excessive hemor-
rhage within the epidural space. The progression of the
clinical signs could also be related to the initial injury
sustained by the disk extrusion and the ensuing inflam-
mation and injury to the spinal cord. Intervertebral disk
disease occurs as two distinct types of degenerative disk
disease, termed Hansen Type I and Hansen Type II.
Traumatic injuries (i.e., vehicular accidents) have been
reported to cause extrusion of normal intervertebral disks
into the spinal canal, but this is rare in dogs. Hansen
Type I disk disease is typically seen in chondrodystro-
phic breeds (e.g., dachshunds, cocker spaniels,
Pekingese, etc.) but has also been identified in nonchon-
drodystrophic breeds.19 The extrusion of disk material
into the spinal canal in Hansen Type I disk disease
revolves around the degeneration of the intervertebral
disk and transformation of the nucleus pulposus by chon-
droid metaplasia. This degeneration of the nucleus is
combined with a weakening and degeneration of the
annulus fibrosis. With overexertion, or even with normal
movements of the vertebral canal, the weakened annulus
cannot restrain the degenerated nucleus, and the nuclear
Nervous System Complications of Von Willebrand’s Disease 427
material is acutely extruded into the spinal canal. This
causes compression of the spinal cord or nerve roots.
Hansen Type I disk extrusions can be expelled laterally
and lacerate the vertebral sinus on the ventral and lateral
floors of the spinal canal, causing hemorrhage.20 The
severity of the injury to the spinal cord is related to the
rapidity of the extrusion, the degree of mechanical com-
pression of the spinal cord, and the various vascular
changes (i.e., ischemia, inflammation, or hemorrhage)
caused by the extruding disk.20 If hemorrhage occurs, it
is typically controlled by the direct compression of the
surrounding tissues within the spinal canal, formation of
a platelet plug, and activation of the coagulation cas-
cade. Hemorrhage is thought to cause some additional
deleterious effects within the spinal canal. These adverse
effects are related to the mechanical compression of the
spinal cord and the secondary inflammatory response
that is stimulated.20 In animals with coagulation abnor-
malities, especially of primary hemostasis (i.e., vWD),
this hemorrhage could be excessive and thereby exacer-
bate the deleterious effects of the initial injury. The exact
source of the hemorrhage was not identified in case no.
2, but was assumed to be from the vertebral sinus sec-
ondary to laceration by the extruding intervertebral disk.
It is unknown if the low venous pressure of the vertebral
sinus is sufficient to cause significant hemorrhage and
consequential compression of the spinal cord within the
spinal canal. On myelography and surgical visualization,
however, an epidural hematoma was identified as caus-
ing compression of the spinal cord, and no obvious arte-
rial or other higher pressure source could be identified.
Case no. 3 experienced complications following neu-
rological surgery for a Hansen Type I cervical disk ex-
trusion. Prolonged bleeding and secondary spinal cord
compression occurred within the spinal canal after inter-
vertebral disk material removal. The location of the disk
rupture and consequential hemorrhage generally deter-
mine the severity of the clinical signs associated with
any intervertebral disk extrusion or protrusion within the
spinal canal. The cervical spinal vertebrae have a rela-
tively larger vertebral canal diameter in comparison to
the thoracolumbar vertebrae.20 Consequently, the cervi-
cal spinal cord is able to accommodate a larger degree of
compression without causing significant clinical signs.
This may explain why there is not significant compres-
sion of the spinal cord seen in all cervical ventral slot
patients that experience hemorrhage secondary to lacera-
tion of the vertebral sinus during the procedure. Case
nos. 1 and 2 (described previously) experienced hemor-
rhage that caused diffuse compression on the spinal cord
in the thoracolumbar spine. Myelography of these cases
demonstrated significant diffuse compression of the spi-
nal cord for up to eight vertebral bodies. The compres-
sive force caused by the hemorrhage was considered to
significantly worsen the severity of the injury to the
spinal cord and, therefore, the severity of the clinical
428 JOURNAL of the American Animal Hospital Association
signs. Case no. 3 had an intervertebral disk extrusion
within the cervical spine that was severe enough to cause
tetraplegia. This animal did not, however, have associ-
ated hemorrhage within the spinal canal until after surgi-
cal intervention. Clinical signs of case no. 3 improved
only after both the disk material and the hematoma were
removed from the spinal canal. The abnormality in pri-
mary hemostasis associated with vWD in these three
animals was considered to predispose them to excessive
hemorrhage within the CNS, either spontaneously or in
association with other injury.
Once identified as a vWD-positive animal, the imme-
diate treatment options available include attempts to
increase the vWF in circulation. For spontaneous hemor-
rhage or excessive hemorrhage associated with surgery
or trauma, administration of fresh-frozen plasma (FFP)
or cryoprecipitate has been advocated.4 Each of these
products are a source of plasma proteins including vWF.
Cryoprecipitate is a concentrated form of FFP and, there-
fore, may provide more vWF and quantitatively more of
the larger multimers of vWF in a smaller volume of
fluid. In a recent study, however, neither of these prod-
ucts were determined to significantly increase circulat-
ing vWF or significantly decrease BMBT in Doberman
pinschers with Type-1 vWD. 21 It was concluded in the
report, however, that cryoprecipitate would be the blood
product of choice, and that the significance of this con-
clusion may have been affected by the low number of
animals in their study. This conclusion is also supported
by a similar report in which cryoprecipitate (but not
FFP) was determined to shorten BMBT in Doberman
pinschers with Type-1 vWD.10 These products are con-
sidered to provide the animal with functional circulating
vWF to assist in primary hemostasis and the formation of
the platelet plug. The disadvantages of these products,
specifically cryoprecipitate, are substantial. The avail-
ability of the products and the technical ability and cost
to produce and store the products preclude their use in
general practice on a routine basis. The half-life of vWF
in circulation (10 to 24 hrs in vivo)2 also decreases their
practicality in anything other than emergency or prophy-
lactic surgical situations. When used, the products should
be given 30 minutes prior to surgery.4
For long-term treatment of vWD, efforts have been
made to increase the release of vWF from storage areas
within the body (e.g., endothelial cells, megakaryocytes,
etc.). Desmopressin (1-desamino-8-D-arginine or DDAVP)
is a synthetic analog of vasopressin which reportedly
increases the release of vWF (specifically the larger and
more hemostatically active multimers) in humans with
vWD. In dogs with vWD, however, it has been demon-
strated that DDAVP does not have the same efficacy to
increase circulating vWF.22 Even when given to normal
dogs, DDAVP only slightly increases the concentration
of vWF in circulation. 22 It has been advocated, however,
that administration of DDAVP to plasma donors may be
September/October 1999, Vol. 35
beneficial in promoting hemostasis, even with only a
minimal increase in the circulating vWF.10
Conclusion
Identification of vWD-positive animals is an important
consideration in veterinary medicine. This disease is
now considered to be an autosomal-recessive trait that is
predictably transmitted in affected individuals. Genetic
screening is now available for Doberman pinschers and
certain other predisposed breeds.6 Rapid screening tests
of platelet function (BMBT) should be performed if the
status of a high-risk breed is unknown and surgery is
considered for that patient. Once identified, animals af-
fected with vWD should not undergo elective surgical
procedures and should avoid any other trauma that could
potentiate hemorrhage. Complications of vWD have been
previously identified as mucosal bleeding, spontaneous
hemorrhages, and prolonged hemorrhage associated with
surgery or trauma that could be life-threatening in some
animals. The three cases presented in this report demon-
strate three similar, but distinct, potential CNS compli-
cations in animals with vWD. Rapid identification of
potential spinal canal hemorrhage from any cause is
necessary to improve the prognosis of the patient by
surgical decompression. Care must also be exercised
during surgical procedures to ensure adequate hemosta-
sis and avoidance of potential complications associated
with vWD, especially in a space-limited area like the
spinal canal.
a
Deoxyribonucleic acid test for von Willebrand’s disease: Breed-specific
(Doberman pinscher) VetGen Veterinary Genetic Services, Ann Arbor, MI
b
Antech Diagnostics; Western Region Headquarters, Irvine, CA
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 Computed Tomographic Findings
of Ceroid Lipofuscinosis in a Dog
A two-year and seven-month-old, castrated male border collie was presented for a two-month
history of progressive neurological signs including blindness, ataxia, dementia, and partial
seizures. A complete blood count, serum biochemical profile, urinalysis, thoracic radiographs,
and cerebrospinal fluid analysis were within reference ranges. Computed tomography (CT) of
the brain showed dilatation of the ventricles and atrophy of the cerebral cortex. A central
nervous system (CNS) storage disease was suspected, and the dog was euthanized due to a
poor prognosis. Light and electron microscopic examination revealed neuronal degeneration
with pigment accumulation in neurons of the CNS, in ganglia of the peripheral nervous system,
and in several non-nervous tissues. Ceroid lipofuscinosis was diagnosed based on the
microscopic and ultrastructural lesions detected. This is the second report of CT findings in a
canine clinical patient with ceroid lipofuscinosis. J Am Anim Hosp Assoc 1999;35:430–5.

Joanne N. Franks, DVM Introduction

Curtis W. Dewey, DVM, MS,
Diplomate ACVIM, Diplomate ACVS
Michael A. Walker, DVM,
Diplomate ACVR,
Diplomate ACVRO
Ralph W. Storts, DVM, PhD,
Diplomate ACVP
C Case Report
From the Departments of Small Animal
Medicine and Surgery (Franks, Dewey),
Large Animal Medicine
and Surgery (Walker), and
Veterinary Pathobiology (Storts),
College of Veterinary Medicine,
Texas A&M University,
College Station, Texas 77843-4474.
Address all correspondence and reprint
requests to Dr. Franks.
Ceroid lipofuscinosis is a broad term describing a group of incompletely
understood diseases caused by an abnormal accumulation of metabolic
by-products within cellular lysosomes of neural and visceral organs. The
disease is reported as an inherited cause of progressive nervous system
dysfunction in humans, nonhuman primates, dogs, cats, cattle, sheep, and
goats.1–11 Clinical signs of disease include impairment of motor function,
conscious proprioceptive deficits, ataxia, progressive blindness, behavior
changes, hypersensitivity to stimuli, and seizures. The disease is variable
in rate of progression, irreversible, and fatal. This report describes the
clinical, computed tomographic, biochemical, microscopic, and ultra-
structural features of ceroid lipofuscinosis in a dog.
A 19.1-kg, two-year and seven-month-old, castrated male border collie of
unknown pedigree was referred to the Texas A&M University Veterinary
Teaching Hospital (TAMUVTH) for a two-month history of progressive
signs of neurological dysfunction. Historically, the owner reported the
dog as being lethargic and less responsive to verbal commands beginning
about two months prior to admission. One month prior to presentation at
TAMUVTH, the dog’s signs worsened to include ataxia, blindness, and
behavior changes characterized by periodic unpredictable aggression.
The referring veterinarian noted dilated pupils, decreased facial sensa-
tion, lack of a menace response, and ataxia. A complete blood count
(CBC) and serum biochemical profile were normal. Prescribed treatments
included doxycycline, enrofloxacin, and prednisone. The owner reported
initial partial improvement in the degree of ataxia, although the blindness
and behavioral alterations remained unabated.
On presentation to the TAMUVTH, the owner reported that the dog
had recently developed intermittent, daily “lip-smacking” behavior. The
dog appeared alert but disoriented. Physical examination findings (aside
from neurological assessment) were within normal limits; however, he
showed anxious, nervous behavior characterized by pacing and restless-

430 JOURNAL of the American Animal Hospital Association

September/October 1999, Vol. 35
Table
Computed Tomographic (CT) Measurements of Brain Opacity*
White Matter
CT Numbers† Range
Patient 37.4±4.99 29–47
Normal #1 33.1±6.12 25–42
Normal #2 30.5±3.33 27–35
* A numeric indication of relative tissue opacity based on the attenuation of X-rays normalized to water. Higher
numbers represent increased tissue opacity.
†
Mean±1 standard deviation for 16 measurements of the patient and eight each of normal dogs
Figure 1—Computed tomographic image of a 3-mm thick,
transverse section through the cerebrum and lateral and third
ventricles in the reported dog with ceroid lipofuscinosis. The
peripheral sulci of the cerebrum are abnormally enlarged. The
ventricles are mildly dilated.
ness. The patient was also hypersensitive to noise and
touch and became agitated and aggressive with restraint.
The gait was characterized by ataxia with hypermetric
thoracic limbs. The dog tended to circle in either direc-
tion and was unable to avoid obstacles; he assumed a
broad-based stance in all four limbs.
Cranial nerve examination abnormalities included lack
of a menace response and dilated pupils that were nonre-
sponsive to light. There was a right head tilt, vertical
nystagmus, diminished facial sensation, and no corneal
reflex. Conscious proprioception and spinal reflexes
could not be performed due to the dog’s behavior and
abnormal mentation. The dog had difficulty prehending
and chewing food, but swallowing and appetite seemed
normal. The owner had not noticed any dysphagia. Lip-
smacking or fly-biting behavior, as described by the
Ceroid Lipofuscinosis 431
Gray Matter
CT Numbers Range
42.8±3.37 38–48
46±6.07 42–60
48.5±3.02 43–52
owner, was not observed and was thought to possibly be
partial seizure activity. Generalized seizures had not been
observed. The neurological lesion seemed to be diffuse
or multifocal brain disease, involving the cerebral cor-
tex, brain stem, and possibly cerebellum.
The dog was anesthetized for further diagnostics. A
CBC with differential, biochemical analysis of serum,
urinalysis, thoracic radiographs, and cerebrospinal fluid
(CSF) analysis were all within reference ranges.
A computed tomography (CT) study of the brain was
performed. Transverse images (3-mm thick) were made
at 3-mm intervals, both pre- and postadministration of
intravenous (IV) contrast medium. Computed tomo-
graphic images showed mildly widened cerebral sulci
and mildly dilated lateral and third ventricles [Figure 1].
No contrast enhancement of the lesions occurred. Com-
puted tomography numbers (X-ray attenuation numbers
which are normalized to the X-ray attenuation by water)
of gray and white matter were obtained at multiple sites
within multiple sections and were compared to two nor-
mal dogs [see Table]. The dog had marginally decreased
opacity of the gray matter and marginally increased opac-
ity of the white matter relative to the normal dogs. The
CT diagnoses were mild cerebral atrophy and mild hy-
drocephalus.
A CNS storage disease was suspected, and the dog
was euthanized due to a poor prognosis. A necropsy was
performed. On gross examination, the size of the brain
appeared smaller than normal for the size of the animal,
but the color and consistency were within normal limits.
There was also a moderate hydrocephalus that involved
the lateral ventricles. Tissues were fixed in 10% buffered
formalin for microscopic examination. Lesions detected
in the nervous system included: a prominent accumula-
tion of pigment in neurons of the brain and spinal cord
that varied in appearance from finely granular to globu-
lar [Figure 2]; a variably mild to moderate neuronal
degeneration (particularly involving the cerebral and cer-
ebellar cortices and pyramidal neurons of the hippocam-
pus); a mild to moderate microgliosis (involving the gray
432 JOURNAL of the American Animal Hospital Association
Figure 2—Cerebellum of a dog with ceroid lipofuscinosis.
Illustrated is a Purkinje cell that contains multiple, variably-sized
granules of accumulated cytoplasmic pigment (upper arrow). The
lower arrow indicates the axon hillock. To the right of the Purkinje
cell is an accumulation of pigment, possibly within an adjacent
cell (Sudan black stain, 1,000X; bar=3.8 µm).
Figure 3—Cervical spinal cord of a dog with ceroid
lipofuscinosis. An accumulation of osmophilic bodies (large
arrow) can be seen at one pole of a neuronal cell body. The
plasma membrane of the cell is illustrated by small arrows
(Osmium tetroxide and lead citrate-uranyl acetate, 7,500X;
bar=2 µm).
and white matter) and astrocytosis (mild to moderate in
the gray matter and moderate in the white matter); and a
focal status spongiosus involving the white matter that
was suspected to have resulted from loss of axons sec-
ondary to the neuronal degeneration. In the floccular and
parafloccular lobes of the cerebellum, there was a reduc-
tion in the thickness of the molecular and granule cell
layers (with the latter accompanied by a reduction in the
number of granule cells) that most severely involved the
floccular lobe.
The accumulated pigment stained positively with
Sudan black and luxol-fast blue (for lipid), periodic acid-
Schiff (PAS) (for carbohydrates), Schmorl’s ferric ferri-
cyanide (for late lipofuscin), and Ziehl-Neelsen (for
acid-fast positivity) [Figure 3]. The pigment was also
autofluorescent when viewed with an ultraviolet light
September/October 1999, Vol. 35
Figure 4—Cervical spinal cord of a dog with ceroid
lipofuscinosis. An osmophilic body (center), surrounded by other
similar accumulations, is illustrated within the cytoplasm of a
neuronal cell body. Several multilaminar profiles (arrows) can be
seen within an irregular, amorphous material. Some of the
profiles (e.g., left side of the photograph) resemble the “finger-
print” pattern that is a characteristic feature of ceroid
lipofuscinosis (Osmium tetroxide and lead citrate-uranyl acetate,
37,600X; bar=0.5 µm).
source (wavelength range, 330 to 800 nm). A Sudan
black staining autofluorescent granular accumulation was
also present in the neurons of the retina (ganglion cells
and neurons of the inner and outer nuclear layers), dorsal
root ganglia, and autonomic visceral ganglia (e.g., my-
enteric plexuses of the intestine and ganglia within the
pancreas).
For ultrastructural examination, nervous tissue was
postfixed in osmium tetroxide, treated with lead citrate-
uranyl acetate, and embedded in Epon-araldite. Affected
neurons contained a variable number of membrane-bound
bodies that consisted of an irregular, amorphous mate-
rial. Some of the multilaminar profiles resembled the
“fingerprint” pattern described as being characteristic
for ceroid lipofuscinosis [Figure 4].
Other cells that contained sudanophilic granular ma-
terial that was autofluorescent included: hepatocytes,
renal tubular epithelium, pancreatic acinar and ductular
epithelium, islets of Langerhans, macrophages of the
liver (Kupffer’s cells), and cells of the spleen (focally in
the white and red pulp). Additional lesions of unknown
cause were limited to a mild to moderate, focal, subpleu-
ral, lymphocytic, plasmacytic, histiocytic inflammation
of the lung.
Discussion
Lysosomal storage diseases are the result of an inherited
genetic mutation resulting in a dysfunctional enzyme
activity that prevents normal degradation of products of
cellular metabolism.3 Without normal function of such
enzymes, metabolic substrates (i.e., lipid, glycoprotein,
or polysaccharide) accumulate within cells.3,7 Although
the mechanism of cell injury by substrate accumulation
September/October 1999, Vol. 35
is incompletely understood, it is proposed that these
metabolic products interfere with normal cellular func-
tion by physically disrupting cellular activities and cell
turnover and by the accumulation of cytotoxins.3 Lyso-
somal storage diseases generally have autosomal-reces-
sive inheritance, affect young animals, and worsen until
the patient dies or is euthanized because of severe neuro-
logical dysfunction.
Ceroid lipofuscinosis represents a group of inherited
diseases characterized by the abnormal accumulation of
lipoprotein pigment within cellular lysosomes. In the
dog, breeding studies have established an autosomal-
recessive pattern of inheritance in the English setter and
border collie. 10,11 Other canine breeds in which this dis-
ease has been reported include the poodle,12 blue heeler,13
Australian shepherd,5 Chihuahua, 14 English setter,10,6 sa-
luki,15 dachshund, 16 cocker spaniel,17 Dalmatian,18 and
Tibetan terrier. 4
Several theories have been advanced regarding the
mechanism of development of ceroid lipofuscinosis. Pro-
posed causes have included abnormalities of lipid
peroxidation,7 of fatty acid metabolism,11 or of lysoso-
mal dolichol phosphate metabolism.5,19 Recent evidence
has suggested the underlying cause in most forms of the
disease to be a mutation affecting metabolism of sub-
unit-c of mitochondrial adenosine triphosphate (ATP)
synthase.1,8 Most, but not all, forms of this disease are
characterized by abnormal lysosomal storage of a com-
ponent of the subunit-c protein and associated phospho-
lipids.1,8 The mechanism by which subunit-c accumulates
has not been clearly defined.
Clinically, ceroid lipofuscinosis is a disease charac-
terized by increasingly severe, progressive, neuronal de-
generation causing such signs as reduction in vision,
ataxia, hypermetria, behavioral abnormalities including
aggression and hypersensitivity, and ultimately seizures
and death.1,5,11 There are typically no abnormalities found
on fundic examination, hematology, biochemical serum
analysis, or CSF analysis.2,11 Visual loss is initially asso-
ciated with normal pupillary light and menace responses
and is likely due to damage of neurons within the occipi-
tal cortex. Progression of the disease likely causes blind-
ness through continued pigment accumulation within
retinal neurons and the optic nerve. Cerebellar disease
may also be responsible for loss of menace response.11 In
this patient, loss of vision and pupillary light responses
is likely due to the accumulation of abnormal pigment
within the retinal ganglion cells.
In humans, various forms of the ceroid-lipofuscinosis
diseases have been described, and most are differenti-
ated clinically by age of onset of clinical signs. Human
ceroid-lipofuscinosis syndromes are classified into four
primary subtypes: infantile, late infantile, juvenile, and
adult. 5,8 Jolly, et al., and others proposed a classification
system for the disease in dogs based on relative age of
onset and rate of progression of signs.1 The first type,
Ceroid Lipofuscinosis 433
prepubertal-protracted disease, is characterized by an
early onset of visual impairment and progression of dis-
ease to include tremors, ataxia, and seizures by 15 to 20
months of age. Some affected dogs may live to be seven
to eight years of age. The second form is the early-adult
acute-course disease, characterized by an onset of clini-
cal signs between 12 and 24 months of age, with increas-
ing severity until death by 28 months of age.1 Consistent
with other reports of ceroid lipofuscinosis in border col-
lies,2,11 the patient of this report fits into this category.
The third class of canine ceroid lipofuscinosis is the
adult form, in which there is a later onset of clinical
signs. 1 Signs may be first noted at three to eight years of
age. Worsening of the adult form may be gradual (seven
years in one report), or deterioration may occur over a
six- to 18-month period.1
Gross lesions of all forms of ceroid lipofuscinosis are
similar and include atrophy of the cerebrum and, in some
instances, the cerebellum,2,8,12 often with a yellow dis-
coloration and increased firmness of the brain tissue.1,8,12
There also is often an associated dilatation of the lateral
ventricles.1,5,8,12
The definitive diagnosis of this disease involves the
microscopic demonstration of abnormal intracellular
accumulation of lipopigment, demonstration of autofluo-
rescence, electron microscopic evaluation, and biochemi-
cal analysis of the storage material in affected tissue.
Special stains have also been used to identify the compo-
sition of the accumulated pigment which stains posi-
tively with Sudan black, Luxol-fast blue, and PAS, and
which stains variably with Ziehl-Neelsen for acid fast-
ness and Schmorl’s ferric ferricyanide method.7,8
Abnormal pigment accumulation can occur in neu-
rons of the brain, spinal cord, retina, and peripheral
ganglia (including neurons of the autonomic nervous
system).2,8 In the CNS there is distinct neuronal loss,
particularly in the cerebral cortex, but possibly also in
the cerebellum.1,4,12 Ceroid lipofuscinosis, more so than
other storage diseases, can have a high degree of neu-
ronal necrosis by an undefined mechanism of cellular
killing.8 Somatic cell involvement includes peribron-
chial phagocytes, hepatocytes, hepatic Kupffer’s cells,
splenic macrophages, renal tubular and thyroid epithelial
cells, and cells of the adrenal medulla. 2 Ultrastructurally,
the lysosomal accumulation can vary in appearance, with
the membrane-bound inclusions described as having a
fingerprint, curvilinear, crystalloid, or multilamellar
morphology. 1,2,5,8
The use of CT or magnetic resonance imaging (MRI)
is important to the diagnosis of many CNS diseases of
animals. The CT appearance of ceroid lipofuscinosis in
the dog has been reported in five English setters9 and one
poodle.12 In the latter report, the only finding on CT
examination was moderate, symmetrical dilatation of the
lateral and third ventricles, presumably due to atrophy of
the brain, which was confirmed on gross examination.12
434 JOURNAL of the American Animal Hospital Association
Computed tomography numbers as indicators of brain
tissue opacity were not reported in these studies.
Serial CT scans of English setters with ceroid
lipofuscinosis were reported in a study of a canine model
for human aging.9 Two, normal, age-matched control
English setters were compared to five dogs with ceroid
lipofuscinosis diagnosed by cerebral biopsy at three to
four months of age. The first affected dog scanned was in
terminal stages of the disease and showed severe brain
atrophy and hydrocephalus. Three English setters with
ceroid lipofuscinosis were scanned every one to four
months from 15 to 20 months of age until death at 24
months (four to five scans per dog). The degree of brain
atrophy and ventricular enlargement correlated with the
severity of clinical signs. Computed tomographic exami-
nation of severely affected dogs showed ventricular dila-
tation and diffuse cerebral-cerebellar atrophy. Mild
symptoms were associated with minimal enlargement of
the lateral ventricles, and as clinical signs progressively
became more severe, ventricular dilatation and brain
atrophy became more apparent. Cerebral atrophy and
ventricular dilatation were recognized only on CT in
animals manifesting signs of disease. A 14-month-old
affected dog with no abnormal neurological signs had
normal cerebral topography at necropsy.9 Although these
dogs had histological confirmation of disease at three to
four months of age, the earliest age at which ventricular
enlargement could be detected was 15 to 17 months.9
Proposed causes of cerebral and cerebellar atrophy were
decreased cell population, reduction in tract size, and
loss of tissue fluid.
In the present report, the CT diagnosis was mild cere-
bral atrophy and mild hydrocephalus. Computed tomog-
raphy (or Hounsfield) numbers, obtained from computer
analysis of images, are an expression of X-ray attenua-
tion normalized to water and represent tissue density. On
the Hounsfield scale, water has a CT number of zero, air
has a value of –1,000, and dense bone has a value of
+1,000. Thus, the higher the number, the greater the
opacity on the CT image. Computed tomography num-
bers of the white and gray matter were obtained from the
affected dog. The CT numbers were compared to images
of two normal dogs, using the same CT window and
centering levels [see Table]. The affected dog had mar-
ginally decreased gray matter CT numbers; therefore,
opacity of gray matter, as compared to that of the normal
control, was decreased. Similarly, the patient’s white
matter showed marginally increased CT numbers, corre-
sponding to an increased opacity relative to white matter
of normal dogs.
There have been several reports in the human litera-
ture regarding the CT appearance of various forms of
ceroid lipofuscinosis. 24–28 The most commonly noted
abnormalities include generalized cerebral atrophy,24,27,28
cerebellar atrophy,25,26 decreased opacity of white mat-
ter,24,28 and ventricular enlargement. 26,27 Magnetic reso-
September/October 1999, Vol. 35
nance images of humans having ceroid lipofuscinosis
show increased signal intensity of periventricular white
matter,22,23 cerebral atrophy, 21–23,25 cerebellar atro-
phy,21,23 hypointensity of the thalamus,21 hypointensity
of grey matter,22 and enlarged ventricles. 23 Several stud-
ies reported a correlation between the severity of CT or
MRI abnormalities and the severity of neurological dys-
function of the patient.21,25
As demonstrated in this report, storage diseases such
as ceroid lipofuscinosis should be considered as a differ-
ential diagnosis for increasingly severe multifocal or
diffuse brain disease in dogs of any age. While storage
diseases primarily affect young animals, it has been
shown that ceroid lipofuscinosis may affect dogs at vari-
ous stages of maturity. The dog of this report was an
adult that experienced a rapid degeneration of neurologi-
cal function. Computed tomographic examination may
be helpful in diagnosing the condition. Signs of cerebral
and cerebellar atrophy and ventricular enlargement are
most commonly noted. The use of objective evaluation
of brain opacity using CT numbers should be more thor-
oughly investigated in normal animals and in those with
CNS disease.
Acknowledgment
The authors would like to thank Miles S. Frey, BS (De-
partment of Veterinary Pathobiology and Image Analy-
sis Laboratory, Texas A&M University, College Station,
Texas) for his assistance in preparing photomicrographs
for this publication.
References
1. Jolly RD, Palmer DN, Studdert VP, et al. Canine ceroid-lipofuscinoses: a
review and classification. J Sm Anim Pract 1994;35:299–306.
2. Taylor RM, Farrow BRH. Ceroid-lipofuscinosis in border collie dogs. Acta
Neuropathol (Berl) 1988;75:627–31.
3. Evans RJ. Lysosomal storage diseases in dogs and cats. J Sm Anim Pract
1989;30:144–50.
4. Cummings JF, de Lahunta A, Riis RC, Loew ER. Neuropathologic changes
in a young adult Tibetan terrier with subclinical neuronal ceroid-
lipofuscinosis. Prog in Vet Neurol 1990;1:3:301–9.
5. Sisk DB, Levesque DC, Wood PA, Styer EL. Clinical and pathologic
features of ceroid lipofuscinosis in two Australian cattle dogs. J Am Vet
Med Assoc 1990;197:3:361–4.
6. Koppang N. Neuronal ceroid lipofuscinosis in English setters. J Sm Anim
Pract 1970;10:639–44.
7. Jolly RD, Hartley WJ. Storage diseases of domestic animals. Aust Vet J
1977;53:1–8.
8. Summers BA, Cummings JF, de Lahunta A. Veterinary neuropathology.
St. Louis: Mosby-Year Book, 1995:233–6.
9. Armstrong D, Quisling RG, Webb A, Koppang N. Computed tomographic
and nuclear magnetic resonance correlation of canine ceroid lipofuscinosis
with aging. Neurobiol Aging 1983;4:297–303.
10. Koppang N. Canine ceroid lipofuscinosis. A model for human ceroid-
lipofuscinosis and aging. Mech Aging Dev 1973;2:421–45.
11. Studdert VP, Mitten RW. Clinical features of ceroid-lipofuscinosis in
border collie dogs. Aust Vet J 1991;4:137–40.
12. Cantile C, Buonaccorsi A, Pepe V, Arispici M. Juvenile neuronal ceroid-
lipofuscinosis (Batten’s disease) in a poodle dog. Prog Vet Neurol
1996;7:82–7.
13. Cho DY, Leipold HW, Rudolf R. Neuronal ceroidosis (ceroid-lipofus-
cinosis) in a blue heeler dog. Acta Neuropathol (Berl) 1986;69:161–4.
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14. Rac R, Giesecke PR. Lysosomal storage disease in Chihuahuas. Aust Vet J 22. Vanhanen SL, Raininko R, Autti T, Santavuori P. MRI evaluation of the
1975;51:403–4. brain in infantile ceroid-lipofuscinosis. Part 2: MRI findings in 21 patients.
15. Appleby EC, Longstaffe JA, Bell FR. Ceroid-lipofuscinosis in two saluki J Child Neurol 1995;10(6):444–50.
dogs. J Comp Pathol 1982;92:375–80. 23. Wisniewski KE, Kida E, Connell F, Elleder M, Eviatar L, Konkol RJ. New
16. Vandervelde M, Fatzer R. Neuronal ceroid-lipofuscinosis in older subform of the late infantile form of neuronal ceroid lipofuscinosis.
dachshunds. Vet Pathol 1980;17:686–92. Neuropediatrics 1993;24(3):155–63.
17. Nimmo Wilkie JS, Hudson EB. Neuronal and generalized ceroid 24. Raininko R, Santavuori P, Heiskala H, Sainio K, Palo J. CT findings in
lipofuscinosis in a cocker spaniel. Vet Pathol 1982;19:623–8. neuronal ceroid lipofuscinosis. Neuropediatrics 1990;21(2):95–101.
18. Goebel HH, Bilzer T, Dahme E, Malkusch F. Morphological studies in 25. Machen BC, Williams JP, Lum GB, et al. Magnetic resonance imaging in
canine (Dalmatian) neuronal ceroid-lipofuscinosis. Am J Med Genet Suppl neuronal ceroid lipofuscinosis. J Comput Tomogr 1987;11(2):160–6.
1988;5:127–39. 26. Dunn DW. CT in ceroid lipofuscinosis. Neurology 1987;37(6):1025–6.
19. Hoover DM, Little PB, Cole WD. Neuronal ceroid-lipofuscinosis in a 27. Wende S, Ludwig B, Kishikawa T, Rochel M, Gehler J. The value of CT in
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1996;15(4):344–7. tomography in disorders of complex carbohydrate metabolism and related
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 Motor Neuron Abiotrophy in a Saluki
A nine-week-old saluki puppy was presented to Tufts University School of Veterinary Medicine
for progressive, generalized weakness and bilateral forelimb deformities. Examination
suggested a diffuse neuromuscular lesion. Cerebrospinal fluid (CSF) analysis showed normal
nucleated cell count and protein level; however, many macrophages had vacuolated cytoplasm.
Electromyography (EMG) recordings suggested denervation in paraspinal and appendicular
muscles. Tibial motor nerve conduction velocity was normal, but direct evoked muscle potential
had reduced amplitude. Histopathology revealed diffuse, symmetrical, degenerative motor
neuronopathy of the ventral horn of the spinal cord with associated lesions in nerves and
muscles. Histopathology was consistent with an abiotrophy that was likely inherited.
J Am Anim Hosp Assoc 1999;35:436–9.

M. Kent, DVM Introduction

K. Knowles, DVM,
Diplomate ACVIM
E. Glass, DVM
A. deLahunta, DVM, PhD,
Diplomate ACVIM
(Internal Medicine),
Diplomate ACVIM (Neurology)
K. Braund, DVM, PhD,
Diplomate ACVIM
J. Alroy, PhD
C nine spinal muscle atrophy (HCSMA), occurs in the Brittany spaniel.3
From the Tufts University School of
Veterinary Medicine (Kent, Knowles, Alroy),
200 Westboro Road,
North Grafton, Massachusetts 01536;
the College of Veterinary Medicine
(deLahunta),
Cornell University,
Ithaca, New York 14853-6401; the
Scotty-Ritchey Research Center (Braund),
College of Veterinary Medicine,
Auburn University,
Auburn, Alabama 36849-5563; and the
School of Veterinary Medicine (Glass),
University of Pennsylvania,
3900 Spruce Street,
Philadelphia, Pennsylvania 19104-6044.
Lower motor neuronopathies have been reported in humans, dogs, cats,
horses, goats, cattle, pigs, and mice.1 In humans, amyotrophic lateral
sclerosis (ALS) is the most frequent lower motor neuron disease in
adults.2 This progressive, degenerative process affects both upper and
lower motor neurons, with patients usually presenting for lower motor
neuron (LMN) signs. There are also a number of heritable LMN diseases
in humans. Werdnig-Hoffmann disease, the most common, is an acute,
progressive, infantile spinal muscle atrophy that is characterized by loss
of brain stem and spinal cord neurons. Infants are usually affected during
the first year of life and usually do not survive beyond three years of age.2
Kugelberg-Welander disease is a milder form of spinal muscle atrophy
that afflicts children in the first several years of life.2 Moreover, there are
other well-documented, inherited, spinal muscle atrophies that affect
various isolated muscle groups.2
In dogs, one of the most well-studied neuronopathies, hereditary ca-
This autosomal-dominant disorder has several phenotypic expressions
that vary from an acute, rapidly progressive syndrome to a more chronic,
slowly worsening disease. The resemblance to Werdnig-Hoffmann and
Kugelberg-Welander diseases has led to the idea that HCSMA of Brittany
spaniels might serve as an animal model for human disease.
Affected Brittany spaniels have pathological changes in brain stem and
spinal cord motor neurons that are a reflection of slow axonal transport,
leading to neurofilamentous accumulation.4 Similar pathological changes
have been seen in rottweilers.5,6
Other LMN diseases have been described in which neurofilamentous
accumulation is not a prominent feature. Stockard’s paralysis is one of the
first descriptions of congenital LMN disease.7 It was observed in Great
Dane and bloodhound crosses and Great Dane and St. Bernard crosses.
Hartley described nine dogs with LMN disease in New Zealand.8 Al-
though the LMN disease was not proven to be inherited, seven of the dogs
were between three and nine months of age. In addition, a hereditary
motor neuronal abiotrophy has been characterized in the Swedish Lapland
dog.9 An autosomal-recessive neurogenic muscle atrophy has been re-
ported in English pointers.10 Two Doberman pinscher puppies have been
studied and found to have degeneration of various brain stem nuclei and

436 JOURNAL of the American Animal Hospital Association

September/October 1999, Vol. 35
bulbar and spinal motor neurons. 1 Finally, a spinal mus-
cular atrophy in German shepherd dogs has been identi-
fied; it differs from previously reported neuronopathies,
because the degeneration is asymmetric and occurs only
in the cervical intumescence.11
The following report describes a newly identified
lower motor neuronopathy in a nine-week-old, male sa-
luki puppy. The degenerative histopathology is consis-
tent with an abiotrophy and is likely inherited.
Case Report
A nine-week-old, male intact saluki puppy was presented
for evaluation of an inability to walk normally and bilat-
eral forelimb deformities. The breeder noticed mild and
occasional generalized tremors and bilaterally symmet-
ric deformities of the carpi. The breeder felt that the
puppy’s ability to ambulate and the deformities had wors-
ened over the course of two weeks. The breeder had
noted that this puppy’s mentation and size were similar
to unaffected litter mates. The puppy was able to eat and
drink normally. No signs of systemic illness were
observed.
The puppy was one of a litter of seven saluki dogs.
There were four males and three females in the litter. No
problems were noted during parturition. At five weeks of
age, the puppies were prophylactically dewormed with
ivermectin. At five weeks of age, the entire litter experi-
enced an episode of diarrhea that lasted for one week and
resolved without medical intervention. Vaccinations were
current, and there was no history of toxin exposure or
trauma.
Similar signs were reported in a male sibling; that
puppy was euthanized and a postmortem examination
was not performed. The dam and sire were clinically
normal; this was the first litter from this cross.
On physical examination, no abnormalities were seen
apart from those involving the musculoskeletal and ner-
vous systems. The puppy stood with his elbows slightly
abducted. His carpi were flexed and showed a slight
varus deformation. In addition, his antebrachii were
slightly supinated. The puppy bore most of his forelimb
weight on the lateral aspects of the metacarpi and pha-
langes. Muscle atrophy was not appreciated.
Neurologically, the puppy was alert and responsive.
Cranial nerve examination was normal. The optic fundi
were also normal. The puppy’s gait was difficult to as-
sess due to his forelimb musculoskeletal abnormalities.
He had difficulty rising in the forelimbs and could sup-
port more weight on his pelvic limbs; however, his pel-
vic limbs often slid out from under him and occasionally
were used simultaneously (“bunny hopping”). Paresis
was evident as the puppy could only take a few strides
and then would lie down in sternal recumbency. The
degree of weakness did not appear to be affected by
exercise or rest. The puppy’s resting tone was normal.
Spinal reflexes, including flexor reflexes of the fore and
Motor Neuron Abiotrophy 437
hind limbs as well as the patellar and the cranial tibial
reflexes, were assessed as normal. If the puppy’s full
weight was supported, results of general proprioceptive
tests were normal. Fine tremors of the head were spo-
radically observed. Occasionally the puppy would ex-
hibit severe ventral neck flexion.
Physical and neurological examinations showed gen-
eralized weakness and limb contracture. The weakness
was attributed to a diffuse neuromuscular disorder. Pa-
thology could involve any portion of the motor unit,
including the cell body in the ventral horn, the LMN, the
neuromuscular junction, or the muscle. A congenital/
inherited disorder rather than acquired disease was sus-
pected due to the puppy’s age and the fact that similar
signs were reported in another litter mate.
Results of a complete blood count (CBC) and urinaly-
sis were normal. Serum biochemical profile results
showed an increase in serum alkaline phosphatase (325
U/L; reference range, 20 to 200 U/L) and serum phos-
phorous levels (9.6 mg/dl; reference range, 3.3 to 6.8
mg/dl). In addition, total protein was low (4.3 g/dl; refer-
ence range, 5.2 to 7.2 g/dl); however, both the serum
albumin and globulin levels were normal. Although out-
side the reference range for this laboratory, these values
were considered normal for the age of the puppy. 12 Se-
rum creatine phosphokinase level was slightly increased
(287 mg/dl; reference range, 20 to 200 mg/dl).
Radiographs, cerebrospinal fluid (CSF) collection, and
electrodiagnostic studies were performed under gas in-
halant anesthesia (i.e., isoflurane-oxygen). Radiographs
of the carpi and vertebral column were considered nor-
mal despite the marked flexion of the carpi. Cerebrospi-
nal fluid cell count and protein levels were normal.
Cytospin preparations showed several macrophages with
vacuolated cytoplasm. This was considered a nonspe-
cific finding that may have represented a change seen in
macrophages present in the CSF for a prolonged time.
Needle electromyograms (EMG) showed increased
insertional activity and denervation potentials (fibrilla-
tion potentials and positive sharp waves) from all the
appendicular muscles. Similar abnormalities were found
in all paraspinal muscles. Tibial motor nerve conduction
velocity was considered normal for the puppy’s age (38
m/sec; reference mean, 36.6±3.9 m/sec).13 Stimulation at
supramaximal intensity (slightly above the tuber calca-
neus and recording from the plantar interosseous muscle)
showed the direct-evoked muscle potential (DEMP) to
be of reduced amplitude (1.4 mV; reference mean,
15.7±0.98 mV).14
The puppy was euthanized, and a full necropsy was
performed. No gross abnormalities were found. Micro-
scopic examinations of the brain, spinal cord, proximal
and distal portions of the sciatic and radial nerves, the
cranial tibial, gastrocnemius, extensor carpi radialis, and
biceps brachii muscles were performed. Motor neuron
degeneration in the ventral grey columns was present
438 JOURNAL of the American Animal Hospital Association
Figure 1—Motor neuron from the ventral grey column of a nine-
week-old saluki puppy with a lower motor neuronopathy. The
affected neuron has a swollen cytoplasm with an accumulation of
vacuolated material and loss of Nissl substance (i.e., chromatoly-
sis) (Hematoxylin and eosin stain, 600X; 1 cm=20 µm).
bilaterally. There was no detectable difference in the
number of affected neurons in different regions through-
out the spinal cord. The affected neurons had swollen
cytoplasm with loss of Nissl substance (i.e., chromatoly-
sis), and they contained a peripheral accumulation of a
finely vacuolated material [Figure 1]. Other neurons were
shrunken or “ghost like” in appearance. Silver-stained
sections revealed swollen dendritic processes and en-
larged axons [Figure 2]. Evaluation of the ventral spinal
roots revealed a few scattered, degenerative fibers repre-
senting wallerian degeneration. There was a greater num-
ber of degenerating fibers in the distal sciatic nerves than
was seen in the proximal portions. No lesions were seen
in the spinal ganglia. The brain was normal, including
the cranial nerve nuclei III, V, VII, and XII.
Evaluation of the gastrocnemius and biceps brachii
muscles revealed mild fiber size variation with occa-
sional, angular, atrophic fibers. However, more pro-
nounced fiber size variation and type II muscle cell
atrophy were found in the extensor carpi radialis and
cranial tibial muscles.
Discussion
This nine-week-old saluki puppy shows some of the
same clinical signs and electrodiagnostic and pathologi-
cal findings as previously described for lower motor
neuronopathies.3–11 However, the distribution of the le-
sion is unique. Neuronal degeneration was observed only
in the LMNs of the spinal cord, and the degeneration was
distributed evenly throughout all of the spinal cord seg-
ments. Interestingly, the forelimbs were clinically more
affected in terms of weakness and muscle/tendon con-
tracture, yet muscle atrophy was not readily appreciated
and there was no difference in the number of neurons
affected in the sixth cervical to second thoracic spinal
cord segments. Despite these findings, the forelimb de-
formities were marked. In HCSMA of Brittany spaniels,
September/October 1999, Vol. 35
Figure 2—Motor neuron from the ventral grey column of a nine-
week-old saluki puppy with a lower motor neuronopathy. The
affected neuron has swollen dendritic processes and an enlarged
axon (Bielschowsky silver stain, 600X; 1 cm=20 µm).
a similar disparity was observed between the clinical
signs of weakness and the distribution and severity of
pathological changes in motor neurons of the spinal cord.3
The forelimb deformities likely represent arthrogryposis.
Arthrogryposis, a limb deformity characterized by cur-
vature or retention of the joint in a flexed or extended
position, has been described in calves infected with
Akabane virus and in Swedish Lapland dogs with an
inherited abiotrophy of somatic efferent neurons.15 In
both of these conditions, arthrogryposis develops in the
limbs innervated by the affected ventral grey column of
the spinal cord. Neurogenic atrophy of the appendicular
musculature most likely resulted in the arthrogryposis
observed in this saluki. In this case, the bones of the
limbs continued to grow while the length of the atro-
phied muscles remained static, placing abnormal stress
on joints, ligaments, and tendons, resulting in limb
deformity.
The electrodiagnostics were consistent with a motor
neuronopathy. The reduced amplitude of the DEMP is
likely a consequence of fewer axons contributing to the
amplitude of the evoked potential. Axon loss was a result
of a loss of neurons. Likewise the increased insertional
activity and denervation potentials were present as a result
of denervated muscle from a loss of ventral horn neurons.
The axonal degeneration in this saluki puppy was
similar to that reported in rottweilers5,6 and pointers10
with motor neuronopathies. The majority of wallerian-
like degeneration was seen in the distal aspects of the
peripheral nerves, with a lesser number of axons affected
in the proximal aspects of the peripheral nerve and ven-
tral spinal roots. It is not known whether this is a result of
the population of neurons affected (i.e., degeneration of
the neurons that innervate the distal limb musculature).
Alternatively, this may be a result of decreased axonal
transport of a trophic factor, culminating in a dying back
phenomenon that first affects the most distal aspect of
the longest axons.
September/October 1999, Vol. 35
This is the first lower motor neuronopathy reported in
the saluki. Given the age of onset and the degenerative
histopathology, this likely represents an inherited neu-
ronal abiotrophy.
References
1. Summers BA, Cummings JF, DeLahunta A. Hereditary, familial, and
idiopathic degenerative diseases. In: Summers BA, Cummings JF,
DeLahunta A, eds. Veterinary neuropathology. St. Louis: Mosby,
1995:307–15.
2. Williams D, Windebank A. Motor neuron disease. In: Dyck PJ, ed.
Peripheral neuropathy. Vol. 2. 3rd ed. Philadelphia: WB Saunders,
1993:1028–50.
3. Cork LC, Griffin JW, Choy C, Padula CA, Price DL. Pathology of motor
neurons in accelerated hereditary canine spinal muscular atrophy. Lab
Invest 1982;46:89–99.
4. Cork LC, Griffin JW, Adams RJ, Price DL. Animal model of human
disease: motor neuron disease: spinal muscular atrophy and amyotrophic
lateral sclerosis. Am J Pathol 1980;100:599–602.
5. Shell LG, Jortner BS, Leib MS. Spinal muscular atrophy in two rottweiler
littermates. J Am Vet Med Assoc 1987;190:878–80.
Motor Neuron Abiotrophy 439
6. Shell LG, Jortner BS, Leib MS. Familial motor neuron disease in rottweiler
dogs: neuropathologic studies. Vet Pathol 1987;24:135–9.
7. Stockard C. An hereditary lethal for localized motor and preganglionic
neurons with a resulting paralysis in the dog. Am J Anat 1936;59:1–53.
8. Hartley H. Lower motor neuron disease in dogs. Acta Neuropathol (Berlin)
1963;2:334–42.
9. Sandefeldt E, Cummings J, deLahunta A, et al. Hereditary neuronal
abiotrophy in the Swedish Lapland dog. Cornell Vet 1973;63
(suppl 3):1–71.
10. Inada S, Sakamoto H, Haruta K, et al. Clinical study on hereditary
progressive neurogenic muscular atrophy in pointer dogs. Jpn J Vet Sci
1978;40:539–47.
11. Cummings J, George C, Delahunta A, et al. Focal spinal muscular atrophy
in two German shepherd pups. Acta Neuropathol (Berlin) 1989;79:113–6.
12. Center S, Hornbuckle W, Hoskins J. The liver and pancreas. In: Hoskins J,
ed. Veterinary pediatrics: dogs and cats from birth to six months.
Philadelphia: WB Saunders, 1995:189–225.
13. Swallow J, Griffiths I. Age related changes in the motor nerve conduction
velocity in dogs. Res Vet Sci 1977;23:29–32.
14. Sims M, Redding R. Maturation of nerve conduction velocity and the
evoked muscle potential in the dog. Am J Vet Res 1980;41:1247–52.
15. Noden DM, DeLahunta A. The embryology of domestic animals:
developmental mechanisms and malformations. Baltimore: Williams &
Wilkins, 1985:206–8.
 Evaluation of a Skin Stapler for
Belt-Loop Gastropexy in Dogs
A new method for attachment of a belt-loop gastropexy using disposable, stainless steel skin
staples was compared with a traditional hand-sewn belt-loop gastropexy technique in 24 fresh
dog cadavers. Mean gastropexy times were 212 seconds for the stapled technique and 435
seconds for the hand-sewn technique. The stapled belt-loop gastropexy was significantly faster
than the hand-sewn technique (P less than 0.001). There was no statistically significant
difference in the mean maximum tensile strength between the two attachment methods. This
study provides a basis for clinical evaluation of the stapled belt-loop gastropexy technique in
dogs. J Am Anim Hosp Assoc 1999;35:440–4.

Bradley R. Coolman, DVM, MS Introduction

Sandra Manfra Marretta, DVM,
Diplomate ACVS, Diplomate AVDC
Gerald J. Pijanowski, DVM, PhD
Shindok L. Coolman, BS, MS
O deterioration of affected dogs.4 The goals of surgery are gastric decom-
From the Departments of
Veterinary Clinical Medicine
(Coolman, Manfra Marretta, Coolman) and
Veterinary Biosciences (Pijanowski),
College of Veterinary Medicine,
University of Illinois,
Urbana, Illinois 61801.
Doctor Coolman’s current address is
Veterinary Surgical Services,
5818 Maplecrest Road,
Fort Wayne, Indiana 46835.
Gastric dilatation and volvulus (GDV) is a life-threatening disorder of
large, deep-chested dogs.1–16 Although numerous risk factors for GDV
have been identified, the exact cause remains unknown.1–5 It has been
estimated that 40,000 to 60,000 dogs in the United States are affected with
GDV each year.6 Recent retrospective studies have shown mortality rates
of 15%1 and 33% 2 for dogs with GDV.
Emergency surgical intervention following patient stabilization is ad-
vocated in cases of GDV because of the high case-fatality rate and rapid
pression and repositioning; evaluation of gastric and splenic viability; and
prevention of recurrence by permanent gastropexy to the abdominal wall.4
Dogs treated for GDV without a gastropexy have recurrence rates as high
as 80%;7 however, recurrence of GDV following a variety of permanent
gastropexy techniques is less than 5%.7–10
Numerous surgical techniques for gastropexy have been described.
The most commonly used techniques are the tube gastropexy, circumcostal
gastropexy, belt-loop gastropexy, and incisional gastropexy.5 Many sur-
geons prefer the belt-loop gastropexy because it is technically simple,
relatively rapid to perform, associated with few complications, and it
creates a strong, permanent adhesion.5,11
The purpose of this study was to evaluate a new method for attachment
of the belt-loop gastropexy with disposable, stainless steel skin staples
instead of monofilament suture material. The authors’ hypothesis was that
a belt-loop gastropexy attached with skin staples would require signifi-
cantly less time to perform, without a loss of attachment strength. The
time required to perform the gastropexy and the immediate tensile strength
of the attachment for a stapled belt-loop gastropexy were compared with a
hand-sewn belt-loop gastropexy in fresh cadaver dogs. This study was
designed to provide a basis for clinical application of the stapled belt-loop
gastropexy technique.

Funded by a grant from the Northern Illinois Materials and Methods

Veterinary Medical Association. Twenty-four, mixed-breed dogs weighing between 22 kg and 34 kg were
A portion of this work was presented at the utilized for the study. The dogs were obtained as fresh cadavers immedi-
Annual Meeting of the American College of ately after euthanasia by intravenous injection of a barbiturate agent,
Veterinary Surgeons, 1998. following termination of an unrelated research project. The Institutional

440 JOURNAL of the American Animal Hospital Association

September/October 1999, Vol. 35
Figure 1—In situ appearance of the stapled belt-loop gas-
tropexy as viewed from the dog’s left side. The right body wall is
at the top of the drawing and the stomach is below. Note the
sutures positioned in each corner which facilitate placement of
the staples.
Animal Care and Use Committee approved all animal
use. The study was performed during three separate ses-
sions, using eight dogs per session. All of the gastropex-
ies were performed by the same surgeon (B. Coolman)
and an assistant, under simulated surgical conditions
within two hours of euthanasia. Biomechanical testing
was completed within four hours of euthanasia. Four
gastropexies attached by each method were performed
and tested during each session, for a total of 24 (12
stapled and 12 hand-sewn) gastropexies.
Surgical Technique
The cadavers were randomly assigned to one of the two
gastropexy techniques. Each cadaver was positioned in
dorsal recumbency, and a 20-cm ventral midline incision
was made from the xiphoid process caudally. The gastric
antrum and the prospective gastropexy site on the right
lateral body wall were identified. Using a tissue marking
pen, a 4-cm long by 2.5-cm wide outline of a rectangular
flap, centered on a serosal blood vessel, was made on the
greater curvature of the gastric antrum. Next, two 2.5-cm
long marks were made (2.5 cm apart) parallel to the
fibers of the transversus abdominus muscle on the right
body wall, starting 3 cm behind the last rib.11
The premarked gastric seromuscular flap and body
wall “belt-loop” outlines were incised using a no. 10
scalpel blade. The seromuscular flap was raised from the
gastric antral submucosa with Metzenbaum scissors, us-
ing a combination of sharp and blunt dissection. Once
raised, the seromuscular flap was passed in a caudal to
cranial direction through the “belt-loop” in the transver-
sus abdominus muscle. The leading edge of the seromus-
cular flap was reattached using a simple interrupted
suture of 0-polydioxanone sulfatea in each corner.
For the stapled anastomosis group, a Royal 12W fixed-
head disposable skin staplerb was used to reattach the
seromuscular layers of the stomach. Four staples were
equally spaced along each side of the flap, and two
Belt-Loop Gastropexy 441
Figure 2—Stapled belt-loop gastropexy at the initiation of
tensiometric testing. The stomach is positioned in the upper
clamp, and the section of right body wall is positioned in the
lower clamp.
staples were placed across the end, between the sutures.
An additional staple was placed in the middle of each
incision in the transversus abdominus muscle to close
the resultant gap. A total of 12 staples were used to
perform each gastropexy [Figure 1]. The hand-sewn belt-
loop gastropexies were attached in a similar fashion
using the same number of identically placed simple in-
terrupted sutures of 0-polydioxanone sulfate.
Total gastropexy time measurements were recorded
from the first incision in the gastric serosa until the final
suture or staple was placed. In addition, the time re-
quired to raise the seromuscular flap and the time re-
quired to attach the gastropexy (subsets of the total
gastropexy time) were recorded for each procedure. Im-
mediately after completion of the gastropexy, the stom-
ach and an 8-cm by 8-cm section of the right body wall,
including the last two ribs, were harvested for tensiomet-
ric evaluation. The tissues were kept moistened in
individual containers at room temperature until the bio-
mechanical testing was performed.
Biomechanical Testing
The maximum tensile strength of each gastropexy was
determined using an Instron materials testing machine.c
Samples were evaluated by placing them into specially
designed vice grips which had textured safety walk tape
covering the jaws to prevent slippage. The section of the
body wall containing the last two ribs was secured in the
bottom clamp, and the full thickness of the body of the
stomach was secured in the top clamp [Figure 2].
Distraction of the stomach from the body wall was
initiated and proceeded at a rate of 20 mm per minute
until the gastropexy failed. A load-displacement curve
was generated for each test, and data was recorded using
customized computer software.d The tensile strength of
each sample was defined as the maximum load sustained
in newtons (N) by the gastropexy before failure [Figure
442 JOURNAL of the American Animal Hospital Association
Figure 3—Maximum tensile loading (61 newtons) of the stapled
belt-loop gastropexy seen in Figure 2. This specimen failed by
tearing of the transversus abdominus muscle fibers.
3]. The tensile strength as well as the mode of failure
were recorded for each sample.
Statistical Analysis
The times required to raise the gastric seromuscular flap,
to attach the gastropexy, and the total procedural times
for the stapled and hand-sewn gastropexies were com-
pared. The mean maximum tensile loads sustained be-
fore failure for the two techniques were compared.
Statistical analysis was performed using the two-sample
t-test, with a significance level set at p less than 0.05.
Statistical analysis was performed on SAS computer
software.e
Results
The mean total gastropexy times were 212±30 seconds
for the stapled technique and 435±41 seconds for the
hand-sewn technique. The stapled technique was signifi-
cantly faster (p less than 0.0001) than the hand-sewn
technique. The mean gastropexy attachment times were
109±17 seconds for the stapled technique and 316±23
seconds for the hand-sewn technique. Mean gastropexy
attachment times were significantly less with the stapled
technique (p less than 0.0001). There was no significant
September/October 1999, Vol. 35
difference in the mean time required to raise the gastric
seromuscular flap for either group.
The mean maximum tensile strengths were
52.87±12.63 N for the stapled gastropexy group and
53.05±15.53 N for the hand-sewn gastropexy technique.
There was no difference in the strength of the two groups
(p equals 0.98).
Although individual sutures and staples failed during
tensile testing, in none of the specimens did the gas-
tropexy fail by complete pull-out of the attachment. Thir-
teen of the gastropexies (five hand-sewn and eight
stapled) failed by tearing of the transversus abdominus
muscle, perpendicular to the parallel incisions. The other
11 gastropexies (seven hand-sewn and four stapled) failed
by ripping of the seromuscular gastric flap near the base,
at the greater curvature of the gastric antrum.
Discussion
Because most dogs undergoing surgery to correct GDV
are high-risk anesthetic candidates, efforts should be
made to minimize operative time.4,5 The belt-loop gas-
tropexy procedure was developed because it is rapid,
technically simple, and creates a consistent, strong adhe-
sion. 11 By attaching the belt-loop gastropexy with stain-
less steel skin staples, the ease and strength of the
procedure are maintained, but the time required to per-
form the gastropexy is reduced by more than half. In the
authors’ study, the mean procedural time was reduced
from seven minutes and 15 seconds for a hand-sewn belt-
loop gastropexy to three minutes and 32 seconds for a
stapled belt-loop gastropexy. Significant time savings were
realized during the attachment phase of the procedure.
The minimum tensile strength required for a gas-
tropexy to effectively prevent GDV is unknown.12 It
appears that several currently used gastropexy techniques
effectively produce a permanent adhesion that is strong
enough to prevent recurrent GDV in most cases.8–16 In
the authors’ study, there was no difference in the imme-
diate tensile strength between the stapled (mean, 52.87
N) and the hand-sewn (mean, 53.05 N) belt-loop gas-
tropexies. Although no prior studies were identified that
report the immediate tensile strength of the belt-loop
gastropexy, the forces sustained by the authors’ gas-
tropexies were within the range of immediate failure
strengths reported for the permanent (mean, 36.79 N)
and tube (mean, 59.35 N) gastropexy techniques.12 How-
ever, the immediate, mean maximum tensile strength
reported for the circumcostal gastropexy was 105.9 N,12
approximately twice that of the belt-loop gastropexies
that were tested. The authors expect that the stapled and
hand-sewn belt-loop gastropexies would have similar
long-term tensile strength as the gastropexy adhesion
forms, and that both techniques would produce an adhe-
sion sufficient to prevent recurrent GDV.
Disposable skin staplers are readily available to vet-
erinary surgeons and are produced by several different
September/October 1999, Vol. 35
manufacturers.17 Autosuture disposable stapling guns
come preloaded with up to 35 stainless steel, single-fire
staples in either regular (4.8 mm by 3.4 mm) or wide (6.5
mm by 4.1 mm) closed staple dimensions. The authors’
preliminary testing in cadavers showed that the wide
staples were preferred for belt-loop gastropexy because
they were easier to securely grasp and reappose the
edges of the seromuscular gastric flap. However, a belt-
loop gastropexy can also be performed with regular-
sized staples. This study compared a hand-sewn belt-loop
gastropexy made with 0-polydioxanone sulfate to a
stapled belt-loop gastropexy using wide-dimension skin
staples produced by a single manufacturer. The authors
have also performed the stapled gastropexy technique
using wide skin staples produced by other manufactur-
ers, and they found them satisfactory.
The use of stapling devices in veterinary surgery is
often limited by cost concerns. Competition among
manufacturers of skin staplers has brought costs down to
a level that is comparable to other traditional methods of
wound closure.17,18 The described technique of a stapled
gastropexy would not add appreciably to the surgical
costs. A single disposable skin stapler containing 35
stainless steel staples would replace several packages of
suture material. Two packages of suture would be re-
placed by the surgical staples for the gastropexy, and
after completion of the gastropexy the remaining staples
could be used for skin closure. In addition, the operative
and anesthetic time saved by using the stapler would
offset the slight increase in the cost of the stapling equip-
ment over sutures.
Skin staples are composed of surgical-grade stainless
steel wire, which is a nonreactive, nonabsorbable suture
material with good mechanical properties.18 The Auto-
suture Royal disposable stapler used for this study contains
staples of 0.56-mm diameter wire. Stainless steel is inert
and can be used in both clean and contaminated surgical
wounds.19 Skin staples have been used successfully for
closure of gastrointestinal wounds in dogs20 and humans21
without reported complications. The staples are radio-
paque and would show up on future radiographic studies.
The gastropexies in this study failed by either tearing
of the body wall belt-loop (n=13) or tearing of the sero-
muscular gastric flap (n=11). In no cases was ultimate
failure achieved by pulling out of the suture or staple
line. Previous authors have suggested that the seromus-
cular gastric flap represents the weakest point of the belt-
loop gastropexy.16 The authors’ data shows that the
seromuscular gastric flap and the muscular body wall
loop fail with almost equal frequency when tested to
failure immediately after attachment. Results of this study
also demonstrate that for both the hand-sewn and the
stapled belt-loop gastropexy, the weakest point initially
is the tissue itself and not the attachment.
Based on the results of this preliminary study, clinical
evaluation of a disposable skin stapler for belt-loop gas-
Belt-Loop Gastropexy 443
tropexy in dogs is justified. The method is easy to per-
form, comparable in cost, significantly faster, and does
not compromise the strength of the initial attachment
when compared to the traditional suturing method. The
significant time savings achieved with the stapled tech-
nique may benefit dogs with GDV syndrome.
a
PDSII; Ethicon, Inc., Somerville, NJ
b
Autosuture Royal, Disposable Skin Staples; United States Surgical Corp.,
Norwalk, CT
c
Instron Mini 44; Instron Corp., Canton, MA
d
Lab View Platform; Amtel, Urbana, IL
e
SAS/STAT Software; SAS Institute, Cary, NC
Acknowledgment
The authors would like to thank the United States Surgi-
cal Corporation, Norwalk, Connecticut for donation of
the surgical staples used in this project.
References
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volvulus syndrome in a veterinary critical care unit: 295 cases (1986–
1992). J Am Vet Med Assoc 1995;207(4):460–4.
2. Glickman LT, Glickman NW, Perez CM, Schellenberg DB, Lantz GC.
Analysis of risk factors for gastric dilatation and dilatation-volvulus in
dogs. J Am Vet Med Assoc 1994;204(9):1465–71.
3. Glickman LT, Glickman NW, Schellenberg DB, Simpson K, Lantz GC.
Multiple risk factors for the gastric dilatation-volvulus syndrome in dogs:
a practitioner/owner case-control study. J Am Anim Hosp Assoc
1997;33:197–204.
4. Matthiesen DT. Gastric dilatation-volvulus syndrome. In: Slatter D, ed.
Textbook of small animal surgery. 2nd ed. Philadelphia: WB Saunders,
1993:584–93.
5. Hosgood G. Gastric dilatation-volvulus. J Am Vet Med Assoc
1994;204:1742–7.
6. Hardie RJ, Flanders JA, Schmidt P, et al. Biomechanical and histological
evaluation of a laparoscopic stapled gastropexy technique in dogs. Vet Surg
1996;25:127–33.
7. Wingfield WE, Betts CW, Greene RW. Operative techniques and
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