VCA Arboretum View Animal Hospital

Transcription

1 Home care instructions for Pepper Internal Medicine Patient care team: Patient Care Coordinator: Jenny Day, Ashley Pittman Internal Medicine Technicians: Elyse Andrews, CVT; Patricia Taylor, CVT; Stephanie Sakwa, Abby Strait; Cindy Peterson, CVT Clinicians: Joao Felipe de Brito Galvao, MV, MS, DACVIM (SA Internal Medicine); Cristiane Otoni, MV, DACVIM (SA Internal Medicine)? Diagnosis: 1. Severe thrombocytopenia - presumed ITP (immune-mediated thrombocytopenia) 2. Worsening regenerative anemia - open - IMHA vs. blood loss 3. Moderately elevated white cell count 4. Severely enlarged liver with few nodules and one mass 5. Enlarged spleen 6. Severe generalized muscle atrophy 7. Soft stools 8. Small nodule on right anal gland 9. Heart murmur 10. Significant proteinuria 11. Flea infestation Current Treatment (type, dose, frequency, route): Medications: Dexamethasone SP 4mg/mL mL IV SID Cerenia 10mg/mL - 1.4mL IV SID Pantoprazole 4mg/mL - 3.5mL IV SID Cyclosporine 50mg Capsules - 1 capsule PO BID Cyclosporine 25mg Capsules - 1 capsule PO BID Aspirin 81mg - 1/4 tablet PO SID IV Fluids (include additives): Isolyte 66mL/hr Diagnostic Procedures: 1. Complete blood count and pathologist review - Severely decreased platelet count. Moderate anemia with significant regeneration. Moderately elevated white cell count. Pathologist review: Reported results/findings are confirmed upon pathologist's review. A regenerative anemia is present in which the cause is not cytologically apparent. No hemotropic organisms or morphologic abnormalities are observed. Hemorrhage (coagulopathy, bleeding neoplasm, GI ulceration, blood sucking parasites) or hemolysis (infectious causes, idiopathic immune mediated process) are the most likely causes of regenerative anemias. Evaluation of the patient for any evidence of hemorrhage is suggested. Additionally, if an immune mediated component is of clinical concern, Coombs testing could be considered. Correlate with clinical findings/history. Additionally, there is a thrombocytopenia in which the cause is not cytologically apparent. General causes to consider include increased consumption/destruction (immune mediated, tick related diseases, DIC, occult neoplasia/paraneoplastic response) and decreased production at the level of the bone marrow (neoplasia, infectious, drug toxicity). If persistent and unexplained a bone marrow aspirate/biopsy could be considered if found to be clinically warranted. Tick borne disease testing could also be considered if found to be clinically warranted/appropriate for this patient. Lastly, there is a significant neutrophilia and monocytosis present. These findings are supportive of an underlying inflammatory process in which the cause is not Page 1 of 5

2 cytologically apparent. General causes to consider include disorders characterized by suppuration, necrosis, malignancy, hemolysis (neutrophilia with a left shift is a common finding with IMHA), hemorrhage, immune injury and pyogranulomatous diseases. Evaluation of the patient for sources of inflammation is recommended. 2. Chemistry - Mildly elevated ALKP. Otherwise unremarkable. 3. Urine analysis - Normal concentration. Large amount of protein present. Otherwise unremarkable. 4. Thyroid level - Normal at PCV /TP - 24% / Abdominal Ultrasound - Assessment: The parents of the stomach and some images of small intestine are suggestive of chronic gastroenteritis; rule-out IBD, food hypersensitivity, intestinal parasites, or other etiologies. Possible pancreatitis, current or resolving, cannot be ruled out. Chronic hepatopathy or hepatitis may be present; nodular change may be benign or could indicate neoplasia. Liver biopsy or cytology could be performed. Alternatively, follow-up ultrasound to evaluate these nodules for change is recommended. Mild splenomegaly; this may be secondary to immune mediated disease, infiltrative neoplasia or inflammation. Mild sublumbar lymph node enlargement is present; rule-out reactive or possible neoplasia. Cytology of the spleen and lymph nodes may be helpful in obtaining a more definitive diagnosis. Specialist Comments: Mild cardiomegaly is observed on the radiographs without signs of heart failure. No pulmonary metastasis is observed. No significant mass effect is identified in the abdomen. If questions or comments, please feel free to contact. To view diagnostic images for this patient online, please go to and enter the following exam number as shown below. Exam number: F Assessment: Pepper was transferred to the internal medicine service for further assessment of anemia and low platelet count. She was acquired by the rescue about 1 weeks ago and just received her vaccines. Initial wellness bloodwork showed slight anemia and elevated white cell count. She was placed on enrofloxacin for possible infection. Bloodwork was repeated a few days later and showed slightly low platelets and significant drop on red blood cells (from 35 to 25% HCT). Lyme, heartworm, anaplasma and ehrlichia tests were negative. A bruise on the skin was found and she was started on metronidazole, doxycycline and prednisone. She then presented to our emergency service to recheck red blood cell percentage. Pepper was doing well at that point. Bloodwork was performed and showed severely low. Pathologist review was also performed and showed no obvious evidence of hemolytic anemia. She was started on cyclosporine to help with treatment of immune-mediated thrombocytopenia (ITP). Pepper has been diagnosed with immune-mediated thrombocytopenia (ITP), which is a disease characterized by destruction of the platelets by the immune system. Destruction of the platelets leads to anemia when the rate of destruction exceeds the minimal level that prevents spontaneous bleeding. Overall platelet count decreases when destruction surpasses bone marrow's ability to produce new platelets. In most cases, there is no underlying cause for the body to start rejecting its own platelets. Then, this process is called idiopathic (of unknown cause) or primary ITP. In some patients, other conditions such as infections, history of being exposed to certain medications, vaccinations, and cancers can trigger the immune system to destroy the platelets, a condition called secondary ITP. The most common infectious causes are tick-borne diseases. Unfortunately, there are several tick-borne diseases that can lead to ITP. Pepper was tested for the most common ones and he was negative. Because it is impossible to test Pepper for all possible tick borne infections, we recommend continuing with the doxycycline treatment for 4 weeks. To look for evidence of cancer or other conditions that could be the cause fr ITP, we recommended an abdominal ultrasound. Thoracic radiographs were performed recently by the family veterinarian and showed mild enlargement of the heart but no causes for ITP. Abdominal ultrasound showed a severely enlarged liver and spleen. There were also a few nodules and one larger mass on the liver. The liver nodules are unlikely to be linked to the ITP however, the enlargement of the liver and spleen, may be secondary to cancers such as lymphoma, which could be the cause for the ITP. Because Pepper's platelets are low, we cannot perform a cytology of these organs due to risk of major bleeding. Therefore, we Page 2 of 5

3 recommend continuing the treatment for ITP and once the platelets are back to normal, we will perform cytology of the spleen and liver to rule out cancer. ITP is treated with steroids (prednisone) and other drugs such as Atopica, used to suppress the immune response that is destroying the platelets. The response to therapy is very individually dependent, and there is no reliable way to predict how patients will respond to therapy long-term. Some patients require lifelong therapy with steroids to maintain their platelet count in normal range. However, most patients that respond to therapy experience remission of their ITP after several months of therapy and do not require lifelong medications. Even though prednisone is the most important immunosuppressive medication, some patients require treatment with other immunosuppressive medications in addition to steroids in order to prevent destruction of their platelets. Also, some patients respond to therapy initially but then experience relapses, necessitating more intensive therapy and even hospitalization in some cases. In addition, steroid therapy can have many side effects, and the goal of treatment of ITP is to reduce the doses to the lowest doses that will control the anemia while avoiding the side effects of the medications. The key to managing ITP is careful monitoring with periodic blood work. Pepper will need to be seen by Dr. your family vet or Dr. Otoni every 4-6 weeks to have his CBC checked. Based on these results, his steroid dose may be changed or additional medications may be added to his regimen. The doses of his medications must be tapered very slowly (25% every 4-6 weeks) so that he does not experience a relapse. It is very important that Pepper's blood work be performed every 4-6 weeks so that his medications can be adjusted appropriately. In addition, vaccinations can trigger the immune response that destroys red blood cells in some patients. Because of this, we may consider measuring Pepper's immune system's ability to respond to common infectious agents via a blood test (called "titers") to determine whether he has adequate levels of protection. If his levels of protection are adequate, vaccines are unnecessary. Overall, ITP is considered a very serious disease with only approximately average 50-75% survival to discharge from the hospital. Unfortunately, only 50-75% of dogs that left the hospital are alive 6 months later. Most causes of death are due to euthanasia because of financial constraints. Less commonly death can be caused by bleeding into the brain or lungs, concurrent infections, relapses and other consequences of long-term steroids. Bleeding in organs such as the lungs, kidneys, and brain, leads to complications such as kidney failure, respiratory distress, and neurological signs. Besides ITP and possibly IMHA, Pepper has other less emergent but also important problems that will have to be addressed in the near future such as generalized severe muscle atrophy, a loud heart murmur and protein being lost via his kidneys. Once his ITP is stable, we will make further recommendations to address the other problems. Surgery at this point is not in Pepper's best interest. Monitoring Observe Pepper carefully at home for increased lethargy, rapid breathing (> 50 breaths per minute when at rest and not panting), breathing with increased effort, abnormal behavior (circling, incoordination, disorientation), bruising, exercise intolerance, weakness, collapse, decreased appetite, vomiting, diarrhea, and paleness of the eyes, ears and gums, and contact your family vet or Dr. Otoni if noted. Medications: Doxycycline 100 mg: Please give 1 capsule orally every 12 hours until gone. This is an antibiotic. Side effects include nausea Page 3 of 5

4 (indicated by drooling and restlessness), vomiting, and regurgitation. If any of these signs are noted, contact Dr. Otoni. Follow this medication with a meal. Prednisone 20 mg tablets: Please give 3/4 tablets orally every 12 hours until otherwise directed by Dr. Otoni. The dose will be adjusted over time. This is a steroid used to suppress the immune response. The side effects that are expected with this medication include increased thirst and urination, increased appetite, weight gain, hair thinning and loss, and panting. These effects will occur, but if they are severe enough to affect Pepper's quality of life, contact Dr. Otoni. Additional side effects include GI ulceration indicated by dark tarry stool, diarrhea, vomiting blood, and vomiting material that resembles coffee grounds. Contact Dr. Otoni if any of these signs are noted. Because this medication suppresses the immune system, Pepper will be more susceptible to infections, particularly of the skin and urinary tract. Our goal is to gradually taper the dose over time to the lowest dose that will control the clinical signs in order to decrease the side effects associated with this medication. Do not stop this medication abruptly. This can lead to life-threatening complications. Non-flavored Aspirin 81 mg: Please give 1/4 tablet orally every 24 hours until otherwise instructed by Dr. Otoni. This medication is being prescribed to prevent blood clots. Side effects include GI ulceration evidenced by blood in stool, dark tarry stool, diarrhea, vomiting blood, and vomit that resembles coffee grounds. Contact Dr. Otoni if any of these signs are noted. Any over-the-counter brand of aspirin may be given, but ensure that the tablet size is 81 mg, and that the tablets contain only aspirin. Cyclosporine (Atopica ) 50 mg: Please give 1 capsule orally every 12 hours until otherwise directed by Dr. Otoni. This is an immunosuppressant. Side effects include increased hair growth, growth of gum tissue, vomiting, decreased appetite, and diarrhea. This medication is veterinary only and Atopica cannot be substituted for human forms of cyclosporine. If any of these signs are noted, contact Dr. Otoni. Give this medication with a meal. Cyclosporine (Atopica ) 25 mg: Please give 1 capsule orally every 12 hours until otherwise directed by Dr. Otoni. This is an immunosuppressant. Side effects include increased hair growth, growth of gum tissue, vomiting, decreased appetite, and diarrhea. This medication is veterinary only and Atopica cannot be substituted for human forms of cyclosporine. If any of these signs are noted, contact Dr. Otoni. Give this medication with a meal. Omeprazole (over-the-counter Prilosec ) 20.6 mg: Please give 1 capsules orally every 24 hours until otherwise directed. This pill cannot be split or crushed. This medication can be purchased over-the-counter from grocery stores or drug stores. This is an antacid used to reduce the acidity of the stomach contents, aiding to treat and prevent GI ulceration. Side effects include vomiting, diarrhea, and decreased appetite. If any of these signs are noted or if Pepper's vomiting becomes more severe while taking this medication, contact Dr. Otoni. Please call 24 to 48 hours in advance for prescription refills Monday thru Friday. Please note, prescriptions called in after 12pm on Friday may not be filled until the following Monday. Nutrition: Previous body weight (date): 5/9/18-33lb 5/21/ lb 6/4/ lb / 15kg Current body weight:29.26lb / 13.3kg Daily caloric nutrient requirement: 975 kilocalories Diet and instructions: We recommend switching Pepper to a senior dog food. The average over the counter dry dog food contains 300 kilocalories. Pepper will need 3 and 1/4 cups to gain weight. Page 4 of 5

5 Plan and recheck: We recommend a recheck of the red blood cell percentage (PCV/TS) and platelets on Monday (6/11/18) to make sure Pepper is no becoming more anemic and that her platelets are recovering. If the platelets are normal, we may schedule a recheck for liver and spleen cytology to rule out possible cancer. Please don't hesitate to contact us if you have any questions or concerns. You may reach us at: (630) or via . Please direct any questions regarding medication refills, appointments, or re-evaluations to: avah.internalmedicine@vcahospitals.com. This is checked Monday through Friday. In case of an emergency or after hours, please call us and speak to emergency staff. ***If your pet had an intravenous injection, blood drawn or an intravenous catheter placed in the hospital, you may notice a small bandage over the injection site upon discharge from the hospital. This bandage can be removed and discarded 1-2 hours after arriving at home. Please ensure your pet does not lick or chew at this bandage as to not accidently ingest the material. Thank you. *** Cristiane Otoni, MV, DACVIM (SA Internal Medicine) Page 5 of 5