WHAT IS YOUR DIAGNOSIS?

Transcription

1 WHAT IS YOUR DIAGNOSIS? A 10 year ld female neutered Brder Cllie was presented t the R(D)SVS Canine Medicine Service fr investigatin f lethargy, inappetance and weight lss. She had been inappetant fr apprximately 6 weeks and weight had decreased frm 21kg t 19.1kg ver this time. The wners reprted a slight increase in thirst with n increase in urinatin. Previus histry included chrnic stearthritis and atpy fr which NSAIDs and prednislne were intermittently administered. N medicatins had been given fr these prblems fr several weeks. On physical examinatin the dg was quiet, alert and respnsive. Bdy cnditin scre was 3/9. She was estimated 5% dehydrated based n tacky mucus membranes. Oral examinatin revealed dental tartar and gingivitis. Mucus membranes were pink with capillary refill time less than 2 secnds. Peripheral lymph ndes were within nrmal limits. Heart rate was 104 bpm with an adequate quality matched pulse. N murmurs were auscultated. Respiratry rate was 20 with n abnrmalities heard n auscultatin f the lung fields. Abdminal palpatin revealed n abnrmalities, the bladder was relatively full. Rectal examinatin and anal glands were nrmal. Rectal temperature was 38.7C. There was alpecia and erythema f the skin n paws with saliva staining cnsistent with the lng term allergic skin disease. A bld sample fr rutine, haematlgy and serum bichemistry was btained and urine by cystcentesis fr urinalysis with results verleaf. The urine sample was als submitted fr culture. page 1 f 6

2 Haematlgy RBC x10 12 /l PCV l/l Haemglbin g/dl WBC x10 9 /l Neutrphils x10 9 /l Lymphcytes x10 9 /l Mncytes x10 9 /l Esinphils x10 9 /l Platelets x10 9 /l Bichemistry Ttal Prtein g/l Albumin g/l Glbulin g/l Bile Acids µml/l Ttal Bilirubin µml/l AP U/l ALT U/l Sdium mml/l Chlride mml/l Ptassium mml/l Calcium mml/l Inrganic Phsphrus mml/l Magnesium mml/l Creatinine µml/l Urea nml/l Glucse mml/l 1) What are yur differential diagnses fr the raised urea and creatinine in this case? 2) What investigatins wuld yu perfrm? page 2 f 6

3 1) Differential Diagnses chrnic/subacute aztaemia Renal Infectius Bacterial pyelnephritis Leptspirsis Lyme disease (leishmaniasis r brrelisis if histry f travel) Inflammatry/Immune-mediated disease Glmerulnephritis/glmerulsclersis Renal Amylidsis Systemic lupus erythematsus Obstructive Renal r ureteral urlithiasis Renal r ureteral neplasia Urinary tract rupture (less likely due t chrnicity f clinical signs) Cngenital Renal dysplasia reprted in many breeds Glmerulpathy reprted in many breeds Other familial/cngenital diseases mstly breed specific and nt reprted in cllies Vascular/Perfusin Dehydratin/hypvlaemia Thrmbsis/infarctin Hyptensin Hypertensin Vasculitis Spay granulma Cardiac failure (unlikely based n physical examinatin) Metablic Hypercalcaemia Hypadrencrticism Pancreatitis Txic NSAIDs (fr arthritis) Adder venm, accidental ingestin (ethylene glycl, grapes and raisns, lilies, lead etc ) (less likely due t subacute presentatin) page 3 f 6

4 2) Further Investigatins Urine was btained by cystcentesis fr analysis and culture Specific gravity was 1.015, ph was 10.0, bacterial rds and many triple phsphate crystals were seen n sediment examinatin. Urine prtein t creatinine rati was elevated at 1.1 Urine culture was psitive fr Prteus mirabilis spp. sensitive t Amxy/clav, Trim/sulphnamides, Cephalexin, Gentamicin and Enrflxacin but resistant t Dxycycline. Inised calcium was 1.31 mml/l (ref mml/l). Therefre the high ttal calcium level was cnsidered nt t be clinically relevant and further investigatin f hypercalcaemia nt warranted. An increased ttal calcium cncentratin with nrmal r lw inized calcium is nt uncmmn with chrnic renal dysfunctin. Bld pressure was mderately elevated at 165 mmhg. Abdminal ultrasngraphy revealed markedly misshapen kidneys with hypergenicity f the crtices. Bth had the appearance f end-stage kidneys. This culd be as a result f chrnic kidney disease but culd als be secndary t previus txic/infectius/inflammatry insult, r renal dysplasia. Mre definitive infrmatin n the aetilgy f the kidney changes wuld require renal bipsy (declined in this case). Subsequently the wners revealed the dg had experienced a previus episde f aztaemia fllwing a urinary tract infectin and NSAID administratin when she was 9 mnths ld. page 4 f 6

5 Diagnsis Prteus mirabilis spp. urinary tract infectin with high suspicin f pyelnephritis. The appearance f the kidneys evidences chrnic renal disease, and therefre likely chrnic renal insufficiency (IRS stage 3 with prteinuria and hypertensin), and s this shuld be treated as a cmplicated urinary tract infectin. Treatment Intravenus fluid therapy fr 24 hurs calculated fr rehydratin (5% f 19.1kg = 955ml ver 12 hurs, plus twice 50ml/kg/24hr = 120ml/hr fr 12 hurs fllwed by 40ml/hr fr 12 hurs. Recmmendatins fr a cmplicated UTI are Antibisis based n culture and sensitivity testing fr a minimum f 4-6 weeks. 250mg ptentiated amxicillin q.12 hurs was prescribed. Urine shuld be btained by cystcentesis 5-7 days fllwing the start f treatment fr sediment examinatin and repeat culture t cnfirm the effectiveness f the antibitic chsen. Culture shuld be repeated befre stpping antibitics (sample 3-4 days befre end f planned curse) and again10-14 days after the antibitics are stpped t ensure the infectin has been eliminated. Benazepril 0.5mg/kg q. 24 h fr prteinuria and cntrl f bld pressure Ranitidine 2ml/kg q. 12 hurs in case f uraemic gastritis cntributing t inappetance. Cmbivit B cmplex injectin (2ml) as chrnic renal insufficiency leads t lss f B vitamins in urine and ptential deficiency Prescriptin Diet frmulated fr chrnic renal insufficiency Outcme The dg was much brighter and ate 10/10 fllwing fluid therapy. Aztaemia was imprved (Urea 23.1 mml/l, Creatinine 224 uml/l). At recheck ne week fllwing discharge, she was still bright and eating well. Urine culture was negative, urine. Bld pressure was 155mg Hg. Urine SG was and UPC was 0.8 indicating likely permanent (but nt cmplete) lss f urine cncentrating ability and a degree f nging prteinuria. Discussin In this case it was unclear whether a lngstanding silent urinary tract infectin was the primary cause f the renal disease r whether it was a secndary event and exacerbated lng standing renal disease due t renal dysplasia r a previus renal insult. Hwever the ultrasngraphic appearance f the kidneys shwed irreversible renal damage and the dg will need clse mnitring and management fr this even after the bacterial infectin has been eliminated. The case demnstrates the imprtance f integrating the findings frm urinalysis, in particular sediment examinatin and bacterial culture, with infrmatin frm diagnstic imaging fr diagnsis, prgnsis and ptimal management fr the patient. Withut all the infrmatin, chrnic renal failure with end-stage kidney may have been diagnsed and the presence f a UTI missed, r an uncmplicated UTI diagnsed withut recgnising the chrnic renal disease. The ideal future management regime fr this patient shuld be based n the clinical signs, and restaging f the chrnic renal disease (creatinine level, prteinuria and hypertensin) page 5 f 6

6 nce the antibitic curse is cmpleted and the infectin eliminated. In particular, the UPC rati is unreliable in the face f a urinary tract infectin. Reference page 6 f 6