Species: dog
Breed: Crossbreed
Sex: m, neutered
Weight: 12.3 kg
Birth date: 2016-02-02 00:00:00
Primary diagnosis: Suspected systemic inflammatory process: polymyositis, polyarthritis
Situation: emergency follow-up
Time since surgery: 0-2 hrs
Medical history: The dog was presented to our clinic on the 21.11.2024. Since 5 November he has been lying a lot, he is not in top form, he shows muscle tremors, keeps his head down. The owner started giving Metacox. (1 time 1 ml per day). On 11 November: no improvement, still a lot of pain, he "falls" with his hind limbs. They went to the private vet and then continued with Metacox. On 20 November they went back to the private vet, and therapy with Tamgesic (on 20.11 at 18 & 00, on 21.11 at 6) and Gabapentin (100 mg the evening before presentation and the morning of presentation) was started. He shows increased pain when getting up, when walking the stairs, he screams when being stroked (everywhere), he lies down a lot and hardly moves. Appetite is less good than normal and he hardly drinks any more. When he stands, he can walk afterwards but not very well (hunched back, tail between his legs, gait not normal). The symptoms got rather worse, especially the day of presentation. No trauma was observed before the onset of symptoms. At our clinic the dog was hospitalized and the day after x-rays of the thorax, an abdominal ultrasound and an MRI of the spine were performed. X-rays report (22.11): Right caudal pulmonary artery abrupt tapering; Mild diffuse interstitial lung pattern, slightly accentuated right caudal lung lobe; Mild thickening of the right pleural fissure ines with bilateral medial bulging of the pulmonary margins --> The abrupt tapering of the right caudal pulmonary artery may be due to the presence of a focal partial obstruction or narrowing of the lumen (fibrosis vs infectious emboli such as seen in dirofilariosis or other causes), less likely artifactual; Consider further work up as indicated; The diffuse interstitial lung pattern, mild pleural thickening and bulging of the pulmonary margins could be due to pulmonary fibrosis; However other causes of interstitial lung disease secondary to vasculitis, inflammation, infection (e.g. dirofilariosis vs pneumonia) cannot be ruled out. Ultrasound report (22.11): Focal mild steatopathy surrounding the splenic and medial and internal iliac lymph nodes --> Focal steatopathy likely reactive, either due to an infectious process, or a vasculitis, lymphadenitis. MRI report (22.11): Diffuse subcutaneous lesions; Mutlifocal myopathy; Polyathropathy; Polyadenomegaly --> The multifocal and diffuse changes involving the subcutaneous fat, muscles, joints, and lymph nodes indicate a systemic disease; Consider infectious (e.g. protozoal, viral, bacterial), immune mediated, or neoplastic (i.e. round cell) diseases. Cytology joints: neutrophilic inflammation --> Finding neutrophilic inflammaiton in at least 2 but probably 3 joints is consistent with polyarthritis, which may be associated with underlying vector-borne infections, inflammation or malignancy remote from the joints, drug administration, or auto-immune diseases. Cytology liver and lymph nodes: neutrophilic inflammation --> The inflammation in the liver and lymph nodes could reflect an immune-mediated process, as suspected in the joints, with infectious aetiologies, particularly vector-borne diseases (e.g. Leishmania, Ehrlichia) remaining equally possible, through direct infection or as a trigger for an immune-mediated response; There is no evidence for neoplasia in any of these aspirates. The dog went home on the 26.11.2024.
Medication: Before presentation: Buprenorphin 0.01 mg/kg on 20.11 at 18 IM and on 21.11 at 00 & 06 PO, Gabapentin 8 mg/kg PO BID (evening before presentation and morning of presentation). Before observation 2: Ondansetron 0.5 mg/kg IV, Metamizol 25 mg/kg IV, Gabapentin 10 mg/kg PO. 21.11 continued/started after observation 2: Metamizol 25 mg/kg IV TID, Ondansetron 0.5 mg/kg IV TID, Gabapentin 10 mg/kg PO TID, Omeprazol 1 mg/kg IV BID, Misoprostol 4 µg/kg PO BID, Methadon 0.1mg/kg IV q4h. 22.11 (nothing given before observation 3): Metamizol & Ondansetron & Gabapentin & Omeprazol & Misoprostol & Methadon same as 21.11, Ketamin CRI 0.002 mg/kg/min IV (started after observation 3), Metoclopramid 0.3 mg/kg IV TID (started after observation 3). 24.11: Metamizol 25 mg/kg IV TID, Ondansetron 0.5mg/kg IV TID, Gabapentin 10 mg/kg PO TID, Omeprazol 1 mg/kg IV BID, Misoprostol 4 µg/kg PO BID, Methadon 0.1 mg/kg IV q4h at 09 and 13 then switch to Buprenorphin 0.02 mg/kg IV TID from 17, Metoclopramid CRI 2 mg/kg/d IV, Dexamethason 0.15 mg/kg IV SID equivalent Prednisolon 1 mg/kg), Cisaprid 1 mg/kg PO TID, Prokolin according to weight PO BID, Clindamycin 12.5 mg/kg IV BID.. 25.11: Metamizol & Ondansetron & Gabapetin & Omeprazol & Buprenorphin & Dexamethason & Cisaprid & Prokolin & Clindamycin same as 24.11, Metoclopramid CRI 1 mg/kg/d IV, Misoprostol 4 µg/kg PO 1x at 09 then stopped.
Neurologic exam: Performed on 21.11.2924. Mentation: moderately reduced, very calm; However, alert during stimulation. Posture: initially lying down, after stimulation standing with good movement of the neck.Gait: Lameness of the right hind limb (anamnestic TPLO) and questionable no weight bearing of the left forelimb; slight to moderate atrophy of the right hind limb. Postural reactions: unremarkable. Cranial nerves: unremarkable. Spinal reflexes: unremarkable. Sensitivity: diffuse dolent on palpation of the back muscles, especially cranial to the thoracolumbar junction, and also rather unpleasant in the muscles of the forelimbs and hindlimbs. Neuroanatomical localisation: diffuse dolence without clear neurological deficits (muscular problems possible). Short EMG performed on 22.11: Pathological spontaneous activity (fibrillation potential, PSW) in the muscles of the forelimbs (especially proximal, between the shoulders) and cervically; hindlimbs unremarkable. Muscle biopsy: M. biceps femoris und M. suprascapularis --> .
Pain type: acute, inflammatory, orthopedic, somatic
Pain origin: neck, back, front legs, hind legs
Pain duration: More than 7 days
Estimated pain severity: 37