February 2006 Issue

Featured case study: eight-year-old neutered male Welsh terrier, Sancho
by Dr. April Brown, North Florida Veterinary Specialists, Jacksonville, FL

Special thanks to Dr. April Brown of North Florida Veterinary Specialists in Jacksonville, Florida, for contributing this case.

Physical Exam

At presentation to the referring veterinarian, Sancho had a very painful and swollen abdomen. Initial in-house laboratory work on mildly lipemic blood revealed increased BUN, creatinine, amylase and alkaline phosphatase, as well as a moderate neutrophilia. There was decreased radiographic detail in the cranial abdomen and ultrasonographic evaluation revealed echogenic changes consistent with inflammatory disease in the area of the pancreas. Also noted were dark, tarry stools, labored breathing and tacky mucous membranes.

Plan

Refer to the North Florida Veterinary Specialists Emergency Clinic for fluid therapy and shock management. The primary clinical suspicion was acute necrotizing pancreatitis, however, the differential included other gastrointestinal disease, including inflammatory, neoplastic, dietary, toxic and idiopathic. In-house laboratory data generated at the emergency clinic revealed persistent neutrophilia, a mildly increased BUN that returned to within reference-range values following fluid therapy, and a persistent increase in lipase (>6,000 U/L, reference range 200–1,800 U/L). Further testing to investigate potential primary or secondary gastrointestinal disease, including pancreatitis, was performed.

Erythron—Erythrocyte mass is on the low end of the reference range, or slightly decreased. The slight macrocytosis (increased MCV) may support an early bone marrow response, however, no significant polychromasia was observed microscopically when reviewing the peripheral blood film. If the erythrocyte mass continues to decrease, evaluation of a reticulocyte count should be considered to help explain the slight macrocytosis. Since no polychromasia is reported with the peripheral blood film evaluation, the decreased erythrocyte mass can be best characterized as a nonregenerative picture, which is most likely associated with the inflammatory process (anemia of inflammatory disease) noted below.

Leukon—There is a slight leukocytosis characterized by a slight neutrophilia with a left shift (presence of band [immature] neutrophil forms) and there is slight neutrophil toxicity noted on the blood film. Changes support active inflammatory disease.

Thrombon—There is a mild thrombocytopenia that is confirmed with examination of the peripheral blood film. The presence of enlarged platelet forms suggests a bone marrow response for the peripheral demand for platelets, and either peripheral consumption or destruction should be considered as likely mechanisms of the thrombocytopenia. Figure 1—Peripheral blood film, Wright’s stain: Note the immature neutrophils, the mild toxicity (primarily increased blue-staining cytoplasm), the decreased platelet numbers and enlarged platelets.

Protein panel—The primary protein abnormality noted is a mild hypoalbuminemia. This is most likely a result of the inflammatory process since albumin is a negative acute phase inflammatory reactant. Mild hypoalbuminemia is commonly seen with active inflammation. Investigation into possible loss of albumin through the kidney (a complete urinalysis) should be considered to more completely characterize the decreased albumin. There is no support with other laboratory data for possible hepatic insufficiency and decreased production of albumin as a likely cause.

Liver panel—The increased ALP is due to either cholestasis or induction, or a combination of the two. Additional support for cholestasis may be seen with the minimal increase in conjugated bilirubin, however, this is extremely minimal and of questionable significance, and there is no other enzymatic (GGT) support for cholestasis. If the increased ALP continues or progresses, detailed diagnostic imaging evaluation of the liver should be considered for further characterization.

Electrolytes—There is a slightly decreased potassium (hypokalemia), which is of questionable significance at this time. This may merely represent the “normal” value for this animal since the decrease is minimal (less than one standard deviation from the low end of the reference range). However, if clinical signs associated with hypokalemia develop, further investigation and supplementation should be considered.

Muscle—There is a minimal and insignificant increase in CK.

Lipase—There is a significant increase in lipase, particularly in light of a lack of any evidence of renal disease or decreased glomerular filtration rate (normal BUN and creatinine). However, the degree of increase in lipase is not greater than threefold above the high end of the reference range, which would be more specific for active pancreatitis. Pancreatitis may be suspected, particularly in light of the clinical presentation, but a diagnosis of pancreatitis is not possible with this degree of increase in lipase. Further evaluation, including diagnostic imaging evaluation of the anterior abdomen and measurement of canine pancreas-specific lipase (Spec cPL®) should be considered.

Spec cPL—The canine pancreas-specific lipase is greater than 400 µg/L, which is consistent with pancreatitis.

Diagnostic imaging—ultrasound evaluation

Preliminary diagnosis

The primary diagnosis is severe acute pancreatitis with secondary peritonitis and mild hepatomegaly secondary to pancreatitis. Secondary diagnosis includes primary liver disease, such as hepatic lipidosis, neoplasia and hepatitis. Potential pancreatic neoplasia must be considered also.

Diagnostic plan

• Cytologic evaluation of abdominal effusion and pancreas (collected during ultrasound evaluation)

Diagnostic cytology

Pancreas—nonseptic, neutrophilic and macrophagic inflammation with no suggestion of neoplasia
Abdominal effusion—nonseptic, neutrophilic inflammation with no suggestion of neoplasia

Final diagnosis

Acute severe necrotizing pancreatitis with secondary peritonitis.

Clinical case outcome

The owners were informed of the guarded prognosis with severe pancreatitis and the fact that the course of the disease could take from several days up to two weeks. Sancho was hospitalized for six days, with several days in the intensive care unit. There was steady clinical improvement and Sancho was eventually released to his owners.

NOTE: Dr. April Brown and the North Florida Veterinary Specialists are participating in an IDEXX-sponsored multi-institutional prospective study investigating the diagnosis of pancreatitis in the dog.

The recommendations contained in Diagnostic Edge educational materials are intended to provide general guidance only. As with any diagnosis or treatment, you should use clinical discretion with each patient based on a complete evaluation of the patient, including history, physical presentation and complete laboratory data. With respect to any drug therapy or monitoring program, you should refer to product inserts for a complete description of dosages, indications, interactions and cautions.

We want to hear from you. Let us know what you think about this case and tell us about any other case topics that you would like to see. E-mail us at diagnosticedge@idexx.com.

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Announcing the IDEXX VetLab® Station with the IDEXX LaserCyte® Hematology Analyzer

We’re offering IDEXX VetLab® system customers an unprecedented level of information management with the IDEXX VetLab Station laboratory information management system (LIMS). The IDEXX VetLab Station will be shipped with all LaserCyte® analyzers ordered in North America beginning in January 2006.

The IDEXX VetLab Station LIMS enables you to integrate data generated by in-house diagnostic instruments to care for your patients on a higher level. With virtually unlimited data storage for patient records and results, the IDEXX VetLab Station gives you more information on each patient at the point of care—when you need it most. Featuring a new, more powerful computer and a larger 10.4" touch screen, parameter-trending capabilities, interpretive summaries and on-screen training guides, the IDEXX VetLab Station with the LaserCyte analyzer provides unparalleled analytical, reporting and medical reference capability.

View the abstract on the LaserCyte analyzer from Ohio State University. (423 KB)

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Education and Events

We offer a variety of training events about emerging trends and best practices in veterinary diagnostics in a forum designed to involve, educate and motivate you and your staff. Here are some of the upcoming educational events. See a full listing.

Webinar

• Uncover Early Renal Disease: Integrate UPC Ratios into Your Practice
  Fred Metzger, DVM, DABVP and Michelle Kahn, MS, DVM

Teleconferences

• Feline Immunodefiency Virus and Feline Leukemia Virus: A Practitioner's View
  Lynn Buzhardt, DVM
• Diagnosing Canine Pancreatitis
  Jörg M. Steiner, med.vet., Dr.med.vet., PhD, DAACVIM, DECVIM-CA

Seminars

• Cornerstone® Annual Course
  IDEXX-Certified Trainer
• Cornerstone® Advanced Practice Management Course
  IDEXX-Certified Trainer
• Update on Feline Retroviruses
  Susan Little, DVM, DABVP

Visit the education and events calendar, click the date to view the details, fill out and submit the form to register.

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Make third reminder calls to increase vaccine compliance
by Wendy S. Meyers

Although compliance for vaccines averages 87%, a typical veterinary practice has hundreds of unvaccinated patients vulnerable to diseases such as distemper, Leptospirosis, parainfluenza, parvovirus, feline rhinotracheitis, calicivirus and panleukopenia, according to the AAHA 2003 Study, A Path to High-Quality Care. A typical companion animal hospital has 2.2 veterinarians who see 1,800 active canine patients and 1,675 active feline patients for a total of 3,475. Using the 13% noncompliance average for vaccines, 452 patients are at risk.

You can improve compliance for these patients with an effective reminder system. Send reminders weekly rather than monthly to keep a steady flow of clients booking appointments, even out cash flow and reduce stress for staff and doctors. Try a three-tiered approach:

1^st reminder: Postcard sent three weeks before due date
2^nd reminder: Postcard with urgent message sent two weeks after due date
3^rd reminder: Telephone call three weeks after due date to set up appointment

The AAHA study found 78% of clients want to be called about overdue vaccines and medications, yet only 52% received a call. Telephone calls help identify whether a client has moved, a pet has died or the client simply needed a nudge to make an appointment.

When making third reminder calls, your receptionist might say, “This is Wendy calling for Dr. Smith at Myers Veterinary Hospital. We are worried that Ollie is past due for his wellness exam and vaccinations and might now be unprotected. Will you please call us at 555-5000?” This communicates urgency because the receptionist is calling “for Dr. Smith,” and telling the client the doctor was concerned enough to have someone call because her pet’s health might be at risk. Another example: “We are updating our files and noticed Ollie hasn’t been seen for his wellness exam. Has Ollie received his exam and vaccines elsewhere?”

To increase chances of catching clients at home, make third reminder calls 5:00–7:00 p.m. on weekdays and 9:00–11:00 a.m. on Saturdays. Reminder calls communicate your compassion to clients, and help you maintain a clean database.

As an added bonus, reminder calls will capture lost revenue. The AAHA study found that increasing vaccine compliance just 10%—from 87% to 97%—could generate 337 additional treatments and revenue of $16,294.

Wendy S. Myers owns Communication Solutions for Veterinarians in Denver, Colorado, and provides consulting services on client service, marketing and hospital management. She is the author of two books and four videos. You can reach her at 1-720-344-2347 or visit www.mycommunicationsolutions.com.

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Can you identify these structures?

Can you identify the structures (indicated by arrows) in this low power field of view of urine sediment from a dog with polyuria, polydypsia, azotemia and an increased urine protein:creatinine ratio (unstained preparation)?

Send your answer in an e-mail to diagnosticedge@idexx.com. Please include your name, practice name, address and telephone number.

The first 10 respondents to correctly identify the cells and structure will appear in the next issue of the Diagnostic Edge.

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