Case Studies In Small Animal

Cardiovascular Medicine

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Rx Pictures 2nd Treatment

Case 27

Plans and Progress Notes

bullet11/12/99 2230 Problem 1: Historical bleeding. S/O: CBC is unremarkable. Chemistry panel is unremarkable. PT and PTT are normal. A: There is no evidence of a bleeding abnormality, no evidence of blood loss, and no evidence of organ dysfunction. Blood found in the mouth may be from the oral cavity, the lungs or the GI tract. The melena may be from swallowing blood or may be from GI bleeding. P: Monitor for vomiting, bleeding, or diarrhea.
bullet11/12/99 2230 Problem 2: Interstitial pulmonary pattern. S/O: Thoracic radiographs show a moderate interstitial pattern in the caudal lung lobes. Blood gases show a PaCo2 of 29.8 mmHg and a PaO2 of 91.5 mmHg. A: His blood gases show that he is hyperventilating. This may be due to an attempt to thermoregulate since he has a fever. It is not due to hypoxemia since his PaO2 is greater than 60 mmHg. P: Monitor respiratory rate and for dyspnea.
bullet11/13/99 1430 Problem 3: Heartworm disease. S/O: Overnight, found coagulated blood in the dog's run once. It was unclear if it had been vomited or coughed up. QAR, urinating, drinking, not interested in food, T=102.2 F, P=118 beats/min, R=64 breaths/min, PaO2=89.2 mmHg, PaCO2=31.4 mmHg, K=3.2 mEq/L. A Snap heartworm antigen test was strongly positive. A Difil microfilarial test was positive. An echocardiogram showed a worm in the right pulmonary artery. A: Marso has heartworm disease and has both adults and microfilariae. He has been coughing up blood due to a ruptured pulmonary artery, which is what the owner saw yesterday, and he has been swallowing blood, which is why he has melena.  Since he appears to have a high worm burden and because of his already compromised lungs (i.e., the hemoptysis), we will treat Marso with one injection now to primarily kill the smaller male worms and two injections in a month to kill the remaining worms. P: Melarsomine (100mg IM) was given at 1100 in the right paralumbar muscles near the 4th lumbar vertebrae. We will keep Marso overnight and watch for reactions to the medication. Send home on strict cage rest for one month. Recheck with Cardiology in one month to have two more melarsomine injections.

Discharge Summary

bulletMarso presented to the VMTH because of blood coming from his mouth.
bulletOn physical exam, he had a fever of 104.0, his mucus membranes were injected, his CRT was less than 1, he had severe tartar and gingivitis, and harsh lung sounds could be heard in all fields.
bulletRadiographs showed a moderate interstitial pattern in the caudal lung lobes and a large main pulmonary artery. His CBC, chemistry panel, PT and PTT were unremarkable. Blood gases showed a PaCo2 of 29.8 mmHg and a PaO2 of 91.5 mmHg. A Snap heartworm antigen test was positive and a Difil microfilarial test was positive. An echocardiogram showed a worm in one of the pulmonary arteries.
bulletMarso was treated with melarsomine 100mg in the right paralumbar muscles near L4. He was sent home on strict cage rest and will need to return in one month for his remaining two injections of melarsomine.

Discharge Instructions

bulletThank you for bringing Marso to the VMTH. He has been a very good patient.
bulletMarso has been diagnosed with heartworm disease. This is a serious disease which involves worms that live in the blood vessels of the lungs. The worms have caused irritation to these vessels. As a result, one of the vessels must have burst into the lung, causing him to cough up blood, which is what you saw yesterday. This is a treatable disease. However, it is very important that you carefully follow directions regarding his care for the next month to improve Marso's chances of recovering fully.
bulletTreatment for this disease requires two steps. The first step is to kill the adult worms that are living in the lungs. In Marso, since he has so many worms in his system, we don't want to kill them all at once, or this could cause worse problems for Marso. Consequently, he received one injection which will kill about half the worms and two injections will be given in one month to kill the remaining hardier worms.
bulletWe gave the first injection on Saturday in the muscles near his lower back. He may be sore in these muscles for up to a week. If he is very sore, if you see marked swelling, or if the area is hot and painful, please call us. 
bulletIt is extremely important that over the next month you keep Marso as quiet as possible. Any excitement or exercise may cause blood flow through his lungs to increase, which may cause large pieces of dead worms to break loose and lodge in his lungs. This can cause a severe reaction and can also cause sudden death. If he is kept quiet, the dead worms will slowly decompose and are less likely to cause a problem.
bulletMarso needs his last two injections in one month. Please make an appointment with the Cardiology Service. At that time, we will keep him overnight, so that we may give two injections 24 hours apart.
bulletThe last step of Marso's treatment will be to kill any microfilariae (heartworm larvae) that are in his system. This will be done after we have treated the adults. We may decide to start this treatment the next time we see him or a month after his next treatment depending on how he is doing. Dr. Macdonald will help you with that decision in one month.
bulletYou should have your other dog tested for heartworm infection and keep him on preventative while Marso is being treated.

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Mark D. Kittleson, D.V.M., Ph.D. All rights reserved.