Case Studies In Small Animal

Cardiovascular Medicine

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Case 29

Follow-Up

Three Months Later

Pertinent History

bulletNimbus has been doing reasonably well at home. She has good energy and is very active, but she tires easily and will lay on her side and pant until she catches her breath again. She has not had any syncope. Her appetite and water consumption are unchanged.

Physical Examination

bulletGen: BARH T = 101.0
bulletInteg: Normal
bulletEENT: Normal
bulletMS: BCS =5/9.
bulletCV: IV/VI left parasternal systolic murmur. Strong synchronous femoral pulses. HR=200. MMs pink and moist, becoming cyanotic when stressed by restraint. CRT < 2 sec. No jugular pulses.
bulletResp: Bronchovesicular sounds ausculted in all lung fields. RR=40-60
bulletGI: Normal
bulletGU: Normal
bulletNS: Normal
bulletLN: Normal

Comments

bulletEchocardiogram: Marked right ventricular concentric hypertrophy with right ventricular free wall thickness of 6mm and a left ventricular free wall thickness of 4mm. Large ventricular septal defect with laminar flow from right ventricle into the overriding aorta; narrowed RVOT with malpositioning of pulmonic valve and pulmonic stenosis - highest velocity recorded across pulmonic valve 5.4 m/s (pressure gradient of 117; therefore approximate RV and LV pressure of 140 mmHg).
bulletThoracic rads: Static cardiomegaly and pulmonary hypoperfusion.
bulletPCV:51% TP=7.4 gm/dl
bulletConclusions: Echocardiography findings again document tetralogy of Fallot with pulmonic stenosis, overriding aorta, VSD, and RV concentric hypertrophy. Right-to-left shunting of blood flow is present with laminar flow evident from the right ventricle through the large ventricular septal defect into the aorta. The PCV of 51% is elevated. If she becomes more polycythemic and exhibits clinical signs we will consider hydroxyurea therapy or phlebotomy. Clinically Nimbus is not cyanotic at rest. When severely stressed by restraint, she did progress to open-mouth breathing with increased abdominal effort and cyanosis which resolved within minutes with rest. The owner is interested in providing a good quality of life for Nimbus, but declines invasive treatments.

 

One Year Later

Pertinent History

bulletNimbus was diagnosed with tetralogy of Fallot here in 1/02. She has been doing reasonably well at home since then. She has good energy and is very active, but she tires easily and will lay on her side and pant until she catches her breath again. The owner is concerned that Nimbus is obese. She is also worried about Nimbus's strange habit of drinking contact lens solution due to the high sodium concentration.

Physical Examination

bulletGen: BARH P-186, RR-60
bulletInteg: Full hair coat. shedding. No masses or lesions noted.
bulletEENT: Normal
bulletMS: BCS = 6/9.
bulletCV: III/VI left parasternal systolic murmur. Strong synchronous femoral pulses. HR=186. MMs pink and moist. CRT < 2 sec. No jugular pulses.
bulletResp: Bronchovesicular sounds ausculted in all lung fields. RR=40-60
bulletGI: Normal
bulletGU: Normal
bulletNS: Normal
bulletLN: Normal

Clinical Diagnoses

bulletTetralogy of Fallot

Comments

bulletEchocardiogram: No change from last echocardiogram.
bulletPCV-50%
bulletConclusions: Echocardiography findings again document tetralogy of Fallot. The PCV of 50% is static, which is a good prognostic sign. The owner was instructed to come back in one year for a recheck unless Nimbus has any problems.

 

Six Years Later

bulletTelephone Conversation - In a conversation with Nimbus' owner, he indicated that she is alive and doing well. She will still play a bit hard and then get winded and have to lie on her side for while and breathe heavily. Other than that he feels that she is quite normal clinically. She is the only pet in the household since the owners feel that another pet would put too much stress on Nimbus. Besides, he feels that Nimbus enjoys being an only child.

 

Twelve Years Later (goes into right heart failure)

Presenting Complaints

bullet Labored respiration
bulletAnemia

Pertinent History

bullet Nimbus, a 12 year old spayed, indoor/outdoor female DSH, presents for recheck of her lethargy, inappetence and increased RR/Effort.
bulletShe was diagnosed with a tetralogy of Fallot about 10 years ago, and had not been seen by a veterinarian until her visit on April 26, 2013.
bulletAbout a month ago, Nimbus became lethargic, flopping to her side after walking only a few steps, and had heavy or labored respirations. She also became anorexic except for fish and shrimp table scraps she received. She has historically vomited about once per week, and the owner feels this has slowed lately. She was presented to the UCDavis Cardiology department to check the progression of her heart disease, and to determine if this was the cause of her clinical signs.
bulletBlood work at that time showed a mild, normocytic, normochromic, non-regenerative anemia with a Hct of 27.7%. No other abnormalities were noted on the differential analysis. No RBC parasites were identified on path review of the blood smear. Occasional reactive lymphocytes were noted, however no neoplastic cells were identified.
bulletA blood chemistry panel was performed with only mild abnormalities: Cl 115 (117-126), BUN 14 (18-33), Glu 153 (63-118), TP 6.0 (6.6-8.4), Glob 2.6 (2.8-8.4), AST 62 (17-58), CK 1547 (73-260 - likely elevated due to restraint and stress).
bulletB12 was elevated at 3877 (279-1254), normal folate levels.
bulletPCR testing was negative for all infectious diseases tested for: Feline Corona Virus (FCoV), FIV, FeLV (exogenous), Mycoplasma spp. (M. haemominutum, M. haemofelis/haemocanis (Haemobartonella), M. turicensis), Bartonella spp. (including henselae).
bulletAn ECG showed changes expected for a patient with tetrology of Fallot, but did not explain her clinical signs or her anemia.
bullet Since her last visit, Nimbus has improved slightly. She is now eating and drinking, although only about 10-20% of her normal amount. She has been eating a bit more the last 4 days. She is still hiding a lot, grooming herself less, and appears weak in her hind legs.
bulletShe was last vaccinated 10 years ago.

Physical Examination

bulletGEN: Appropriate mentation, T:99.4, HR:240 ,RR:60 MM:light pink CRT:1.5 sec
bulletINTEG: Full haircoat, mild scaling along dorsum and mildly greasy haircoat. appropriate for season, no ectoparasites noted.
bulletEENT: Ears mild cerumen AU. Eyes - No ocular discharge present, corneas and sclera are clear OU. Good tear film. Nose - No nasal discharge observed. Oral- Moderate tartar, moderate calculus. Throat palpates normally, no thyroid slip.
bulletMS: BCS: 7/9, ambulatory x4, good symmetrical muscling
bulletCV: Mucous membranes moist and pink, CRT <2 sec, IV/VI systolic murmur present, no arrhythmias detected, strong synchronous femoral pulses. Warm extremities
bulletRESP: Increased respiratory effort with shallow breaths. Breath sounds ausculted in dorsal lung fields, but muffled in ventral lung fields. Thorax not easily compressible. No crackles or wheezes.
bulletGI/ GU: Mild pain in caudal abdomen on palpation. Liver does not extend beyond the costal arch. Kidneys palpable- smooth and approximately 4 cm. Smooth bowel loops palpated.
bulletNS: Alert and oriented, no CP or CN deficits notes. Full neuro exam not performed
bulletLN: All WNL.

Problems

bulletTetralogy of Fallot
bulletNormocytic, normochromic, nonregenerative anemia
bulletPleural and peritoneal effusions
bulletEnlarged heart

Clinical Diagnoses

bulletRight heart failure (pleural [chylous] and peritoneal effusions)
bulletTetralogy of Fallot
bulletNormocytic, normochromic, nonregenerative anemia (r/o chronic dz, chronic effusion)
bulletHyperbilirubinemia

Discharge Summary

bulletNimbus, a 12 year old spayed, indoor/outdoor female DSH, presents for recheck of her lethargy, inappetence and increased RR/effort.
bulletShe was diagnosed with a tetralogy of Fallot about 10 years ago, and had not been seen by a veterinarian until her visit on April 26, 2013.
bulletAbout a month ago, Nimbus became lethargic, flopping to her side after walking only a few steps, and had heavy or labored respirations. She also became anorexic except for fish and shrimp table scraps she received. She was presented to the UCDavis Cardiology Service on 4/26/13. Blood work at that time showed a mild, normocytic, normochromic, non-regenerative anemia with a Hct of 28%.
bulletB12 was elevated at 3877 (279-1254), normal folate levels.
bulletAn ECG showed changes expected for a patient with tetralogy of Fallot, but did not explain her clinical signs or her anemia.
bulletSince her last visit, Nimbus has improved slightly, but is still only eating about 10-20% of her normal amount.
bulletOn physical examination, we thought that Nimbus had decreased ventral lung sounds, and a minimally compressible chest. She had a heart murmur, and was possibly painful in the abdomen. Thoracic radiographs revealed marked pleural effusion. 114ml of cloudy serosanginous fluid were removed from her chest and her breathing effort improved. Cytology of fluid revealed chylous effusion with evidence of chronic hemorrhage. Repeat chest X-rays showed an enlarged heart, as well as peritoneal effusion (ascites).
bulletOn abdominal ultrasound, we confirmed the presence of peritoneal effusion. Additionally, she had mildly irregular kidneys, enlarged and rounded lymph nodes, and a nodular and irregular pancreas.
bulletMost likely cause of Nimbus' clinical signs is the pleural effusion - most likely chylous based on fluid analysis. CHF must be considered as well as intrathoracic neoplasia.
bulletHyperbilirubinemia most likely due to may be due intrahepatic cholestasis. Despite lack of ALP elevation, lipidosis is of concern in Nimbus as she is an overweight cat who has been eating minimally.
bulletOwners declined hospitalization and cardiac consult tomorrow. Elect to take Nimbus home with treatment for heart failure and recheck with cardiology service.
bulletMEDICATIONS:
bullet1) Furosemide 12.5mg tablets - Give ONE (1) tablet by mouth TWICE daily. Nimbus will be next due for furosemide this evening at approximately 10pm.
bulletMain side effects include dehydration, which may be harmful if he has underlying kidney disease.
bullet2) Enalapril 2.5mg tablets - ***Do not start until advised*** Give HALF (0.5) of a tablet by mouth TWICE daily. This can worsen her azotemia, so we recommend rechecking her kidney values 5-7 days after starting this medication to make sure we are not running into trouble there.
bulletMONITORING:
bulletPlease monitor her breathing rate by taking a count of her sleeping respiratory rate when you get home tonight, before you go to bed, and then tomorrow morning..
bulletFOLLOW UP:
bulletIf Nimbus improves with treatment for heart failure, please make sure to make an appointment with the Cardiology Service in 1 week for a recheck of chest X-rays and serum chemistries.
bulletIf Nimbus does not improve overnight, or if we find other abnormalities on the tests we submitted today, then we would recommend making an appointment to bring her back through Internal Medicine for further evaluation.

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