Anemia case lecture

Question 1

6 year old S/F boxer
History of coccidioidomycosis, takes daily fluconazole for 5+ years
Had gastric metallic wire removed endoscopically in June 15. No problems in last 5 months since procedure.
Due for vaccinations and coccidiomycosis titer.
BAR, happy dog..
Assessment

Answer 1

Valley fever; historical, asymptomatic
Ceruminous debris AU
Grade 1 dental disease

Low HCT (PCV)
Low Hb
Clumping noted
Albumin low
Globulin High
ALP HIGH
Serum electrolytes normal

Question 2

Fluconazole dose for treating active fungal disease?

Answer 2

5-10 mg/kg PO BID

Question 3

Valley Fever Profile

Answer 3

CBC/Chem/UA

Coccidiodes titer

Question 4

If patients coccidiodides titers are stable from last year and patients CBC is normal…

Answer 4

Consider discontinuing fluconazole

Question 5

Vaccine protocol..

Dogs

Answer 5

DA2PP Vax: right shoulder
Rabies: R hip
Bordetella va: intranasal
Consider flucosamine supplementation

Question 6

Coccidiodies titers

Answer 6

IgM
IgG (positive in sadies case)
IgG titer 1:8

Question 7

Anemia

Answer 7

Regenerative? r/o hemorrhage/loss (3rd space, GI tract) unlikely hemolysis s
Non-Regenerative: r/o ACD, decreased production (immune disease/PRCA/non-regenerative IMHA, myelofibrosis, myelodysplasia, neoplasia) - unlikely CKD.

Question 8

Hypoalbuminemia

Answer 8

Loss 9kidney/PLN0 - unlikely GI tract due to hyperglobulinemia
Negative acute phase reactant
Decreased production- no strong suspicion for hypoadrenocorticism or liver disease.

Question 9

Hyperglobulinemia

Answer 9

Immune stimulation (dental disease, known infection (historically valley fevere), undiagnosed infection, inflammation.
Neoplasia (unlikely due to mild elevation)

Question 10

Elevated ALP (normal ALT)

Answer 10

Drug reaction (fluconazole)
Endocrinopathy (HAC, HypoT4) no associated clinical signs
Other ALP isoenzyme (bone, steroid)
Infiltrative hepatic disease (neoplasia) intrahepatic cholestasis
Extrahepatic cholestaisis (pancreatitis, cholelith, mass, mucocele)

Question 11

Diagnostics recommended with..

Anemia

Answer 11

Reticulocyte count

Abdominal ultrasound

Question 12

Diagnostics recommended with..

Hypoalbuminemia

Answer 12

UA +/- UPC ratio

Question 13

Diagnostics recommended with..

Hyperglobulinemia

Answer 13

No specific diagnostics, can consider protein electrophoresis if increases.

Question 14

Diagnostics recommended with..

Elevated ALP

Answer 14

Abdominal ultrasound

Discontinue fluconazole.

Question 15

Abdominal ultrasound can look for..

Answer 15

Evaluate the hepatobiliary tree
Evaluate for third space losses
Evaluate for GI masses

Question 16

What is a 4DX?

Answer 16

Tests for 
(erhrlichia) E. Canis
(anaplasma)A. Platys
heartworm d. immitis
lyme disease b. burgdorferi

Question 17

Reticulocyte counts over what are considered regenertative?

Answer 17

60,000

Question 18

Markedly anemic dog
inappropriate regenerative response
Classically expect reticulocyte count below 200
negative for ehrlichia
major concern is decreased production
undiagnosed bone marrow neoplasia.
Revised diagnostics?

Answer 18

Chest radiographs: screen for metastatic disease or diagnosed infection/lymphadenopathy
Bone marrow aspirate/biopsy if radiographs are clear.

Question 19

Pale pink, normal LN

Femoral pulses bounding, 2/6 L apical systolic murmur.

Answer 19

Tramadol to control discomfort.

Question 20

Myelofibrosis

Answer 20

Proliferation (non-clonal) of fibroblasts in bone marrow- bone marrow scarring.
Primary myelofibrosis not well documented in dogs
May occur secondary to bone marrow necrosis
-likely to damage to bone marrow microvasculature
Underlying possibilities:
-Immune mediated disease
-infectious disease (septicemia, e. canis)
-drugs (estrogen, cephalosporin’s)
-neoplasia (usually hemolymphatics)

Question 21

Suspct myelofibrosis secondary to immune mediated disease

Answer 21

Guarded prognosis and usually takes 3-4 months to respond to treatment
Treat with immunosuppressive medication
-concern for underlying coccidiomycosis and potential recrudescence)
Prednisone 30-40 mg/day
Cyclosporine 100-125 mg PO q12 hr
Discontinue fluconazole because it can be to due to chronic fluconazole treatment.

Question 22

What is fluconazole?

Answer 22

?