Exam 6 Flashcards
Clinical Signs and Diagnostic Testing for Immune Mediated Disease
Discuss basic tenets and components of innate vs. acquired immune systems
Natural/Innate
-Phagocytic WBCs
-Prior exposure to antigens not required
-Complement proteins
-Natural killer lymphocytes
Acquired
-Prior exposure to antigen required
Antigen
-Any substance capable of inducing an immune response
-Immune response = production of antibodies
-Cell mediated response via T-Lymphocytes
Antibody
-Protein molecule produced by B-lymphocytes/plasma cells in response to specific antigens (aka immunoglobulins)
Acquired immunity
-T and B lymphocytes responses:
-IgG, most prevalent, any time exposure, passive immunity mostly. Monomer, phagocytosis
-IgM, means recent exposure, Pentomer (largest antibodies), viruses.
-IgA, Prevalent in secretions (saliva, milk, sweat), Mucosal surfaces.
-IgD, Mature B-lymphocytes, induction of tolerance during fetal development
-IgE, VIP for allergic reaction, degranulation = eosinophils recruitment
T-Lymphocytes = Helper = CD4+ MCH2 receptors = Cytokines, inflammatory cascade
B-Lymphocytes = Cytotoxic = CD8+ MCH1 receptors = antigen mediated attack and destruction
Regulatory T-Lymphocytes = regulate inflammatory response.
T-Cells
Th0: naive
Th1: Cell-mediated immunity and inflammation
Th2: Antibody-mediated
T-reg: Immune tolerance
Superantigens
-Staphylococcus aureus
-Streptococcus pyogenes
-Mycoplasma arthritiditis
-Pseudomonas aeruginosa
-Clostridium perfringes
The complement system pathways
- Classic pathway
-C1-C4 proteins
-Primarily activated by IgG and IgM
- Alternative pathway
-C3, B, D, and P proteins
-Key player in innate immunity
-Can be activated by microbial surface proteins in the absence of antibodies
- Terminal pathway
-After one of the previous pathways has been activated
-Results in the formation of the membrane attack complex
-Water and ions diffuse through holes created in the cell membrane leading to rupture
Discuss clinical signs and symptoms seen in C/F patients with common immune mediated diseases
Discuss pathogenesis and review of the four major hypersensitivity reactions (type I-IV)
Type I
-Allergic, Anaphylaxis, Atopy
-IgE mediated
-Histamine and bradykinin
-Activates the complement and coagulation systems
-Hives, atopy, lymphoplasmacytic enteritis, eosinophilic granuloma complex.
Type II
-AntiBody
-IgG or IgM mediated
-Soluble complexes formed
-Ex: penicillin, sulfas, Anaplasma, Babesia, IMHA, ITP, pemphigus, myasthenia gravis.
Type III
-Immune Complexes
-IgG mediated
-Excessive amount of antigen compared to antibodies
-Deposits in kidneys, joints
-Damage to host tissue via classic pathway
-Ex: glomerulonephritis, lupus, vasculitis
Type IV
-Delayed
-Takes 24 hours to develop, weeks for maximal response, and months to resolve completely
-T-lymphocytes
-Mononuclear inflammation
-Ex: cutaneous drug reaction
Discuss the diagnostic testing approach to the patient with common immune mediated diseases for each diagnostic modality
The key phenomenon behind any immune mediated disease is the loss of self-tolerance
-May be generalized or organ specific
-Multifactorial influences
C/S
-Non specific
-Ddx infectious or neoplastic
- Minimum Data Base
- Great history and PE
- CBC, chem, UA
- Play the hunt: chest rads, abdominal rads, ultrasound.
Treatment of Immune mediated diseases
Key = halt the immune reaction underlying the disorder without turning off the immune system completely, increasing the risk for a serious infection
Discuss principles of treatment for immune-mediated diseases in the C/F patient
- Halt immune reaction
- Not fully turning off immune system
- Lowest dose necessary to control disease
- Least number of medications necessary
- Most specific therapy best
Discuss the side effects of immunosuppressive therapy
-Infection
-Vomiting, diarrhea, anorexia
-Bone marrow suppression
-Hepatotoxicity
-PU/PD/PP. panting, muscle wasting, hepatomegaly
-Insulin resistance/antagonism
Discuss how to monitor a patient receiving therapy for immune-mediated disease and appropriate supportive care for the patient when side effects arise
-Routine examinations
-Recheck labs: CBC/Chem?UA/urine culture. 2 weeks post initiation then q3-6 mts or as indicated
-Therapeutic drug level blood testing when available
-Supportive care: ex: liver antioxidants
Discuss glucocorticoid physiologic, anti-inflammatory and immunosuppressive therapy dosing strategies, including differing potencies of individual glucocorticoids and side effect of glucocorticoids
MOA
-Stabilizes the cell membrane
-Inhibition of chemotactic factors production, altering leukotrienes inflammatory mediators
-Inhibit Phospholipase A2
-Inhibiting the release of arachidonic acid, decreasing the production of prostaglandins and leukotrienes
-Blocks NF-kB
-Modifies protein, carbohydrate and fat metabolism
-Suppress acute inflammation by inhibiting vascular permeability, vasodilation, and leukocyte migration from capillaries
Side effects
-PU/PD
-Weight gain (muscle loss with redistribution of fat)
-Calciuresis - calcium oxalate calculi
-Insulin resistance - diabetes mellitus
-Fluid retention, volume overload, CHF
-Thromboembolic disease, hypercoagulability
-Infectious
-Vomiting, diarrhea, etc.
Discuss other pharmacologic immunosuppressive therapies and non pharmacologic immunosuppressive adjunctive therapies used to treat common immune mediated diseases in the C/F patient
Cyclosporine
-Blocks calcineurin-mediated T-cell activation
-Inhibits production of IL-2, IL-3, IL-4, TNF-alpha, INF-gamma
NOT myelotoxic, effect is not noted immediately
-Cytochrome P450 system metabolism in liver
-Caution in patients with MDR1 mutation (Collies, Australian Shepherds)
Dosage reductions to remember
-Ketoconazole: up to 75% reduction in Cyclosporine dose
-Fluconazole: up to 30-50% reduction
Immunosuppressive dose: 3-6mg/kg PO BID
-Vomiting, diarrhea, anorexia, promotes development of neoplasia especially lymphoma in dogs/cats
-Peak: 2 hours after administration
-Trough: 12 hours canine (500ng/ml), feline (300-600 ng/ml)
-Cytokine levels can be re-checked 7-10 days after dose adjustment
Azathioprine
MOA
-Acts as a purine analog
-Metabolized to ribonucleotide monophosphate
-Leads to intracellular accumulation of monophosphates = feedback inhibition of further nucleotide synthesis
-Decrease antibody formation
-Suppresses macrophage function
Clinical response up to 6 weeks
Cats highly susceptible to myelosuppression due to low thiopurine methyltransferace NOT recommended for cats
-Giant Schnauzers also similar to cats
-Light sensitive drug
-Interactions: Ace inhibitors, Allopurinol, Corticosteroids
Azathiaprine
-Myelosuppression: non regenerative anemias long term
-Pancreatitis
-Mutagenic/Teratogenic
DO NOT split tablets
-Caution: pregnant females avoid handling drug.
2mg/kg PO SIB, then reduce after 1 week
-Recheck CBCs/Chem every two weeks
Mycophenolate Mofetil
MOA
-Inhibts inosine monophasphate dehydrogenase
-Rate limiting step for purine synthesis
-Inhibits T and B lymphocytes proliferation
-Suppression of antibody formation and leukocyte recruitment
Non myelotoxic replacement of Azathioprine
-Give on an empty stomach preferably
GI, and Enterocolitis side effect
Drug interactions
-Antacids, aspirin, azathioprine, iron
8-12 mg/kg PO BID dog, 10mg/kg PO BID feline
-Recheck CBCs every 2-3 weeks, then 2-3 months
Leflunomide
MAO
-A synthetic organic isoxazole
-Prevents pyrimidine synthesis
-Decrease DNA and RNA synthesis, at higher concentrations inhibits tyrosine kinases
-Metabolized by intestinal mucosa
-Time to peak: 5 hours dogs, cats 8 hours
-Highly protein bound
-Less drug interactions
Canine 2mg/kg PO SID, feline 2-3 mg/kg
-Elevated liver enzymes in dogs
-Monitor CBC and liver chemistries, 2 weeks then 1-2 months
Cyclophosphamide
MOA
-Acrolein
-4-OHCP
-Suppresses both T cell and antibody production
-Alkylation of DNA
-Peak concentration 45 minutes PO or IV
-Minimal protein binding
Cyclophosphamide-induced Cystitis CIC in dogs
-Hemorrhagic cystitis
-Pulmonary infiltrates
-Myelosuppression WBCs
Drug interactions
-Allopurinol
-Cyclosporine
-Chloramphenicol, etc.
Dog: Do NOT exceed 4 weeks, 150-200mg/m2 weekly divided in three days
Feline 2-2.5 mg/kg PO SID
-Recheck once per week, no refills.
AVOID in patients with IMHA
Adjunct therapies
Intravenous Immunoglobulin
MOA - hypothesis
-Neutralizes antibodies
-Negative feedback
-Suppressing cytokines and phagocyte activity
-No drug interactions
-Rapid onset of action
-Elimination half-life 7-9 days
Side effects
-Hypertension
-Anaphylaxis risk
-Volume overload, colloid like properties
-Thrombotic events
Salvage procedure
Other Treatment
-Splenectomy
-Plasmapheresis
Common Immune Mediated Diseases
Discuss the etiology, clinical features, diagnosis, treatment, complications, and prognosis
Canine IMHA (primary vs secondary)
Pathogenesis
-Autoantibodies bind to antigen on the erythrocyte membrane
-Complement or antibody mediated RBC destruction
-Removed from circulation
Intravascular
-Free Hemoglobin within the plasma and urine
-Mores sick
-More transfusions
Extravascular - more common
-More gradual
-Bilirubin in urine and plasma
-Spleen and liver antibody, reticuloendothelial system
Primary
-Idiopathic or autoimmune
-Most common
-Hemolysis in the absence of trigger
Secondary
-Neoplasia
-Infectious disease
-Drug interactions: may resolve quicker
Triggers will dictate the diagnostic workup
Other types of hemolytic anemia
Non-immunologic Hemolytic Anemias
- Fragmentation
-DIC
-Caudal caval
-Torsion (spleen, liver, GDV)
-Valvular disease
-Neoplasia
-Vasculatis
-Schistocytosis
- Toxicant Induced
-Onion, garlic, PG, Acetaminophen, Benzocaine, Zinc, Copper, Naphthalene, Antibiotics.
-Haptens secondary response
- Heritable
-Phosphofructokinase deficiency: Crocker Spaniels
-Pyruvate kinase deficiency: RBC breakdown: Basenji, Beagle, Cairn, Lab, Pug, WHWT
-Osmotic fragility
- Metabolic
-Hypophosphatemia
-Hemolytic-uremic syndrome
-Osmolarity changes (HHS)
-Envenomation
-Hypotonic fluids
Common Clinical Signs
-Middle aged to older dogs
-Females
-Crocker Spaniel, Shih Tsu/Lhasas, Duchshunds, Labradors, Poodles, Border collies, Springer spaniels.
-Warmer months
-Lethargy, weakness, anorexia, vomiting, pigmenturia, brown or bloody urine, icterus, collapse
-Tachycardia
-Tachypena
-Systolic ejection murmur
-Hepatomegaly
-Fever
Diagnosis
-3 causes of anemia
-Look for sequelae
-Determine primary or secondary
- Loss
-Decreased albumin, globulin, TP
-Secret GI bleeding!!
-Evidence of external or internal hemorrhage - Decreased production
-Usually normal TP
-Without evidence of hemolysis (bilirubin, hemoglo binemia)
-Pancytopenia
-No evidence of regeneration (polychromasia, reticulocytes)
-Reticulocytes 3-5 days to regenerate - Hemolysis
Tests
-CBC
-Chemistry
-Urinalysis
-PCV/TS: severe if <25%
-Blood smear: Heinz bodies = precipitated hemoglobin, denatured RBCs, indicative of oxidative injury, toxins garlic, onion.
-Spherocytes: the slam dunk cell! loss of central parlor, Antibodies bound leads to cytophagocytosis
-Slide agglutination
-Hemoglobinuria/hemoglobinemia
-Leukocytosis: can be very high
-Bilirubinuria/bilirubinemia
-Prognostic >60,000
-Thrombocytopenia
-Platelet <30,000
-Concurrent tick borne disease possible
Coombs Test
-Definitive for IMHA
-AKA direct antiglobulin test
Heptan Molecules
-Recent vaccination
-Within 3 weeks
-Sulfas, penicillins, cephalosporins
Treatment
-Improve DO2: IV fluids, transfusions, no pre-med, 1-4 hours transfusion, watch for fluid overload
-Treat underlying cause/trigger
-Immune suppression
-Manage hyper coagulable state
Transfusion trigger
-Tachycardia
-Syncope
-Hyperlactemia
-Chronicity
-Comorbidities: fluid overload due to anemia
Meds
-Steroids: mainstay of treatment
Prednisone best
-Decrease IFN, IL2, suppress T cell function
2mg/kg/day Max 60 mg per day
Rescue Meds
-Mycophenolate Mofetil: 10mg/kg BID. GI effects. Inhibitor of purine synthesis
-Azathioprine: Thiopurine analog. Works in 10-14 days, cheaper than cyclosporine . 2mg/kg/day, big dogs 40-50mg/m2. SID x 7d. Pancreatitis
-Cyclosporine: Blockage of calcineurin, IL2, IL3, IL4, TNF. 5mg/kg BID
-hIVIg: FC receptor blockage, rapid onset
-Splenectomy: risks anesthesia, thrombosis, bleeding.
Thromboembolic events
-Hypercoagulable state
IMHA hyper coagulable state
-Expression of tissue factor on monocytes and endothelium
-Binding of F VII initiation of coagulation
-Phagocytosis of RBCs trigger CKs and TF expression, free hemoglobin decreased NO = platelet aggregation and vasoconstriction
-Thrombi in 46-80% of non-survivors
-DIC in 45%
-Early anticoagulant treatment is warranted
-Venous thrombi: fibrin rich, low shear stress
-Arterial thrombi: high shear stress, platelet activation.
Test Dx
-PT/PTT
-ACT
-Specific factor antigen assay
-AT, fibrinogen
-FDPs and D dimers
-thromboelastography (fancy test)
Tx
-Clopidrogel: ADP, PAR1 binding, decrease activation of fibrinogen R
-Aspirin: TXA2 decreased
-Heparins: PTT check, risk of bleeding (LMWH)
-Thrombin inhibitors: Ximelgatan & Dabigatran
-Anti-Xa drugs: Rivaroxaban, Apixaban
CHAOS score
PRCA, PIMA, IMHA
PIMA
-Precursor directed immune mediated anemia
-PCV <10%
-Erythroid hyperplasia, bone marrow analysis
-Tx: transfusion, splenectomy
-Thromboembolic 50%
Feline IMHA
-2nd more common than primary
Never Azathioprine to cats
Causes
-FeLV, FIV, FIP, Babesia felis, Mycoplasma haemofelis, cytauxzoon
-Neoplasia
-Drugs: methimazole, penicillin, TMS, levamisole
-Inflammatory diseases and other causes: SLE, cystitis, prostatitis, pyothorax.
-Similar treatment and monitoring
Thrombocytopenia
-Spurious is common
Make a smear, don’t always trust the machine
-Decreased production in bone marrow, infectious = consumptions, sequestration spleen/liver due to SLE, ehrlichiosis
ITP - Immune Mediated Thrombocytopenia
-Anti-platelet antibodies
-Crocker spaniel, mini poodles, OES, Vizlas, Scotties, Dachshunds
2nd ITP causes
-Drugs: sulfas, cephalosporins, vaccines, neoplasia, HSA, myeloma, RMSF, Ehrlichia, ana plasma
-Spontaneous bleeding if <40-50k count
Dx
-Confirm platelet count
-CBC, chem, UA
-Infectious dz PCR/serology
+/- Neoplasia hunt, platelet antibody testing, bone marrow aspiration/biopsy
Treatment
-As per IHMA
-IV IgG can be considered when severe hemorrhage
Doxycycline 4 weeks when infectious negative still do it
SLE
-Type III hypersensitivity reaction
-Immune complex deposition with secondary neutrophilic inflammation
-Middle age
-GSD
-Large breeds
-No sex predilection
SLE Dx
-Positive ANA in 95% of cases, sensitive but not specific
-Plus 2-3 classical clinical symptoms
-Coombs’s positive in 17%
-Anti IgG ab 20%
Circulating immune complexes in 75% of cases
Treatment
-Prednisone
-Other immunosuppressants
-Prognosis: varies, poor if renal failure
Acquired myasthenia gravis
C/S
-Weakness and collapsing episodes
-Unable to get up on their own
-Lethargy
Ddx
-Lethargy: CV disease (syncope, arrhythmia), metabolic dz (hypoglycemia, hypokalemia), orthopedic (cruciate rupture, osteoarthritis), neurologic, neuromuscular (myasthenia gravis)
Dx
-CBC, chem, UA
-Ortophedic exam
-Neurological exam
Results
-Isosthenuria 1.012
-Orthopedic exam: no cranial drawer sign, no crepitus, good muscle mass, normal musculoskeletal exam
-Neuro: normal mentation, cranial nerves normal except: mild decreased gag reflex, palpebral decrease with repetitive stimulation. Conscious normal proprioception and sensation. Flexor reflexes decreased in all four limbs
Plan
-Radiographs thoracic
-Tensilon test
-Acetylcholine antibody titer
Results
-Megaesophagus with mild aspiration pneumonia
Therapeutic plan
-Acetylcholinesterase inhibition: Pyridostigmine
-Immunosuppression: Prednisone, mycophenolate
-Megaesophagus: elevated feeding
Review polyarthritis, MMM, dermatomyositis, perianal fistulas, glomerulonephritis
Congenital Macrothrombocytopenia
-Cavalier King Charles Spaniel
-Greyhound, Shiba, Polish Ogar. Ashi Cairns (cats)
-Affected dogs do not have bleeding disorders
Persistently low platelet count in absence of history or evidence of abnormal bleeding and is non-responsive to treatment with antibiotics or steroids
Platelet Function Testing
Buccal Mucosal Bleeding Time
-Differentiates primary from secondary homeostatic disorders
-Thrombocytopenia
-Thrombocytopathia
-vWD
-Severe uremia
-Intra and intra operator variability
-No evidence that BMBT directly correlates with platelet function
Platelet aggregation test
-Measures the effect of certain drugs such as pimobendan, NSAIDs, aspirin, clopidogrel, etc.
-Bedside abalyzers
Thrombocytopenia differentials
Decreased production
-Drug effect
-Tick borne illness
-Marrow disease
Splenic sequestration
Utilization increased
-Bleeding
-DIC
Increased destruction
-IMHA
-Immune mediated thrombocytopenia
Heartworm disease Lecture
Compare and contrast the life cycle of dirofilaria immitis in the dog and cat
Dog
-Infected mosquito ingests microfilariae
-L1-L3 in 10-14 days
-Mosquito bite, infected larvae in new host: Tissue phase
-L3: 3-4 days
-L4: 45-65 days
-Adult stage: Bloodstream phase, developing adult 4-5 months
-Mature adult: producing microfilariae (pre-larvae stages) 6-7 months post infection
-Adults live 5-7 years
-Microfilariae can live 1-2 years
Cat
-Infected mosquito ingests microfilariae
-L1-L3 in 10-14 days
-Mosquito bite, infected larvae in new host: Tissue phase
-L3: 3-4 days
-L4: ~ 2 months
-Adult stage: Bloodstream phase, developing adult 4-6 months
-Mature adult: producing microfilariae (pre-larvae stages) 7-8 months post infection
-Adults live 2-4 years
-Microfilariae rarely circulate
Discuss the pathophysiology of heartworm disease
Organ pathology
Dogs
-Heart & lungs; little significance; depending on size, activity of dog
-Exacerbated by shear stress of high blood flow with exercise.
-Severe pathology can be seen with low worm burden in athletic dogs.
-Death of worms associated with severe pulmonary parenchymal disease
-Intense inflammatory reaction in pulmonary vessels and parenchyma, resulting in fibrosis
-Pulmonary thromboembolism
-Chronic infection can lead to liver damage and cirrhosis
-Caval syndrome (class 4) mechanical obstruction
-Intravascular hemolysis and hemoglo binemia
-Antigen: glomerulonephritis
C/S
-Asymptomatic
-Signs of right-sided heart failure CHF
-Aberrant migration: lesions in skin, eyes
-Cough, shortness of breath
-Weight loss
-Jugular distension and pulses
-Cachexia
-Ascites
-Abnormal lung sounds
-Murmurs and arrhythmias
Cats
-Potentially fatal (lungs)
-Acute pulmonary reaction
-L5 reaches lungs at 3-4 mts
-Mortality high
-Heartworm associated respiratory disease (HARD)
-Respiratory crisis
-Embolism
-Lungs edematous and acute failure
C/S
-Acute, sudden death is more common
-Coughing, dyspnea, vomiting in chronic cases
Wolbachia
-Endobacteria
-Transmitted vertically
-Obligatory symbionts
-Immunopathology role
-Anti-Wolbachia surface proteins circulation
-Doxycycline reduces all stages
Diagnosis
Dogs: relatively simple
-ELISA, false negatives with low worm burden, male unisex infection, immature worms, HW Ag-Ab complexes & lab error
-Concentration test (modified Knott’s or filter test) 1 ml of blood
Cats: complex
-Detection of Antibodies in an antigen negative but symptomatic cat is clinically significant
-Thoracic radiographs
-Need 2-3 mts post infection for antibody test to detect
Antigen testing is the Gold Standard
-Start testing dogs 7 mts old, no reason to test puppies <6mts
-If needed repeat the antigen test with a new sample that has been heat treated to unmask the blocked antigen
Discuss the treatment plans for heratworm disease
Pre-treatment Work-up
- Thorough PE
- Screening bloodwork CBC/Chem/UA
- Thoracic radiographs
-Can be normal early on
-Blunted and torturous appearance of caudal lobar pulmonary arteries.
-Main pulmonary trunk bulge (MPA)
-Reverse D heart shape RV enlargement
-Patchy interstitial or alveolar infiltrates = pneumonitis, fibrosis or PTE - +/- Echocardiogram
- Stage the HWD (class 1-4)
Treatment
-Dogs: 1 approved compound
-Complications manageable
-Cats: none approved
-High risk of complications
-Prophylaxis: several approved for dogs, 3 approved for cats
-Doxycycline
Average worm burden in dog: 15 worms, cats: 1-3, less than 6
AHS guidelines
- Macrocyclic lactone/isoxazoline: for 2 months before adulticide . +/- antihistamine and steroids
- Doxycycline prior to the 3-dose melarsomine regimen. 10mg/kg BID for 4 weeks.
- Melarsomine regimen
-3 injection protocol. - Activity restriction 6-8 weeks
- Spectrum of care
Melarsomine - Adulticide therapy
-HW treatment: IM L3-L5 epaxial muscle
-1st IM injection kills 50%
-One month later 2nd and 3rd doses given 24 hours apart. 98% killed
-Monitor for 1/9 mts post treatment and HW Ag test at 9 mts
-Continue monthly preventative/microfilaricide treatment
Complications
-Injection site pain and inflammation
-Coughing, dyspnea, pulmonary emboli, pneumonitis
-Rapid microfilarial death: depression, lethargy, anorexia, hypotension, shock
Exercise restrictions are essential
Adulticide therapy not recommended as routine therapy
Discuss HW prophylaxis medication in the C/F patient
Macrolide Endectocides
-Ivermectin (heartgard) MRD1 dogs toxicity CNS may select other macrocyclic lactone, test Collies
-Milbemycin (Interceptor, Sentinel, Trifexis)
-Selamectin (Revolution)
-Moxidectin (Advantage multi, ProHeart6)
Rabies Lecture
Discuss the current epidemiology of the rabies virus in the US and worldwide
-Mexican free-tailed bats associated cases
-In US increased in 2021
-PEP is recommended for any bat contact when a bite or scratch can be ruled out
-10 million people receive post exposure treatment/year worldwide. US 30-60K 40% under 15 years old
Worldwide dogs are the primary host
US and Canada bats are the primary transmitters
Recognize the clinical manifestations of rabies in a canine and feline patient
-No fear to humans
-Agitated
-Inappetence
-Dysphagia
-Altered vocalization
-Ataxia
-Paralysis
-Seizures
Discuss handling and quarantine of dogs and cats following suspected rabies exposure and following bite incidents
-Mode of transmission by bite or wound or scratch
-Incubation 3-12 weeks; up to 6 mts
-Dogs shed virus in saliva for 14 days prior to c/s, cats 1-2 days
-Rabies Vaccine at 3 months of age
-Booster 1 year later regardless of age at primary immunization
-Booster every 3 years thereafter
-Animal considered immunized 28 after initial vaccination
-Booster immediately considered immunized
Complications
-Type III hypersensitivity Immune Complexes Ischemic dermatopathy
Human Bitten by an animal
- Wash wound thoroughly with soap and water.
- Seek medical attention
- Healthy dog, cat, ferret: Observe for 10 days. Healthy domestic animal: very low risk
Do not vaccinate during quarantine - Raccoon, skunk, fox, bat: contact health department to arrange testing for animal. Exposure prophylaxis if animal not available for testing
- Other wild animal: testing or post exposure prophylaxis
Patients - Animals
-Vaccinated or booster due: revaccinate immediately and observed for 45 days under owner’s control. Any illness during observation should be reported.
-Unvaccinated: euthanize immediately or, if owner is unwilling, vaccinate as soon as possible and place in strict isolation for 4 months
-Other: euthanize immediately, test for rabies
Recognize the difference in quarantine procedures between a small animal patient and a human with a suspected rabies exposure
Patients - Animals
-Vaccinated or booster due: revaccinate immediately and observed for 45 days under owner’s control. Any illness during observation should be reported.
-Unvaccinated: euthanize immediately or, if owner is unwilling, vaccinate as soon as possible and place in strict isolation for 4 months
-Other: euthanize immediately, test for rabies
Discuss rabies vaccination strategy in dogs and cats
Canine Preventive Health
Obtain and integrate a thorough history to formulate an appropriate preventive health care plan
- Core
*6-8 weeks old, then 2-4 weeks later, with final booster between 14-16 weeks.
*Booster in 1 year
*MLV or recombinant (CDV): produce immune response in presence of maternal antibodies
-Rabies
-Canine Distemper virus
-Canine Adenovirus -2
-Canine Parvovirus: current strains 2a, 2b, 2c vax effective. CPV SNAP test identifies all strains of CPV-2. Vaccine failure due to maternal antibodies interference. Final puppy vaccine must be 14-16 weeks of age then booster 1 year, then every 3 years
+/- Parainfluenza (non-core by itself)
- Non-core
-Lyme (4 servers). In both humans and animals, tick control is the most successful tool for prevention of infection.
OspA monovalent vaccine, novel. 9 weeks old, 2 doses, 2-4 weeks apart, then annual booster
-Bordetella bronchiseptica: initial series of 2 vaccines, 2-4 weeks apart. Booster annually. Oral or intranasal product, onset immunity 3-5 days . Booster every 6-12 months. only intranasal prevent shedding of virus and viral replication, IgA
-Leptospirosis: zoonosis. Geographic prevalence varies. 4 server vaccines: L. canicola, L. icterohemorrhagica, L. grippotyphosa, and L. pomona (best protection). No vaccine is 100% protective. Initial 2 doses, 2-4 weeks apart. Annual booster, if >2 years, then repeat finial series. for 9 weeks or older.
-Canine influenza (H3N8, H3N2): Spreads via respiratory secretions and fomites. Incubation period 2-4 days, most infectious period. Vax does not prevent infection but decreases clinical duration and period of virus shedding. Risk factors: high density housing
-Parainfluenza
-Crotalus atrox (diamondback rattlesnake)
- Not recommended or generally not recommended
-Canine coronavirus
-Canine Adenovirus 1, cross protection from CAV-2
Plan and discuss and individualized and optimal vaccination plan utilizing AAHA guidelines
Plan and discuss individualized and optimal parasite testing and prevention AAHA-AVMA guidelines
Testing
-Annual heartworm
Control
-Year-round broad-spectrum product with efficacy against heart worms, intestinal parasites, and fleas.
-Tick control
Fecal Testing
-4 times in the first year of life
-1-2 times per year adults
Plan and discuss a comprehensive wellness plan to include laboratory testing, dental care, weight management, pain control, etc.
Vaccine associated adverse events
Young adult, small breed neutered dogs receiving multiple vaccines at greater risk
-Vaccine induced ischemic dermatopathy
-Hives
-Angioedema
-Immune mediated disease
-Report adverse reactions to manufacturers
Immunization Failures
- Maternally derived antibodies interference
- Body temperature >103.6F to prevent immunization
- Exposure to infection before fully vaccinated
- Strain differences, lepto serovars
- Failure to mount an adequate immune response
- Improper handling/storage/manufacturing error/administration
- Concurrent therapy with blood products: delayed vaccination 2 weeks
Feline Preventive Health
Vaccine Risks
-Serious sign of allergic (anaphylactic) reactions most commonly involve vomiting, diarrhea and collapse in the cat
-Injection site sarcoma
3,2,1 Rule
Get incisional biopsy
-Mass persistent 3 or >3mts
-2 cm or greater
-Growth increase in 1 month
Obtain and integrate a thorough history to formulate an appropriate preventive health care plan for the feline patient
Core Vaccines
- Rabies
- Rhinotracheitis (FHV-1)
-Readily inactivated by disinfectants
-80% infected cats become chronic intermittent shedders with stress
-MLV protection within 48 hours
-Vaccine protocol same as FPV/FRV
-Kittens >6 wks and <16 weeks
-Every 3-4 weeks until 16 weeks
-Adults >16 weeks initially 2 vaccines 3-4 weeks apart (1 vax intranasal + annual booster)
3 year booster after 1st annual
-Boost if high risk, 1 year intranasal, 3 year injection
- Calicivirus
Oral ulcerations
-May shed 75 days up to 2 years
-Vaccination protocol same as FPV/FRV
-Kittens >6 wks and <16 weeks
-Every 3-4 weeks until 16 weeks
-Adults >16 weeks initially 2 vaccines 3-4 weeks apart (1 vax intranasal + annual booster)
3 year booster after 1st annual
-Boost if high risk, 1 year intranasal, 3 year injection - Panleukopenia
Kittens < 4 weeks old = cerebellar degeneration if vaccinated C/S: ataxia, wobbly gait, intention tremors, hypermetria, wide-legged stance.
-Kittens >6 wks and <16 weeks
-Every 3-4 weeks until 16 weeks
-Adults >16 weeks initially 2 vaccines 3-4 weeks apart (1 vax intranasal + annual booster)
3 year booster after 1st annual
-Inactivated by bleach
-High mortality in kittens
-Resistant for 1 year in environment
-Shed in urine/feces up to 6 weeks after recovery
MLV immunity in 24-48 hours
-Maternal immunity broken through by 12 weeks, may prevent immunization until 18 weeks
- Feline Leukemia (<1 yo)
-Shed in saliva, respiratory secretions, bites
-Susceptible to disinfectants and drying
-80% initially healthy shedders die in 3 years
Protocol
-All cats (any age) need initial 2 vaccine series
-High risk cats
-Test by ELISA or IFA
-at 8 weeks old, then 2 doses 3-4 weeks apart.
-Left rear distal site
-Annual booster for high risk
Complications
-Amputate if leg develops tumor Vaccination site sarcoma
Plan and discuss an individualized and optimal vaccination plan for the feline patient using AAHA/AAFP guidelines
Non-Core Vaccines
Feline leukemia virus
->1 yr old
-FeLV + cats susceptible to IMHA, Lymphoma, bone marrow disorders, infectious diseases.
Bordetalla bronchiseptica
Chlamydia psittaci
Not recommended
-Feline infectious peritonitis
-FIV: maternally derived antibodies to FIV in cats <6mts old = positive test results. If still positive after 6 mts then infected. Test every 60 days
-Giardia
Plan and discuss individualized an optimal parasite testing and prevention for the feline patient utilizing the AAHA-AVMA feline guidelines
-Annual heartworm testing
-Antigen and antibody test
Control/Prevention
-Year-round broad spectrum product against heart worms, intestinal parasites, and fleas
Common small animal Behavior Challenges Lecture
Discuss the most commonly occurring behavioral challenges in C/F patient
-Aggression
-Elimination problems
-Separation anxiety
-Noise phobia
-Cat to cat aggression
Feline
-3-8 weeks of age prime socialization period to humans, learning and play begins
-Exposure to adults, children, scratching posts, litter boxes
-Late socialization 9-16 weeks of age. Need vertical space
Adolescent
-17 weeks to 1 year
-Spray and elimination problems, spay or neuter to lessen risk
Canine
-Neonatal up to 2 weeks of age
-Gentle handling promotes resilience to stress later
-Capable of learning within first few days of life
-Transitioning period: eyes, ears open. Locomotion proceeds from crawling to walking
Socialization period
-5-8 weeks likely optimal time
Stable learning begins at 8-9 weeks of age
-Traumatic events to the puppy at this age can adversely affect social development
Juvenile
-12 weeks to sexual maturity
-Socialization must be continually reinforced
Development
-Obedience lessons usually start at 6 months of age
-Barking begins at 2-4 weeks. Aggressive barks usually do not occur before 12 weeks of age
-Chewing: common to continue for 1.5 years or more. Common problem in pound adopted pups
-Crate training
Housebreaking
-By 9 weeks puppies orient to a specific elimination place
-Patience, praise, confinement and schedule! after awakening, after activity or excitement, every 2 hours, before bed time
-Rule of thumb: puppies can hold urine for 1 hours for every one month of age + 1
-Problems: incomplete urination/defecation, incomplete house training. Praise, not punishment
Feline
Litterbox
-Substrate preference and scratching starts at 3 weeks of age
-Unscented, activated charcoal preferred by cats
-1+1 box theory
Understand age-specific normal and abnormal behavior to ensure developing or existing behavioral problems are recognized and addressed
Desensitization
-Stimulus is associated with undesirable behavior is presented at a level below which elicits a response
Counterconditioning
-Patient reactive to a specific stimulus, learns to become accepting of that stimulus
Alternate Behavior Training
-Appropriate behavior is taught as an alternate positive reinforcement
Distraction and redirection
-Food/reward to lure patient’s attention away from undesirable behavior
Environmental enrichment
-Addition of one or more external factors in order to reduce an unwanted behavior
Avoidance
-The act of preventing an individual from engaging in an unwanted behavior
Flooding & aversive techniques Not recommended
Identify commonly used pharmacologic interventions for behavior modifications, focusing on the US veterinary approved drugs
Benzodiazepines
-Diazepam
-Alprazolam
-Gabapentin
Tricyclic antidepressants
-Amitriptyline
-Clomipramine
Selective serotonin reuptake inhibitors (SSRIs)
-Fluoxetine
-Paroxetine
-Separation anxiety
Dual serotonin 2A antagonist/serotonin reuptake inhibitors (SARIs)
-Trazadone
-Nefazodone
Monoamine oxidase inhibitors
-Selegiline
Azapirones
-Buspirone
Centrally acting 2A agonists
-Clonidine
-Medetomidine
-Dexmedetomidine
Local anesthetics
-Lidocaine gel
-Used before venipuncture, vaccination or anal sac expression, especially for patients that have experienced procedure-related fear or pain
Discuss these basic behavior modification techniques for desensitization, counterconditioning, flooding, training an alternate behavior, distraction and redirection, environmental enrichment, avoidance
Desensitization
-Stimulus is associated with undesirable behavior is presented at a level below which elicits a response
Counterconditioning
-Patient reactive to a specific stimulus, learns to become accepting of that stimulus
Alternate Behavior Training
-Appropriate behavior is taught as an alternate positive reinforcement
Distraction and redirection
-Food/reward to lure patient’s attention away from undesirable behavior
Environmental enrichment
-Addition of one or more external factors in order to reduce an unwanted behavior
Avoidance
-The act of preventing an individual from engaging in an unwanted behavior
Flooding & aversive techniques Not recommended
Dietary Management for all Life Stages Lecture
Accurately identify body condition scores and how those correlate to estimated percentage of body wight over ideal body condition
Ideal
-4-5/9 Dogs
-5/9 in cats
Percentage over ideal
-Each BCS >5/9 = 10% overweight
-Ex: 9/9 = 40% overweight. 40kg * 0.4 = 16 kg overweight. Ideal weight 40-16 = 24 kg
Discuss the key points in maintaining healthy body weight throughout the following life stages, adult senior
Maintenance of healthy weight
- Puppy and kitten feeding
- Evaluating BCS and adjusting feeding when changes are noted at home particularly after spaying or neutering
- Maintain an ideal adult weight
- Maintain exercise activity
- Behavior training using interactive rewards as alternative to food
- Educating clients about the limitations of pet food labels and label feeding recommendations
Weight loss calculation
RER = 70 * BW^0.75
Daily energy requirement = RED * DER factor = Kcal/day
Example:
30 kg
BCS 8/9 = 30% overweight
Ideal weight 30*0.3 = 9, 30-9 = 21kg ideal
RER = 70 (21)^0.75 = 686.7 = ~700
Treats
-No more than 10% of daily calories should come from treats
Calculate the daily caloric requirements for patient growth, adult maintenance, and weight loss.
Nutrients
Fat
-Energy dense 2.25 kcal/gm
-Preferred source for aerobically fit dogs and endurance type dogs
-Allows higher calories count in a smaller kibble
-Increases palatability
Protein
-Building blocks for muscle repair, cell line replenishment, etc
-Used metabolically for enzymes
-Too little protein leads to anemia, poor performance, and injuries
-Too much protein taxes the kidneys
Carbohydrates
-Provides fuel source for immediate energy and brain metabolism
-Glycogen is used for metabolic fuel first 2-5 minutes of fast twitch muscle activity
-Dogs short digestive tract difficult to process grains like whole corn
Diet Choices
Commercial diets
-AAFCO standards
-Quality control
-Consistent ingredients
-Potential for contamination
-Better geared for life stages and activity levels
BEG - Boutique, exotic, grain free
-Dilated cardiomyopathy
-Taurine levels
-Breed
Home cooked diets
-Can be adjusted for hypoallergenic pet, picky eaters
-Deficiencies and lack of balance easy
-Secure.balanceit.com
Raw diets
-Risky
-Zoonotic bacteria
Prescription diets
-Know your reps
-Renal, urinary, digestive, hypoallergenic, joints, dental, neurological/brain
Growth diet
-Nursing Up to 6-8 weeks of age
-Up to 12-14 mts of age
-Increased calcium, phosphorus, NaCl, protein, fat
Adult diet
-18-25% decrease in maintenance caloric requirement in older dogs, >7 years old
-Cats approximately 3% per year until 12 years old, then increase
