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marbury 08-20-2014 10:21 PM

Medical Mystery!
OK, guys! How about a challenge?

4 year 4 month old female spayed GSD. Known history of enlarged spleen. Ultrasound performed, aspirates taken with unremarkable findings (secondary inflammation of the spleen). All other systems normal.

On Sunday (8/17) she was given a tiny 0.3cc bump of torb (torbugesic) as a prep drug for a blood donation. CBC normal, exam normal. Slightly distended soft abdomen which is normal for her. 33.6kg, TPR normal. She donated just over 475ml of whole blood. She received 700ml SQ LRS and was eating and drinking normally an hour after her donation. Appeared normal, happy, slightly tired as would be expected from a donor.

Monday (8/18) normal, happy, active, eating and drinking readily. After dinner bedtime was normal. No apparent physical changes.

Tuesday (8/19) asks to go out in morning to vomit, emesis is substantial quantity of undigested kibble from previous night. Waist is pinched with distended abdomen. Begins refusing food mid-day and refuses water mid-afternoon. Vomiting continues, transitions from undigested food to food and bile and finally to clear liquid with light white foam. Visible discomfort in abdomen, pacing, restless. TPR normal. Lethargic, begins showing signs of dehydration.
We went into work and did a full blood panel and an ultrasound. Weight was 30.6kg. Everyone who knew her remarked that she looked awful. At this point she was fairly skeletal with a pendulous distended abdomen. Blood panel was unremarkable. Ultrasound came back with an extremely enlarged spleen, enlarged splenic lymph node, and enlarged blood supply to spleen. Small (1cm) pocket of fluid along the spleen. Pyloris functional, small amount of food in small bowel. Large bowel normal but completely empty. We did a SQ Cerenia inj. and 600ml SQ LRS.
She perked up after the meds but would not eat or drink when we got home. She vomited twice after her Cerenia.

Today, 8/20 short choppy breathing while sleeping. Temp normal, resp shallow, pulse decreased. Marked discomfort, multiple attempts to vomit, urgency to pass stool. No stool; passing clear mucous jelly. Trouble laying down but marked lethargy. No interest in food or water.
In afternoon we headed back to work. Weight down to 29.2kg. Put on IV fluids and some buprenex to keep her comfortable. I left her there for a second ultrasound, radiographs, and repeat bloodwork. Bloodwork again unremarkable save for the expected dehydration, ultrasound increased size of spleen, increased amount of fluid. Abdominal x-ray shows food in the colon but she continues to only pass the clear jelly with urgency (5-10 minute intervals). Fluid tap glucose compared to blood glucose suggests sepsis.

No exposure to raw fish, no known exposure to pesticides or rodenticides, no change in environment or new places, no medications, flea and hw prevention last given 8/1.

Current theories are intermittent torsion, either splenic or colonic, that we're just not catching in action.

We've successfully stumped two radiologists, four ER doctors, two surgeons, two Internal Medicine specialists, and a whole batch of interns. She's continuing on IV drip for dehydration overnight for a reassessment tomorrow or emergency surgery overnight. She's stable but darn it if we can't find an explanation for what's happening.

Ideas? Anything out of the box is welcome.

ugavet2012 08-20-2014 10:37 PM

An "atypical" addisonian? Does she have a stress leukogram during all of this? (Stressful event set it off) Tick disease?
Does she normally donate blood? My 50-53 lb GSD donated that exact amount, ate a can of dog food, and then went on a 1 hour hike mid day in April in Georgia. No SQ fluids, nothing, and was totally normal. Just seems like "tired" isn't a word I thought of to describe her after all that. Wonder if that's actually when everything started.
What does abdominal tap show besides low glucose? Fluid analysis? Did they look at the heart? (Metastasized hemangio....coming from the heart?)
Clear jelly stool would be from the colon, like colitis, and intussusception doesn't explain the issue with the spleen...?
Sounds like you might have to bite the bullet and do some biopsies of spleen and intestines, many of the faculty at UGA thought that splenic aspirates were a waste because they always came back inconclusive.

Juliem24 08-20-2014 10:42 PM

Having trouble posting, apparently. I'll try again.
In kids, currant jelly stools and sepsis symptoms =intussuception (telescoping bowel)which is a surgical emergency. Same symptoms as the dog. It's seen almost exclusively in infants, but there is the outlier, of course. They can get very shocky very quickly, with obviously dire consequences. I'm not sure if this translates in dogs, but it would be in my differential. Good luck.

marbury 08-20-2014 10:58 PM

No stress identified, tick panel neg. No ticks found anyway.
I have 4 dogs that donate, they can be groggy. Most of the time they're totally fine but this was her first donation. I've had first timers be a bit 'off'.

I'm going back to check on her and her files tonight. I'll let you know specifics on her reports.

I've had a dog with intussusception, he had 4 inches of small bowel removed. He had similar symptoms which is why it's so frustrating we aren't finding it on ultrasound. I watched her whole session and her bowel was flat and pretty the whole way through.

Either way, she's still in the ICU and on potential SX watch tonight. Updates later, thanks guys!

Anubis_Star 08-22-2014 01:41 AM

intermittent colonic torsion? Doesn't even sound possible to me. Not only is a colonic torsion rare enough, but one that is caught in time, gets into surgery in time, and actually survives? I've seen 1.

GSDs are prone to enlarged spleens. Butaspirates could be missing potential masses that aren't found on xray or ultrasound.

Could just consider an abdominal explore and splenectomy, send the whole thing off for pathology.

If there was even the chance that my dog could be septic, the board certified surgeon would be cutting him right then and there. Especially with free fluid, enlarged spleen.

Anubis_Star 08-23-2014 09:28 PM


Colie CVT 08-24-2014 12:35 AM

Yeah, I am with Anubis on this one. :/ As wonderful as diagnostic imaging can be, honestly if the ultrasound isn't finding anything, we often would recommend a CT with contrast to see if there is anything oddly enhancing or it also allows you to see things in a more clear picture, since you get a kind of "3D" model, and the contrast helps enhance the vessels.

Some days if you aren't super sure about something, it never hurts to just "let the demons" out with surgery. Another thing to try would be potentially, especially if sepsis is a concern, to give some fresh frozen plasma to see if that potentially helps to boost up the plasma proteins in the system and maybe give her a boost with what is needed.

My golden donates and I have noticed when he gives larger volumes of blood (which they should really only be donating about 10% of their body weight max - which would be around 300 ml for your dog with her original weight) that he is a little off for a day or so. A little more tired, sometimes his stomach seems a little off. I do give him SQ fluids when he donates over his "limit" and I tend to give him a can or so of a rich wet food after he donates, which could contribute to his tummy upsets. However, he has never had that kind of reaction where it almost seems like she's bloating.

I would definitely not have her donating again. Could be with the way her spleen is enlarged that the sudden drop in the amount of blood in the system caused it to release more of the stored cells than it should have, and her body didn't compensate to recover well. Almost like it was stretched a bit too thin and had trouble rebounding. Kind of thinking like when you do manage to untwist that GDV or remove the blood from a hemoabdomen then quickly try to get the offending organ (usually spleen) to stop bleeding so your system basically drops drastically and goes nuts renormalizing if that makes sense.

Hope your girl is doing better.

Anubis_Star 08-24-2014 03:13 AM

I too would be concerned about a sliding intussusception that wouldn't necessarily be seen on ultrasound. Spleen growing in size could be splenic torsion. I guess, talking to our surgeon, that she thinks during gdvs the splene can intermittently torse likely due to pressure. So it could potentially be possible in this case?

Either way I think I would still lean towards exploratory surgery if this was my dof

dogfaeries 08-24-2014 11:15 AM

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Russell's intussusception didn't show up in his ultrasound. They had to do exploratory surgery, and that's when they found it. Turns out it had telescoped about 10", and had to have 3" removed. Couldn't see any of that on his ultrasound.

JeanKBBMMMAAN 08-24-2014 12:02 PM

Those things - the intussusceptions - can do that, so the dog seems normal, then not. You have to open them up to see it from everything I've heard, unfortunately, so I'd get to a university with her for them to take a look at things.

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