Case Of the Month

Acute hepatic encephalopathy due to mushroom toxicity in a 14-month-old Miniature Australian Shepherd dog: Our January 2016 Case Of the Month

The patient is a 14 month old M Miniature Australian Shepherd dog who presented with an acute case of vomiting, lethargy and ataxia. The owner was unaware of any exposure to toxins or ingestion of obstructive material. Physical exam: 10% dehydrated; mm pink but tacky; abdomen tender on palpation; weight wnl. CBC/Chem: WBC 21,120, decreased cholesterol and protein; elevated CK, ALKP, ALT, BUN and ammonia. Lepto negative.

DX

Acute hepatitis/cholangitis pattern. Free fluid, potentially owing to neoplasia or portal hypertension.

Outcome

On subsequent referral to Oregon State University, it was determined that the patient did indeed suffer from mushroom toxicity (specifically, one of the genus Amanita, which were found in the patient’s backyard and appeared to be partially eaten). Treatment consisted of supportive care and reducing neurotoxins produced in the GI tract. The patient’s treatment plan included Denamarin, Lactulose, Cerenia and Omeprazole and a diet of Hill’s L/D. Repeated chemistry panel on 10/29/15 and again on 11/23/15 showed progressive decreases in the levels of BUN, GGT and ALKP until normals were attained.

Sampling

Ultrasound-guided FNA of the liver was performed without complication. Cytology results: Mild vacuolar degeneration with suggested regeneration Comment: The mild vacuolar change noted could be associated with a toxic event as suggested. No evidence of underlying disease was detected and overt inflammation was not observed.

Sonographic Differential Diagnosis

Acute hepatitis/cholangitis pattern. Free fluid, potentially owing to neoplasia or portal hypertension. Based on the ultrasound results, treatment for gastritis, cholangiohepatitis and pancreatitis would be recommended in this patient. Leptospirosis or toxin exposure is possible. Plasma expander +/- plasma transfusion would be ideal. No complication to FNA was noted. Volume contracted heart with shocky contractility. Very guarded prognosis depending upon underlying cause.

Image Interpretation

The spleen was volume contracted. The liver was swollen and hypoechoic with a double layered gallbladder. The stomach presented fluid accumulation. The small intestine was unremarkable. There was no evidence of a foreign body. The pancreas was largely uniform with minor, heterogenous changes noted in the right limb. This is consistent with pancreatitis. Surrounding free fluid was noted in the abdomen. Rapid view of the heart revealed volume contraction and shocky contractility.