- 9 year old FS Brussels Griffon presented for lethargy, increased respiratory effort, exercise intolerance, and acting clingy.
- History of Cushings diagnosed June 2016. Started Vetoryl and responded well at a previous veterinary hospital. Owner stopped treatment on September 2nd due to collapse episode and vomiting. Patient has been lethargic and had rough breathing episodes since.
- HWT/Tick screen was negative in January 2016 and has been on HWP monthly since.
- 9 year old FS Brussels Griffon presented for lethargy, increased respiratory effort, exercise intolerance, and acting clingy.
- History of Cushings diagnosed June 2016. Started Vetoryl and responded well at a previous veterinary hospital. Owner stopped treatment on September 2nd due to collapse episode and vomiting. Patient has been lethargic and had rough breathing episodes since.
- HWT/Tick screen was negative in January 2016 and has been on HWP monthly since.
- CBC showed a mild leukopenia and thrombocytosis. Chem prof showed ALT=128 and ALP=422, and GGT=12
- Chest radiographs read by a boarded radiologist stated an enlarged heart, possible LA enlargement, mildly dilated pulmonary vasculature, and a perihilar interstitial pulmonary parenchymal pattern. Differential diagnoses included emerging CHF secondary to MVI except to murmur ausculted, cardiomyopathy or pulmonary hypertension. The radiologist recommended a lasix trial which was initiated 4 days ago.
- BP measured 150mmHG.
- Abdominal US showed hepatomegaly and mild bilateral adrenal gland enlargement with retention of normal shape and no local vascular invasion.
- The echo showed normal measurements except for increased FS=57% (IVSd=7.1mm, LVDd=21.8, LVPWd=10.6, IVSs=13.4, LVDs=9.4, and LVPWs=13.1). The LA was 14.8mm and the LA:Ao was normal at 0.87. There was no visible MVI or TVI seen on PW and CF Doppler. The MPA:AO ratio was also normal. Please see the attached pics.
- So, I am thinking that even though this dog is on Lasix (and owner thinks it helps), her respiratory problem is not cardiac related. I cannot prove PHT but cannot rule it out. My differentials include PTE, pneumonia, or perhaps pulmonary neoplasia?
- What do you think? Would you treat with clopidogrel anyways? Start antibiotics? Taper off the lasix?
Comments
I don’t see a need for Lasix
I don’t see a need for Lasix based on both the echo and the radiographs. The rads give the appearance of cardiomegaly because the films are end-expiratory, but the heart is clearly normal in size based on the echo, and the absence of any evidence of cardiac dysfunction strongly suggests that the respiratory signs are not cardiogenic in origin. Unfortunately, because of the end-expiratory nature of the radiographs, as well as the fact that only a singel lateral image was submitted, the lungs cannot be properly evaluated to determine whether primary respiratory disease is present. I think that significant pulmonary hypertension is unlikely given the lack of PA dilation or RV hypertrophy. It’s possible that there could have been an acute event that led to a rapid increase in PA pressure, however, the spectral Doppler profile of PA flow is not consistent with the presence of significant pulmonary hypertension. It probably won’t hurt to treat with clopidogrel, but I don’t see an obvious indication for it.
I don’t see a need for Lasix
I don’t see a need for Lasix based on both the echo and the radiographs. The rads give the appearance of cardiomegaly because the films are end-expiratory, but the heart is clearly normal in size based on the echo, and the absence of any evidence of cardiac dysfunction strongly suggests that the respiratory signs are not cardiogenic in origin. Unfortunately, because of the end-expiratory nature of the radiographs, as well as the fact that only a singel lateral image was submitted, the lungs cannot be properly evaluated to determine whether primary respiratory disease is present. I think that significant pulmonary hypertension is unlikely given the lack of PA dilation or RV hypertrophy. It’s possible that there could have been an acute event that led to a rapid increase in PA pressure, however, the spectral Doppler profile of PA flow is not consistent with the presence of significant pulmonary hypertension. It probably won’t hurt to treat with clopidogrel, but I don’t see an obvious indication for it.
Thanks Keith. There is a VD,
Thanks Keith. There is a VD, but the forum wouldn’t let me upload it (received an error message stating I have exceeded the disk quota of 2000MB). I will open another post and see if I can post the VD there (sorry Eric ;). I am concerned that the radiology report has led the primary vet and patient down the wrong pathway. The dog does have an increased expiratory effort in the hospital but it is difficult to determine if this is all Cushing’s related or a separate pulmonary problem.
Most adrenal glands are plump
Most adrenal glands are plump on Trilostane.
Is that a soft tissue density within the gas in the mid abdomen?
Did you say you did an abdominal ultrasound?
Pulmonary hypertension should give us a TI.
I am concerned about some sort of neoplasia.
Surely nojt cardiogenic…
Surely nojt cardiogenic… think pain, thromboembolic (Cushings is a hypercoagulable state), inhalent allergens….trilostane as randy says does plump up adrenals… zoom in on the phrenic veins too with power doppler and look for thrombosis there to support potential TED..I find thrombosis more often there than anywhere.
I completely agree with
I completely agree with Keith. And: Griffons (at least in my experience) usually have strange thoracic radiographs. Even if they are inspiratory.
Peter
Pulse oximetery or (ideally)
Pulse oximetery or (ideally) blood gas should give an idea of respiratory disease. Also consider doing an ACTH stimulation test as dog may have developed Addison’s disease
Great, thanks for all of the
Great, thanks for all of the help! I will pass your suggestions on to the primary vet.