Hello all –
Thanks for help on this case.
I have a 10 year old MC shih tzu who came in for being unable to close his mouth. Besides having hideous dental disease, this dog has muffled heart sounds on the left side of the chest. The right side heart sounds normal with no murmur and synchronous pulses. The owner did not notice anything wrong with the dog in terms of exercise tolerance or cough, but the admitting veterinarian noticed the muffled sounds of the left side of the chest and took rads. Radiographs are attached.
Hello all –
Thanks for help on this case.
I have a 10 year old MC shih tzu who came in for being unable to close his mouth. Besides having hideous dental disease, this dog has muffled heart sounds on the left side of the chest. The right side heart sounds normal with no murmur and synchronous pulses. The owner did not notice anything wrong with the dog in terms of exercise tolerance or cough, but the admitting veterinarian noticed the muffled sounds of the left side of the chest and took rads. Radiographs are attached.
I was called in to scan the chest to look for fluid. We have an old (VERY) limited machine, but fluid is definitely visible on the left side of the chest. The problem is that it looks to be mostly pericardial on the left side, with not much fluid accum on the right. If I stand the dog up and scan the heart area, the fluid remains pericardial rather than traveling towards the diaphragm. So I don’t think this is actually pericardial effusion, but it isn’t pleural effusion either, or if it is, it is contained within a pocket near the heart (mediastinal?) Sorry, our crappy old machine can’t download images.
The owner has limited finances so we do not have blood work or other diagnostics. It is my feeling that the prognosis in this case is probably guarded to poor, even if we tap. The owner is willing to tap therapeutically but the dog seems to feel ok right now as is.
To me, the heart sillouette on the DV appears globoid and enlarged, but there also seems to be pleural effusion in the lateral. The VD is rotated due to discomfort being placed on his back.
Wish I had a better ultrasound machine!
I’d like everyone’s thoughts. My feeling is that this is bad enough that there is no conservative therapy that will provide any long term response, but I want collaboration on that.
Liz
Comments
Oops – was in VIN mode, not
Oops – was in VIN mode, not sonopath mode. Sorry no bullets! 🙂
Oops – was in VIN mode, not
Oops – was in VIN mode, not sonopath mode. Sorry no bullets! 🙂
Looking at the radiographs I
Looking at the radiographs I would go for left-sided pleural effusion rather than pericardial effusion, as there is border effacement of the heart, pleural fluid lines, and no tracheal elevation. Even with an old machine it should still be relatively easy to see a pericardial effusion and possible tamponade. I would recommend a tap both for therapeutic and diagnostic reasons.
Once tapped spin the fluid down, do a SG and a urine dipstick on the supernatant and smear out and stain the sediment plug and evaluate it microscopically. Quick in-house diagnostic procedure.
Looking at the radiographs I
Looking at the radiographs I would go for left-sided pleural effusion rather than pericardial effusion, as there is border effacement of the heart, pleural fluid lines, and no tracheal elevation. Even with an old machine it should still be relatively easy to see a pericardial effusion and possible tamponade. I would recommend a tap both for therapeutic and diagnostic reasons.
Once tapped spin the fluid down, do a SG and a urine dipstick on the supernatant and smear out and stain the sediment plug and evaluate it microscopically. Quick in-house diagnostic procedure.
Thanks Remo –
I can
Thanks Remo –
I can usually see pericardial effusion with this machine, and usually even use the machine to guide pericardiocentesis – but this case was weird. The fluid was localized around the heart; moving the animal around did not move the location of the fluid. There was no evident tamponade but the heart rate was quite high. The lungs themselves had a bit of the “shower curtain” effect…Could it be that the lungs are diseased and fibrosed and causing the fluid to stay in a certain area?
What do you think about the heart sillouette on DV? It looks big to me. Is this just artifact?
Can we go over differentials here? I am thinking either infection (no fever), heart failure (no murmur), chylothorax (why unilateral?), or neoplasia (which seems most likely).
If these folks have no ability to place chest tubes or go to surgery, I’m not sure what good identifying the fluid will do (they don’t even really have the $300 for the chest tap).
So, I’m just wondering if we can think of a differential which, if I identified it, could be treated conservatively with medication. If so, I can call the owner and ethically recommend drainage and cytology. Otherwise, I feel obligated to recommend euthanasia once this dog becomes uncomfortable. Thoughts?
Dang money anyway.
Thanks Remo –
I can
Thanks Remo –
I can usually see pericardial effusion with this machine, and usually even use the machine to guide pericardiocentesis – but this case was weird. The fluid was localized around the heart; moving the animal around did not move the location of the fluid. There was no evident tamponade but the heart rate was quite high. The lungs themselves had a bit of the “shower curtain” effect…Could it be that the lungs are diseased and fibrosed and causing the fluid to stay in a certain area?
What do you think about the heart sillouette on DV? It looks big to me. Is this just artifact?
Can we go over differentials here? I am thinking either infection (no fever), heart failure (no murmur), chylothorax (why unilateral?), or neoplasia (which seems most likely).
If these folks have no ability to place chest tubes or go to surgery, I’m not sure what good identifying the fluid will do (they don’t even really have the $300 for the chest tap).
So, I’m just wondering if we can think of a differential which, if I identified it, could be treated conservatively with medication. If so, I can call the owner and ethically recommend drainage and cytology. Otherwise, I feel obligated to recommend euthanasia once this dog becomes uncomfortable. Thoughts?
Dang money anyway.
Things that do this arent
Things that do this arent good liz. Maybe lung lobe torsion especially if hemothorax present. Lung neoplasia is my primary diff though that can sneak up without symptoms. Run the probe up the rib spaces til you find a consolidation and fna. This should give the answer and is the most efficient way tot he dx.
Things that do this arent
Things that do this arent good liz. Maybe lung lobe torsion especially if hemothorax present. Lung neoplasia is my primary diff though that can sneak up without symptoms. Run the probe up the rib spaces til you find a consolidation and fna. This should give the answer and is the most efficient way tot he dx.
Difficult to judge
Difficult to judge cardiomegaly on these radiographs.
Most likely etiologies would be neoplasia (number 1), chylothorax (which can be unilateral), and chronic granulomatous disease (hence the no fever). The shower curtain effect would indicate lung disease but not really apparent in the history.
A chest tap would narrow the diagnosis, however, with financial constraints treat with diuretics and see what happens to the fluid.
Difficult to judge
Difficult to judge cardiomegaly on these radiographs.
Most likely etiologies would be neoplasia (number 1), chylothorax (which can be unilateral), and chronic granulomatous disease (hence the no fever). The shower curtain effect would indicate lung disease but not really apparent in the history.
A chest tap would narrow the diagnosis, however, with financial constraints treat with diuretics and see what happens to the fluid.
Thanks very much, guys. The
Thanks very much, guys. The VIN folk guessed pericardial, but the more I think about it, the more I agree with Remo. You can’t really have a unilateral pericardial effusion. I think I’m going to get the dog back in n/c and maybe give a little torb and see if the dog will relax enough to allow a better u/s.
Thanks again for your input.
Liz
Thanks very much, guys. The
Thanks very much, guys. The VIN folk guessed pericardial, but the more I think about it, the more I agree with Remo. You can’t really have a unilateral pericardial effusion. I think I’m going to get the dog back in n/c and maybe give a little torb and see if the dog will relax enough to allow a better u/s.
Thanks again for your input.
Liz