A challenging case: A dog with intermittent pain and fever

A challenging case: A dog with intermittent pain and fever

This dog was repeatedly evaluated because of waxing and waning pain. A key radiographic sign in determining the diagnosis did not appear until much later.
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Dec 01, 2006

A 2.5-year-old spayed female mixed-breed dog was presented to Claiborne Hill Veterinary Hospital for evaluation of a one-day history of pain when walking. The dog's vaccination status was current. The patient had vomited in the car on the way to the hospital.

PHYSICAL EXAMINATION FINDINGS AND INITIAL DIAGNOSTIC PROCEDURES

On physical examination, the patient weighed 43 lb (19.5 kg) and walked slowly. The dog's temperature was 102.4 F (39.1 C), heart rate was 128 beats/min, and respiratory rate was slightly elevated at 25 breaths/min. Its hydration status and mucous membrane color were normal. On palpation, pain was elicited along the lower abdomen but not along the dorsal or lateral aspect of the entire vertebral column.

Butorphanol tartrate (0.25 mg/kg subcutaneously) was administered for analgesia, and within a few minutes, the dog had a bowel movement consisting of firm stool followed by softer stool that contained mucus and blood. The results of fecal direct smear and simple flotation examinations were negative for parasites. The results of a urinalysis with sedimentation were normal. An abdominal radiographic examination revealed decreased serosal detail and fluid-filled bowel loops, without evidence of gastrointestinal obstruction. No other radiographic abnormalities were evident at this time.


Vital Stats
An in-clinic complete blood count (CBC) revealed a marked leukocytosis with neutrophilia (Table 1) and increased platelets (523 × 109/L). An in-clinic serum chemistry profile revealed hypoalbuminemia (2.56 g/dl; reference range = 2.7 to 3.8 g/dl), hypoglycemia (60.2 mg/dl; reference range = 77 to 125 mg/dl), and a serum alkaline phosphatase activity of 212 U/L (reference range = 23 to 212 U/L).

Within a relatively short period, the patient had a second bowel movement that consisted of bloody diarrhea. Our differential diagnoses at this time included sepsis, hemorrhagic gastroenteritis, and an unknown gastrointestinal disorder. Additional differential diagnoses include pancreatitis (the dog's amylase activity on presentation was 709 U/L; reference range = 500 to 1,500 U/L), peritonitis, hepatic abscess, stump pyometra, and acute abdomen. Other diagnostic tests, including abdominal ultrasonography and diagnostic peritoneal lavage, could have narrowed the list of differential diagnoses.

INITIAL TREATMENT

We initiated empirical treatment with intravenous lactated Ringer's solution with 5% dextrose (2.7 ml/kg/hour) and cefazolin (21.5 mg/kg b.i.d. slowly intravenously). We also administered ketoprofen (2 mg/kg given once intramuscularly) for its antipyretic and analgesic effects and oral metronidazole (13 mg/kg b.i.d.). Within a few hours, the patient appeared more comfortable, was wagging its tail, and had a heart rate of 100 beats/min.

On the morning of the second day of hospitalization, the dog was bright, alert, and responsive. Its rectal temperature was 102.4 F. We continued the intravenous fluids and cefazolin and oral metronidazole. The patient ate canned Purina Veterinary Diets EN (Nestlé Purina). But by late afternoon, the patient was reluctant to eat, cried when its abdomen was palpated, and vomited. We changed the fluid therapy to intravenous lactated Ringer's solution with potassium chloride (20 mEq potassium/L).

On the morning of Day 3, the patient was again bright, alert, and responsive. It had a rectal temperature of 102 F (38.9 C) and did not cry in pain but exhibited slight splinting during abdominal palpation. The dog urinated well and ate some of the canned diet. We continued the oral metronidazole, intravenous cefazolin, and fluid therapy.

A subsequent in-clinic CBC showed an elevated but slightly improved white blood cell count with neutrophilia (Table 1) and increased platelets (556 x 109/L). We initiated oral enrofloxacin therapy (7 mg/kg once a day) and continued to feed the canned diet, which the patient ate well.