Gary is an 8-year-old neutered male Yorkshire Terrier whose owners took him to his regular veterinarian when they noticed he was intermittently vomiting and having diarrhea. Gary’s veterinarian found that he had hypoproteinemia and abdominal effusion and referred him to Veterinary Referral Hospital of Hickory.

Day 1
Gary came through Veterinary Referral Hospital of Hickory’s emergency service, where an emergency veterinarian performed a physical exam and ran bloodwork. Gary had good body condition, but his fur was dull and dry, and he had some abdominal distension. He weighed in at 10.9 pounds. His incoming blood work identified a panhypoproteinemia, hypocholesterolemia, a low total calcium, and mild leukocytosis. Lab work competed by the emergency service identified:

Test Value Reference Range
pO2 44.9 24.0-54.0 mmHg
cSO2 78.1 40.0-90.0%
pCO2 45.4  30.0-47.0 mmHg
Bicarbonate 25.1 16.0-28.0 mmol/L
cTCO2 26.5 18.0-28.0 mmol/L
pH 7.350 7.360-7.460
BE, ECF -0.5 -5.0-5.0 mmol/L
Sodium 150 140-151 mmol/L
Potassium 4.2 3.5-5.0 mmol/L
Chloride 119  106-127 mmol/L
Calcium, ionized 0.77 1.13-1.42 mmol/L
Anion gap 10 5-22 mmol/L
Lactate 0.75 0.60-3.00 mmol/L
Glucose 85 63-124 mg/dL
HCT 52 36-55%
 cPL  normal
 Magnesium  1.0  1.5-2.4 mg/dl

The emergency doctor started Gary on IV fluids, administering:

  • 45% NaCl + 2.5% dextrose + 20mEq KCl/L @mtn
  • IV Hetastarch 4 cc/hr
  • SQ Cerenia 0.5 cc SID
  • IV Protonix -.7 mg/kg SID

His tentative diagnosis on this day was hypoproteinemia due to GI loss. The emergency veterinarian requested that Gary be transferred to Dr. Scott Helms in our internal medicine service.

Day 2

  • Administer IV Mg/Ca over 12 hrs:
  • 1 mEq/Kg/24 hr Mg
  • 1 ml/kg/Ca Gluconate 10% diluted in D5W

TPR is normal, ate RCLF well

Dr. Helms sees Gary for the first time on this day, performs a comprehensive exam, and continues to monitor his bloodwork. His exam revealed a distended abdomen and a grade III medial patellar luxation on the left.

The fluid therapy is working and Gary’s bloodwork starts to normalize.  Blood protein levels are up. His lab work at noon showed:

Test Value Reference Range
pO2 35.4 24.0-54.0 mmHg
cSO2 64.9 40.0-90.0%
pCO2 44.5  30.0-47.0 mmHg
Bicarbonate 24.9 16.0-28.0 mmol/L
cTCO2 26.3 18.0-28.0 mmol/L
pH 7.356 7.360-7.460
BE, ECF -0.6 -5.0-5.0 mmol/L
Sodium 150 140-151 mmol/L
Potassium 4.9 3.5-5.0 mmol/L
Chloride 114  106-127 mmol/L
Calcium, ionized 1.04 1.13-1.42 mmol/L
Anion gap 16 5-22 mmol/L
Lactate 1.18 0.60-3.00 mmol/L
Glucose 98 63-124 mg/dL
HCT 40 36-55%
 Magnesium  2.4  1.5-2.4 mg/dl

Dr. Helms continues Gary’s fluid therapy, including calcium gluconate and magnesium sulfate to resolve the low calcium and magnesium blood levels. He continues to monitor Gary’s bloodwork to look for response to the fluid therapy.

At this time, the main concern for Gary is his low protein levels. Low protein can be an effect of various conditions. Gary’s weight and body condition do not suggest emaciation, and there are no indications of kidney disease. As such, Dr. Helms began looking for the next cause: a GI issue, which is consistent with Gary’s vomiting and diarrhea.

Dr. Helms performed an ultrasound on Gary, which showed some free fluid in the abdomen and mesenteric thickening. Gary’s kidneys, bladder, adrenal glands, and spleen appeared normal. Gary’s liver was enlarged and the edges rounded, and gall bladder distended without evidence of extrahepatic biliary tract obstruction. Dr. Helms identified diffuse thickening of the wall of the small intestine, but there was no visible evidence of cancer. Abdominal lymph nodes appeared normal.

Dr. Helms took a urine sample to be submitted for urinalysis including urinary protein/creatinine ratio, and blood for bile acids. Dr. Helms updated Gary’s rDVM at this point, and Gary was monitored overnight.

Day 3
Gary is quiet, alert, and responsive. He has had no vomiting or diarrhea but was still on medication to prevent both. His abdomen remained distended.

Lab work on this day showed:

 

Test Value Reference Range
pO2 46.8 24.0-54.0 mmHg
cSO2 80.5 40.0-90.0%
pCO2 41.8  30.0-47.0 mmHg
Bicarbonate 23.4 16.0-28.0 mmol/L
cTCO2 24.7 18.0-28.0 mmol/L
pH 7.355 7.360-7.460
BE, ECF -2.1 -5.0-5.0 mmol/L
Sodium 149 140-151 mmol/L
Potassium 5.1 3.5-5.0 mmol/L
Chloride 115  106-127 mmol/L
Calcium, ionized 1.08 1.13-1.42 mmol/L
Anion gap 16 5-22 mmol/L
Lactate 0.87 0.60-3.00 mmol/L
Glucose 83 63-124 mg/dL
HCT 42 36-55%
 Total protein 2.6 5.5-7.6 g/dl
 Albumin <1.0 2.5-4.0 g/dl
 Globulin No result available 2.0-3.6 g/dl
 Magnesium  2.0  1.5-2.4 mg/dl

With the ultrasound not definitive, Dr. Helms schedules an endoscopy of Gary’s GI tract to take biopsies. At this point, considerations for Gary’s underlying condition include:

  • Inflammatory bowel disease
  • Pancreatitis
  • Liver disease

Anesthesia:
Pre-med: Butorphanol (10mg/ml) 0.8 mg
Induction: Propofol (10 mg-ml) 17.5 mg IV
Maintenance: Isoflurane
Intra-op medications: atropine (0.5 mg-ml) 125 mcg IV
Intra-op fluids: LRS 21 ml/hr and hetastarch at 4 ml/hr IV
Recovery: uneventful

The endoscopy showed a normal esophagus, but increased granularity was noted in the gastric body and fundus. There was also increased granularity and friability in the duodenum. Biopsy samples were taken of the stomach and duodenum and sent to Idexx for histopathology.

Gary’s urinalysis showed:

 

Test Value Reference Range
Specific gravity 1.009 1.015-1.050
pH 8.0 5.5-7.0
Protein Negative Neg
Glucose Negative Neg
Keton Negative Neg
Bilirubin Negative Neg  to 1+
Blood Negative Neg
WBC None 0-3 HPF
RBC None 0-3 HPF
Casts None seen
Struvite (MgNH4PO4) crystals 2-3
Bacteria None seen
Squamous epithelia 0-1 0-3 HPF
Protein/creatinine ratio 0.3 <+ 0.5 ratio
 Bile Acid 6.0
Creatinine (urine) 14.1
UBA/UCR 4.3 <7.3

Day 4-8
Over the next four days, Dr. Helms monitors Gary, taking bloodwork each day to look for improvement. His low levels rise and stabilize. Gary’s biopsy results were as follows:

MICROSCOPIC DESCRIPTION
Duodenum: Multiple small sections of small intestinal mucosa are examined. There are mildly to moderately increased numbers of lymphocytes and plasma cells within the lamina propria, with 5 to 7 mononuclear cells sometimes separating crypts. Crypts are occasionally mildly to moderately dilated and contain luminal eosinophilic proteinase material with admixed cellular debris (crypt abscesses). Rare globule leukocytes are also noted. Normal villous architecture is present, and no infectious organisms are observed. There is no evidence of lymphangiectasia.

Stomach: The examined gastric samples consist of antrum, gastric body, and fundus. Mucosal lymphoid follicles within the pyloric antrum are often mildly hyperplastic. There is mild edema of the lamina propria, with mildly increased numbers of scattered lymphocytes and plasma cells. Samples from the gastric body are characterized by mild edema of the superficial lamina propria. Samples from the fundus are characterized by mildly increased numbers of lymphocytes and plasma cells scattered throughout the lamina propria. There is no evidence of erosion/ulceration, fibrosis, or neoplasia, and no infectious organisms are observed.

MICROSCOPIC INTERPRETATION
Duodenum: Mild to moderate lymphoplasmacytic mucosal enteritis
Stomach: Mild lymphoplasmacytic mucosal gastritis with edema and lymphoid hyperplasia

Dr. Helms gives Gary a definitive diagnosis of lymphoplasmacytic enteritis causing his panhypoproteinemia. The exact cause of lymphoplasmacytic enteritis is not known. It has been speculated that genetics, food allergies, intestinal parasites, and intestinal bacteria; each has the potential to cause IBD.

Gary responded to supportive care and improved significantly during his time at Veterinary Referral Hospital of Hickory. His blood work on the final day showed:

 

Test Value Reference Range
pO2 46.1 24.0-54.0 mmHg
cSO2 79.7 40.0-90.0%
pCO2 48.6  30.0-47.0 mmHg
Bicarbonate 27.8 16.0-28.0 mmol/L
cTCO2 29.3 18.0-28.0 mmol/L
pH 7.366 7.360-7.460
BE, ECF 2.5 -5.0-5.0 mmol/L
Sodium 148 140-151 mmol/L
Potassium 4.8 3.5-5.0 mmol/L
Chloride 110  106-127 mmol/L
Calcium, ionized 1.28 1.13-1.42 mmol/L
Anion gap 15 5-22 mmol/L
Lactate 1.44 0.60-3.00 mmol/L
Glucose 98 63-124 mg/dL
HCT 40 36-55%
Total protein  3.4  5.5-7.6 g/dl
Albumin  1.4 2.5-4.0 g/dl
Globulin  2.0  2.0-3.6 g/dl

Dr. Helms recommended a hypoallergenic diet (K-9 Z/D can, 5.5 oz, feed 1 2/3 to 2 cans daily), plus:

  • Prednisone: 5 mg, #30. 1 tab by mouth morning and evening.
  • Metronidazole: 250 mg, #1.5. ¼ tab given by mouth morning and evening.
  • Omeprazole DR: 10 mg, #30. 1 capsule by mouth every 24 hours, continue while on prednisone.
  • Cernia: 16 mg, #1. ½ tab by mouth as needed. Can be given for four consecutive days, then skip one day before starting again.

Dr. Helms schedules Gary for a recheck in one week.

For consultations or referrals to Veterinary Referral Hospital of Hickory, please call us at 828.328.6697.