Marie E. Kerl

Update on canine and feline fungal diseases.

Systemic fungal diseases cause significant morbidity and mortality in dogs and cats. Blastomycosis, histoplasmosis, coccidiomycosis, and cryptococcosis represent the four most common systemic fungal diseases. Young adult, large breed dogs generally are predisposed; cats usually do not have predictable predispositions. Intact cell-mediated immunity is essential to initial resistance to infection and response to treatment in animals. Several body systems can be affected. Diagnosis can be confirmed on the basis of clinical signs and demonstration of the causative organism. Serology is helpful with coccidiomycosis and cryptococcosis. Treatment is complicated by limited availability of fungicidal antimicrobials and the necessity of long-term treatment with expensive drugs.

Characterization of acute kidney injury in hospitalized dogs and evaluation of a veterinary acute kidney injury staging system

OBJECTIVE To retrospectively apply standards characterizing acute kidney injury (AKI) used in human medicine to a population of critically ill hospitalized dogs in order to identify dogs with potential AKI based on subtle increases in plasma creatinine concentration. DESIGN Retrospective study. SETTING University Veterinary Medical Teaching Hospital. ANIMALS One hundred and sixty-four client-owned dogs admitted to the intensive care unit. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Medical records of 164 dogs meeting the study inclusion criteria were reviewed to identify age, results of creatinine measurements, discharge status, length of stay, performance of general anesthesia, number of diagnoses, and calculated survival prediction index scores (SPI2). A veterinary AKI (VAKI) staging system was retrospectively applied to classify dogs based on increase in creatinine concentration from baseline as follows: stage 0 (S0; <150%), stage 1 (S1; 150-199% or ≥26.5 μmol/L [≥0.3 mg/dL]), stage 2 (S2; 200-299%), or stage 3 (S3; ≥300%). Of the dogs evaluated, 140/164 were VAKI stage S0, 19/164 were classified as S1, 3/164 as S2, and 2/164 were S3. Mortality rate was greater for S1-3 (13/24; 54.2%) compared to S0 dogs (22/140; 15.7%) (P < 0.0001). Length of stay, general anesthesia, and number of diagnoses were not associated with survival. In a logistic regression model, stage and age were jointly, significantly associated with mortality (P = 0.0002 and P = 0.0330, respectively). Mean SPI2 scores were not different between S0 (0.52) and S1 (0.59) dogs (P = 0.23). Only 4/19 (21%) of S1 dogs had a peak plasma creatinine concentration above the laboratory reference interval. CONCLUSIONS Dogs meeting VAKI stage 1-3 criteria were less likely to survive to discharge. Small increases in plasma creatinine concentration may be clinically relevant even when absolute values are within reference intervals.Objective To retrospectively apply standards characterizing acute kidney injury (AKI) used in human medicine to a population of critically ill hospitalized dogs in order to identify dogs with potential AKI based on subtle increases in plasma creatinine concentration. Design Retrospective study. Setting University Veterinary Medical Teaching Hospital. Animals One hundred and sixty-four client-owned dogs admitted to the intensive care unit. Interventions None. Measurements and Main Results Medical records of 164 dogs meeting the study inclusion criteria were reviewed to identify age, results of creatinine measurements, discharge status, length of stay, performance of general anesthesia, number of diagnoses, and calculated survival prediction index scores (SPI2). A veterinary AKI (VAKI) staging system was retrospectively applied to classify dogs based on increase in creatinine concentration from baseline as follows: stage 0 (S0; <150%), stage 1 (S1; 150–199% or ≥26.5 μmol/L [≥0.3 mg/dL]), stage 2 (S2; 200–299%), or stage 3 (S3; ≥300%). Of the dogs evaluated, 140/164 were VAKI stage S0, 19/164 were classified as S1, 3/164 as S2, and 2/164 were S3. Mortality rate was greater for S1–3 (13/24; 54.2%) compared to S0 dogs (22/140; 15.7%) (P < 0.0001). Length of stay, general anesthesia, and number of diagnoses were not associated with survival. In a logistic regression model, stage and age were jointly, significantly associated with mortality (P = 0.0002 and P = 0.0330, respectively). Mean SPI2 scores were not different between S0 (0.52) and S1 (0.59) dogs (P = 0.23). Only 4/19 (21%) of S1 dogs had a peak plasma creatinine concentration above the laboratory reference interval. Conclusions Dogs meeting VAKI stage 1–3 criteria were less likely to survive to discharge. Small increases in plasma creatinine concentration may be clinically relevant even when absolute values are within reference intervals.

Age‐associated changes to pathogen‐associated molecular pattern‐induced inflammatory mediator production in dogs

OBJECTIVE To determine whether older dogs will have a more pronounced pro-inflammatory response and blunted anti-inflammatory response to pathogen-associated molecular patterns (PAMPs) compared with younger dogs. DESIGN Prospective. SETTING University teaching hospital. ANIMALS Thirty-eight privately owned sexually altered dogs of various ages. INTERVENTIONS Blood was collected for HCT, WBC count, plasma biochemical analysis, and whole blood culture. Whole blood was stimulated with lipopolysaccharide (LPS) or, lipoteichoic acid or, peptidoglycan or, addition of phosphate-buffered saline. Tumor necrosis factor (TNF), interleukin (IL)-6, and IL-10 production from whole blood were compared among young, middle aged, and geriatric dogs. MEASUREMENTS AND MAIN RESULTS LPS, lipoteichoic acid, and peptidoglycan stimulated significant TNF, IL-6, and IL-10 production from canine whole blood compared with phosphate-buffered saline. Whole blood from geriatric dogs had a blunted IL-10 response to LPS stimulation and middle-aged dogs had increased LPS-induced TNF production compared with the other groups. CONCLUSION PAMPs from gram-positive and gram-negative bacteria stimulate TNF, IL-6, and IL-10 production from canine whole blood. The inflammatory mediator response to PAMPs from gram-negative bacteria alters with age and may be one factor contributing to mortality in geriatric dogs with sepsis.Objective – To determine whether older dogs will have a more pronounced pro-inflammatory response and blunted anti-inflammatory response to pathogen-associated molecular patterns (PAMPs) compared with younger dogs. Design – Prospective. Setting – University teaching hospital. Animals – Thirty-eight privately owned sexually altered dogs of various ages. Interventions – Blood was collected for HCT, WBC count, plasma biochemical analysis, and whole blood culture. Whole blood was stimulated with lipopolysaccharide (LPS) or, lipoteichoic acid or, peptidoglycan or, addition of phosphate-buffered saline. Tumor necrosis factor (TNF), interleukin (IL)-6, and IL-10 production from whole blood were compared among young, middle aged, and geriatric dogs. Measurements and Main Results – LPS, lipoteichoic acid, and peptidoglycan stimulated significant TNF, IL-6, and IL-10 production from canine whole blood compared with phosphate-buffered saline. Whole blood from geriatric dogs had a blunted IL-10 response to LPS stimulation and middle-aged dogs had increased LPS-induced TNF production compared with the other groups. Conclusion – PAMPs from gram-positive and gram-negative bacteria stimulate TNF, IL-6, and IL-10 production from canine whole blood. The inflammatory mediator response to PAMPs from gram-negative bacteria alters with age and may be one factor contributing to mortality in geriatric dogs with sepsis.

Immunomodulatory effects of opioids.

Objective – To review the immunomodulatory effects of opioids. Data Sources – Original research publications and review articles using the PubMed search engine with the following keywords – opioids, morphine, immuomodulation, and immunosuppression. Veterinary and Human Data Synthesis – Opioids have been shown to modulate the immune system in animal models by affecting both the acquired and innate arms of the immune system. Natural killer cell activity, T-cell proliferation, antibody production, phagocytic cell function, and cytokine production have all been shown to be affected by opioids. Many of these effects are reversed by opioid antagonists. Opioids have also been shown to induce sepsis in laboratory animals. Opioid administration alters immune parameters in healthy humans at analgesic doses and may increase the risk of infection in some patient populations. Conclusions – While opioids remain the most powerful and widely used analgesics available, their negative effects on the immune system are well established in the laboratory setting. Thoughtful consideration should be given to the use of certain opioids in critically ill patients, especially those with pre-existing immunocompromise.OBJECTIVE To review the immunomodulatory effects of opioids. DATA SOURCES Original research publications and review articles using the PubMed search engine with the following keywords--opioids, morphine, immuomodulation, and immunosuppression. VETERINARY AND HUMAN DATA SYNTHESIS: Opioids have been shown to modulate the immune system in animal models by affecting both the acquired and innate arms of the immune system. Natural killer cell activity, T-cell proliferation, antibody production, phagocytic cell function, and cytokine production have all been shown to be affected by opioids. Many of these effects are reversed by opioid antagonists. Opioids have also been shown to induce sepsis in laboratory animals. Opioid administration alters immune parameters in healthy humans at analgesic doses and may increase the risk of infection in some patient populations. CONCLUSIONS While opioids remain the most powerful and widely used analgesics available, their negative effects on the immune system are well established in the laboratory setting. Thoughtful consideration should be given to the use of certain opioids in critically ill patients, especially those with pre-existing immunocompromise.

State‐of‐the‐Art‐Review: Immunomodulatory effects of opioids

Objective – To review the immunomodulatory effects of opioids. Data Sources – Original research publications and review articles using the PubMed search engine with the following keywords – opioids, morphine, immuomodulation, and immunosuppression. Veterinary and Human Data Synthesis – Opioids have been shown to modulate the immune system in animal models by affecting both the acquired and innate arms of the immune system. Natural killer cell activity, T-cell proliferation, antibody production, phagocytic cell function, and cytokine production have all been shown to be affected by opioids. Many of these effects are reversed by opioid antagonists. Opioids have also been shown to induce sepsis in laboratory animals. Opioid administration alters immune parameters in healthy humans at analgesic doses and may increase the risk of infection in some patient populations. Conclusions – While opioids remain the most powerful and widely used analgesics available, their negative effects on the immune system are well established in the laboratory setting. Thoughtful consideration should be given to the use of certain opioids in critically ill patients, especially those with pre-existing immunocompromise.OBJECTIVE To review the immunomodulatory effects of opioids. DATA SOURCES Original research publications and review articles using the PubMed search engine with the following keywords--opioids, morphine, immuomodulation, and immunosuppression. VETERINARY AND HUMAN DATA SYNTHESIS: Opioids have been shown to modulate the immune system in animal models by affecting both the acquired and innate arms of the immune system. Natural killer cell activity, T-cell proliferation, antibody production, phagocytic cell function, and cytokine production have all been shown to be affected by opioids. Many of these effects are reversed by opioid antagonists. Opioids have also been shown to induce sepsis in laboratory animals. Opioid administration alters immune parameters in healthy humans at analgesic doses and may increase the risk of infection in some patient populations. CONCLUSIONS While opioids remain the most powerful and widely used analgesics available, their negative effects on the immune system are well established in the laboratory setting. Thoughtful consideration should be given to the use of certain opioids in critically ill patients, especially those with pre-existing immunocompromise.

A comparison of total calcium, corrected calcium, and ionized calcium concentrations as indicators of calcium homeostasis among hypoalbuminemic dogs requiring intensive care.

OBJECTIVE (1) To evaluate whether total calcium (tCa) correlates with ionized calcium (iCa) in hypoalbuminemic dogs; (2) to evaluate whether calcium adjusted for albumin (Alb), or total protein (TP), or both accurately predict iCa concentrations and hence can be used to monitor calcium homeostasis in critically ill hypoalbuminemic dogs; and (3) to evaluate factors associated with any potential discrepancy in calcium classification between corrected total and ionized values. DESIGN Prospective observational clinical study. SETTING Small animal intensive care unit in a veterinary medical teaching hospital. ANIMALS Twenty-eight client-owned dogs with hypoalbuminemia. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS iCa was determined using ion-specific electrode methodology, on heparinized plasma. The tCa concentration was adjusted for Alb and TP using published equations. In total 29% (8/28) of the hypoalbuminemic, critically ill dogs in this study were hypocalcemic at intensive care unit admission, as determined by iCa measurement. Corrected calcium values failed to accurately classify calcium status in 67.9% and 64.3% of cases, according to whether the Alb-adjusted or TP-adjusted values, respectively, were used. The sensitivity and specificity of the tCa to evaluate hypocalcemia was 100% and 47%, respectively. The sensitivity and specificity of the correction formulae were 37.5% and 79% for the Alb-adjusted values and 37.5% and 74% for TP-adjusted values. tCa overestimated the presence of hypocalcemia and underestimated the presence of normocalcemia, while corrected calcium values overestimated the presence of normocalcemia and underestimated the presence of hypocalcemia. CONCLUSIONS Calcium homeostasis in hypoalbuminemic critically ill dogs should be evaluated by iCa concentrations rather than tCa or calcium adjusted for Alb or TP. Given that tCa has 100% sensitivity for detecting hypocalcemia in this population it is recommended that all hypoalbuminemic and critically ill patients with low tCa should be evaluated with an iCa measurement.

Bone marrow hypoplasia associated with fenbendazole administration in a dog.

A 1.5-year-old Doberman pinscher was presented with sudden-onset of fever and malaise. Twelve days prior to presentation, fenbendazole therapy was initiated for a suspected lungworm infection. Results of a complete blood count on presentation showed pancytopenia, while histopathological evaluation of a bone marrow core sample revealed bone marrow hypoplasia of undetermined etiology. Bactericidal antibiotics and fluid therapy, as well as discontinuation of fenbendazole administration, led to a complete resolution of clinical and hematological abnormalities within 15 days. An idiosyncratic reaction to fenbendazole was suspected based on the absence of infectious, neoplastic, autoimmune, and toxic etiologies, as well as resolution of clinical signs and pancytopenia upon drug withdrawal.

Nutritional plan: matching diet to disease

Institution of appropriate, timely nutritional support in the anorexic or critically ill patient has become accepted medical practice in people and animals. This article focuses on the benefits of appropriate nutrient intake in critically ill animals, recommended nutrient requirements for dogs and cats receiving enteral feeding, and mechanics of food preparation and delivery for a variety of feeding tubes. General nutrient requirements for all patients, specific recommendations for certain illnesses such as renal failure, pancreatitis, and hepatic disease, and nutritional alterations for critical illness are reviewed. Commercial liquid diets manufactured for people and pets, and pet-food diets practical for formulation of gruel are presented. Institution of and weaning from feeding are explained.

Fatal hemothorax following management of an esophageal foreign body.

A 10.8-year-old, spayed female toy poodle presented with an esophageal foreign body. The foreign body was removed endoscopically, and a gastrostomy tube was placed to provide nutritional support during esophageal healing. The gastrostomy tube was later removed by endoscopic retrieval of the bulb through the esophagus. Immediately afterward, the dog developed hemothorax and eventually died. It was determined that many small arterial branches were avulsed from the aorta. The involved sections of aorta histopathogically evidenced medial necrosis, which was believed to be related to a prior disruption of blood flow through the vasa vasorum.

Comparison of whole blood and plasma colloid osmotic pressure in healthy dogs.

OBJECTIVE To determine the difference between colloid osmotic pressure (COP) values determined from plasma versus those determined from whole blood. DESIGN Prospective observational study. SETTINGS University veterinary teaching hospital. ANIMALS Fifty-three healthy dogs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Whole blood and plasma COP, CBC, plasma biochemistry. In all dogs, plasma COP values were significantly lower (P=0.02) than whole blood COP, with a mean of difference of 0.5 mm Hg. The mean and median whole blood COP was 21.75 and 21.4 mm Hg, respectively, with a range of 17.9-27.1 mm Hg. The mean and median plasma COP was 21.2 and 20.9 mm Hg with a range of 16.7-28.9 mm Hg. CONCLUSIONS While significant difference exists between plasma and whole blood COP, the individual values are within expected reference intervals for dogs (21-25 mm Hg). Using either sample appears to provide the same information in clinically healthy dog; however, it is recommended that clinicians utilize the same sample type for comparison in an individual patient.