ABC’s of Vitamin Deficiencies: B9 or Folate Deficiency
Ok, ok... I was just getting tired of talking about biochemistry and how it relates to vitamin deficiencies in animals. So I'm skipping ahead! But I cannot skip the biochemistry of Folate and Cobalamin deficiencies. Click on the photo below to get some more information on the relationship between Folate and Cobalamin. Do you remember the Folate Trap?? That's a tough one. Anyway, the active form in the body for Folate is Tetrahydrofolate (everyone in the TTC community knows what I'm talking about here). In order to convert inactive folic acid/folate to active tetrahydrofolate you also need Vitamin B12 (cobalamin). That being said a Vitamin B12 deficiency can also present signs of a Folate deficiency. I think most people know that a woman needs folic acid or folate supplementation to prevent neural tube defects during embryogenesis... a.k.a. early pregnancy. Neural tube closure occurs similarly in all mammalian species (as far as my limited knowledge goes - see here for more embryology information). Also see here for a more visual representation of neural tube formation in embryogenesis. In the pregnant woman model of folate deficiency we get improper closure of the neural tube and the resulting fetus can develop a condition called spina bifida. Spina bifida is seen in most species and usually results in dysfunction of the tail and anus, incontinence, and sometimes pelvic limb weakness. (Merck Veterinary Manual) Not all cases of neural tube defects are due to folate deficiency, but it is just well-known, so something to keep in mind for your list of differentials. Folate Deficiency in Dogs and Cats Since the last few Vitamin deficiency posts have been about poultry, I wanted to ensure I included some information on companion animals. The main one I wanted to discuss is malabsorptive forms of protein-losing enteropathies. If you have a condition that limits your absorption of nutrients from the small intestines, you can end up with a folate or cobalamin deficiency. Patients with malabsorptive protein-losing enteropathies will present with a good appetite, the animal has chronic diarrhea (this may or may not be responsive to antibiotics like Metronidazole or Tylosin), or chronic intermittent diarrhea. Sometimes vomiting (I find more of this in cats with PLE). If it is the first time seeing a patient, you may consider treating the symptoms, as the diagnostics are more invasive. You may decide to try a novel protein diet or anallergenic diet in cases of suspected food intolerances or inflammatory bowel disease, along with probiotics. When you go to perform your blood work, you can collect enough of a sample for your chemistry panel and CBC, which if you want to ensure you are not missing anything, you can add on a folate and cobalamin level to this (fewer pokes for your patients as long as your laboratory runs these tests). A TLI (trypsin-like immunoreactivity) test will rule out exocrine pancreatic insufficiency (EPI - I can tell you I have never found a positive, so it is not that common). The patient I would test for EPI would be a young, undernourished German Shepherd dog that is still eating a lot of calories, but not able to put on weight. Ultimately, your diagnosis of what type of chronic enteropathy your patient has is an intestinal biopsy. Check with your pathology lab on what they need for your samples, some prefer full thickness intestinal biopsies and others can read endoscopically acquired samples. You job as the primary care veterinarian is to collect diagnostic samples. Folate deficiency can show up in proximal small intestinal diseases, but I have seen more laboratory confirmed cases of Cobalamin deficiency, more commonly found in cats. A folate deficiency can also be a cause of an anemia. Treatment for a folate deficiency is simple and more cost effective for a pet owner than the anesthesia for biopsies, so a supplement of folate (and cobalamin) may be in order prior to biopsy.
ABC’s of Vitamin Deficiencies: B5 or Pantothenic Acid Deficiency
Did you noticed that I skipped a number? According to online textbooks, there are eight B Vitamins: thiamin (vitamin B1) riboflavin (vitamin B2) niacin (vitamin B3) pantothenic acid (vitamin B5) pyridoxine (vitamin B6) biotin (vitamin B7) folate (vitamin B9) cobalamin (vitamin B12) While Choline is sometimes considered a B vitamin, I won't include it here. But may get to it later on. So what is Vitamin B5 used for? Then, what does a deficiency in this vitamin cause? Again, this isn't one of the ones that I am familiar with. So let's see what we can find from some of the experts - Merck Veterinary Manual. Do you remember back in biochemistry when they are talking about cellular metabolism, and metabolism changes from carbohydrates to fats? Yes, of course! Well, remember that thing called Acetyl-CoA? Actually, that reminds me of those YouTube videos on biochem (Khan Academy). Highly recommend Khan Academy for those visual learners. The CoA in Acetyl-CoA stands for coenzyme A. Within coenzyme A is our topic of the day: pantothenic acid. Geesh! How did all my Vitamin Deficiency posts end up with a biochemistry review?! Let's keep these ones short! So a deficiency in Vitamin B5 or pantothenic acid will cause issues with fatty acid metabolism, glycolysis and the Kreb's cycle. We're looking a poultry and swine in this case. It appears to show the most lesions in the nervous system, as well as in the skin (dermatitis). Again, most commercial diets have supplemental vitamins, including Vitamin B5. It also kind of reminds me of a lecture I sat in on honeybee farms. It's unlikely that the larger, well-established commercial farms are going to have this as a cause of poor production. But the smaller facilities, backyard laying hens and such that may show some deficiencies if they are not also offered a well-balanced diet. It is not that corn is bad! Just eating corn is bad!
ABC’s of Vitamin Deficiencies: B3 or Niacin Deficiency
A niacin deficiency can be caused by an amino acid deficiency, called tryptophan. Again, we’re talking about poultry, though chickens are less affected than turkeys, ducks and geese. Most supplemental feeds for poultry will have sufficient niacin (or tryptophan). Niacin is also converted to niacinamide. Niacinamide is used in part of the treatment for discoid lupus and lupoid conditions. I had a few cases of suspect lupoid onychodystrophy which I can maybe go into here. I say suspect, because it's based on clinical judgement. The diagnosis is made by histopathology - which requires amputation of P3. The cases were young dogs around the age of 4-5, that came in for "broken nails". Broken nails itself is not the issue, but how the nail looks and sloughs off with inflammatory exudate between the nail and the nail bed. It's more common than I expected and really reminds me of laminitis in horses. I tried to do a Google Scholar search once to see if there was any relationship between lupoid onychodystrophy and laminitis and there isn't much, other than they are both inflammatory conditions of the "nail". Maybe you know of a pathologist who can look into that for me?? Either way, I start those patients on high doses of EPA/DHA, niacinamide and possibly tetracycline/doxycycline. And sometimes pain medication. Back to chicks and ducks! The condition in chicks is called "black tongue" and it causes decreased egg production in hens. Here's a little blog post from a hatchery on niacin deficiency which has a few images for you to browse. The chickens and ducks may have issues with their hock joints where they will have splayed legs. There is also the PoultryDVM site for more information on chickens! Again, I don't have any personal stories about chicks or ducks to share, but niacin seems to be fairly easy to supplement for those poultry farmers. Also note that a chick with leg issues, may have differential diagnoses to think about!
Glucose Metabolism: Freestyle Libre
I have been using a Freestyle Libre on myself. Initially I bought it to learn about it, so I could teach my dad, as well as teach pet owners of diabetic cats. What I didn’t know is that I get nocturnal hypoglycemia, where my blood glucose drops below 3.9 mmol/L. Somethings it’s as low as 2.2 mmol/L. What I have discovered is that those nights where I get startled awake before my alarm, it is because I’m hypoglycemic. We know that insulin resistance can affect fertility, but how does low glucose affect fertility? It can’t be good. Insulin-induced hypoglycemia in ewes caused a decrease in estradiol concentrations for 8 to 12 hours, and delayed the LH surge by 15 hours.
In cattle, the post-partum period is a time of negative energy balance. There is evidence that hypoglycemia can contribute to poorer oocyte quality and embryo development. I don’t know how long these hypoglycemic events have been going on for, but I’m glad I discovered this, so that I can try to fix it! So far what works is not prolonged fasting, avoiding high carb meals before bed, and having a high protein snack before bed to keep it going. A smoothie with some protein powder, chia seeds and hemp seeds, or yogurt with some seeds seems to work well for me. I will keep you posted on how working with the Freestyle Libre and balancing my glucose at night affects my fertility! Until then, here’s a little video on the Freestyle Libre in a cat!
Euthyroid Sick Syndrome
You’re presented with a middle-aged patient with lethargy and weight gain, you decided to run blood work including a total T4, and the only thing on blood work is a lower than normal total T4. The next step is determining if that low total T4 is truly hypothyroidism or if there is something else that is lowering that T4. I have seen a lot of patients, I mean, relatively speaking, but many of the so called hypothyroid patients that were started on thyroid replacement therapy, without any further testing. Hypothyroidism is one of the most over-diagnosed diseases in dogs. Please, do not be that clinician. If you think that supplementing a little thyroid medication in a “suspect” hypothyroid dog is not going to have any consequences, you have not had to manage and then diagnose an iatrogenic hyperthyroid patient! There is no evidence that thyroid hormone supplementation is beneficial in dogs with sick euthyroid syndrome, and it may be detrimental. Case: 4yo MN Doberman Pinscher This case came to me during emergency hours on a holiday. The patient was being referred for a full abdominal ultrasound due to severe elevation of liver enzymes and an echocardiogram. The ultrasound was taking place after the holiday, but this patient wasn’t eating so naturally the owner was very concerned. We pulled a blood sample and assessment hydration. Since the patient was dehydrated we admitted for hospitalization and monitoring. The patient was thought to have heart failure and put on furosemide at a high dose by its regular veterinarian. The patient was then clinically dehydrated, so I trickled in fluids and warned the owner of any concurrent heart failure being an issue, so it was going to be a balancing act. The bloodwork came back with elevated blood urea nitrogen, liver enzymes (ALP and ALT) and when I found out through the history that the patient was ‘diagnosed’ with hypothyroidism, then about 6 months later had a cancerous tumour removed from its leg, I was suspicious of the diagnosis of hypothyroidism as being misdiagnosed and the patient was actually euthyroid sick with cancer. So what is euthyroid sick syndrome? Euthyroid itself means normal thyroid gland. Euthyroid sick is when you have a normal thyroid gland, but an abnormally low T4 due to some other illness. The pathophysiology of why thyroid hormones are decreased with chronic illnesses is considered complex. All you need to know is that you don't want to be that veterinarian that over-diagnoses hypothyroidism! Try anyway. :) I do not diagnose a dog with hypothyroidism when they have a low total T4. Look at what their clinical signs are, if it is just that they are overweight, with no other signs. You will want to do further testing. Many laboratories will suggest a free T4 by equilibrium dialysis, so I will do that with an endogenous TSH. It turned out that my patient was being treated for suspected hypothyroidism, where the only clinical sign was weight gain, and after the cancer was removed, the dog's thyroid gland turned to it's normal function. However, no one checked the thyroid levels after this. After taking a thorough history of what had been going on, and mentioned euthyroid sickness to the owner, and when we tested the thyroid levels, he was hyperthyroid. This is called iatrogenic hyperthyroidism. Once you start thyroid medications, due to the feedback loop to the brain to release or suppress TSH (thyroid stimulating hormone), you cannot just stop the thyroid medication as then you can have iatrogenic hypothyroidism. So wean them down slowly. The iatrogenic hyperthyroidism may also be a reason for the elevated liver enzymes. Though we cannot rule out right-sided heart failure as a cause of this as well. It was a complicated case, with a lot of different issues that could be going on. The main point is to have some skepticism when evaluating your lab work. What are all the causes of the changes on that lab work?
ABC’s of Vitamin Deficiencies: B2 or Riboflavin Deficiency
I do have to say that a vitamin B2 deficiency is not all that commonly seen. Which means that, this post is going to be a short one! The Merck Veterinary Manual is my source. Since I have no personal experience with the deficiency, I think it’s best you head over here. According to the Manual, poultry that are fed a vitamin deficient diet will see the effects of Vitamin B2 deficiency first. It is also called curled toe paralysis. Riboflavin is a precursor to FAD. Do you remember seeing FAD as one of the recipients for electrons in cellular metabolism along with NAD? It’s vaguely in my brain. It is also important for glutathione reductase one of the enzymes responsible for balancing oxidative stress in cells. I don’t recall it being in my list of things to study for the NAVLE, which goes to show you that it’s not as important for the general practitioner in small animal practice! Either way, poor energy metabolism causes weakness and death. If you read the Manual, you see that it is a cause of hind limb paralysis in chickens. There appears to be irreversible nerve damage to the sciatic nerve in chickens with a riboflavin deficiency. As an aside, note that hind limb paralysis in birds is not pathognomonic for Vitamin B2 deficiency. I may get to that later! Until then, here’s a refresher for the biochem enthusiast that want to remember where FAD is accepting those electrons! Stay tuned for more posts in this series of ABC’s of Vitamin Deficiencies!
ABC’s of Vitamin Deficiencies: B1 or Thiamine Deficiency
Welcome back for this post in my series the ABC’s of vitamin deficiencies. There are a lot of Vitamin B’s. Today we’ll focus on Thiamine deficiency or Vitamin B1 deficiency. Again, I’ll be focusing on those food producing animals. It can happen in your cat and dog patients, but I have not seen it. I did see it in a dairy calf. Clinical signs in calves are neurologic, maybe ataxia (stumbling), opisthotonos (the head being craned backwards), head pressing, and blindness, leading to anorexia, severe dehydration, collapse and death if not treated quickly. Thiamine deficiency is one of the causes of polioencephalomalacia. Say that ten times fast! If diagnosed early, treatment with thiamine can reverse the signs. It is most common in young ruminants that do not have a well-developed rumen. They depend on thiamine in their food, not as in adult cattle where the rumen microbiome contributes to the thiamine needed for life. Bacterial organisms that have thiaminase can also cause thiamine deficiency if there is overgrowth in the rumen. Remember, vitamins are cofactors for enzymes. Ahhhh good ol’ biochemistry! I’m having flashbacks from my biochem course. It’s a tough subject. Regardless, it’s something that you should know for your board examinations. Oddly enough, I also remember, both during my zoo keeping days and in my vet school days, injecting thiamine paste into herring to feed to pelicans. Freezing, storing and thawing fish can cause a decrease in thiamine, so thiamine needs to be supplemented for piscivorous animals in captivity.
Back to calves, thiamine is a cofactor for many enzymes in cellular metabolism. Well, for all animals, not just calves. The bolded enzymes in the diagram require thiamine. If the enzyme pyruvate dehydrogenase is slowed due to a lack of cofactor then pyruvate cannot be converted to Acetyl CoA. This kicks in anaerobic metabolism creating lactate from pyruvate. An elevation in lactate leads to an increase in acidity of the blood taxing the acid-base balance of the body, eventually leading to cell death.
Fun. Thiamine deficiency is not just a matter of making sure your cattle get enough thiamine. You have to watch that the cattle are not consuming plants with thiaminase or high sulfur (Brassica), as this also affects thiamine absorption. Thiamine can be given by injection, or by oral drench. Calves with minimal signs may recover 100% within 48 hours. Water soluble B vitamins will get flushed out in the urine if you have too much thiamine, so unlike Vitamin A, you won’t overdose your patient on Vitamin B1. That’s it for now. Stay tuned for more ABC’s of Vitamin Deficiencies!
ABC’s of Vitamin Deficiencies: Hypovitaminosis A
I was just thinking about how many exotic pets I’ve been seeing since starting at this new clinic. I thought I had already posted about scurvy or vitamin C deficiency in guinea pigs, but I guess I didn’t - at least I couldn’t find it! We all know that COVID has put a damper on our regular routines. I’ve had a few folks from GADVASU reading and sending me messages on what they can do to help them study when their restricted due to stay-at-home orders. I just wanted to acknowledge my friends at GADVASU for taking the time to read these posts! Given that these veterinary scholars are reading, the next few posts are going to be geared towards them. I thought I would start this series with Hypovitaminosis A. I thought, hey! I could do the ABC’s of vitamin deficiencies - it kind of rhymes! Hypovitaminosis A is a vitamin A deficiency. Birds are the ones that I am looking for these signs in. However, we do see this is turtles as well. Pet birds - psittacines, as well as food-producing poultry are both susceptible to this vitamin deficiency. Do you remember learning about squamous metaplasia of epithelium? Yea, I forgot too. I think we all know that Vitamin A is good for vision in humans. Vitamin A is found in meat products as retinoids and in plant products as beta-carotene. The key is a balanced diet. Those red and orange veggies are where you will want to chow down or feed to your parrots and poultry. All seed based diets are vitamin A deficient. That’s one of the first things to look for when you’re trying to determine why the bird (or turtle) is sick: what are they feeding these animals? What clinical signs are you going to look out for? Some you won’t see without a necropsy, so if you are planning on being a poultry veterinarian you will end up sacrificing an individual to gain information on the pathology of the disease that is affecting the flock. See here for more on poultry pathology. The dietary history should direct you to a possible diagnosis. Vitamin A is responsible for reducing keratinization of epithelium, and regulates cell division. It’s important in the immune response. Digestion will be affected because of the mucosal lining being affected. Reproductively active birds on a seed-based diet are likely vitamin A deficient. They might present with egg binding as it affects the epithelium of the reproductive tract, or bleeding from the reproductive tract from hemorrhaged follicles. On physical exam, you may see blepharoedema or swelling of the eyelids, conjunctivitis, plaques in the oral cavity, and I’m always looking for blunting of the choanal papillae. Hyperkeratosis can occur on the feet. The lining of the esophagus and trachea may be affected if you get to necropsy. In turtles, it’s usually the eyes that we are looking at. Bulging, swollen eyes; it’s usually hypovitaminsis A. For the future exotic pet vets, here is a little article on the condition in turtles. Treatment involves injectable vitamin A and transitioning the birds/reptiles to a different diet that is balanced, usually a balanced pelleted diet for the parrots, and well a feed analysis for the poultry. In poultry flocks they may supplement Vitamin A in the water. Vitamin A should be given at a higher dose for two weeks, then dialed down to a maintenance amount. Keep in mind that fat soluble vitamins such as vitamin A can also be over supplemented causing toxicosis. Do not overdose with injectable Vitamin A. When in doubt for your tiny patients, give an oral dose. As always, Merck Veterinary Manual outlines a little information on exotic pet birds as well as poultry. You can also visit here for some photos. If you want a list of foods to offer your turtle patient, check out this list of foods high in Vitamin A. See you with the next letter - B!
Looking for a Good Dog Trainer
I was going to finish up my CE requirements for my Fear Free renewal, but for some reason the sound does not play on my phone. So, I got to thinking about where I can find a Fear Free certified dog trainer near my clinic to refer to. There are none within 50 miles of our location! How am I supposed to find a good dog trainer?! Which brought me to good ol’ Google. The first line item when I searched ’dog trainer credentials’ is the Certification Council for Professional Dog Trainers® (CCPDT®). This is good! But what does it mean when a dog trainer is certified by CCPDT? They will display their credentials on their websites and social media platforms CPDT-KA. But, what is the difference between a dog trainer that is certified by them and one that has a different certification? The CCPDT is the leader in the development of rigorous exams to demonstrate mastery of humane, science-based dog training practices. This means if you want to be a dog trainer, your goal is to be on that list — your name on the list with some of the world‘s best dog trainers! Humane: this will mean non-aversive, no pain, fear, or anxiety is used to manipulate a dog’s behaviour to what us as human’s feel is right. Science-based: just as we practice veterinary medicine, as evidence-based medicine, so should dog trainers. Reward-based training works! Fear-based training or aversive methods of ‘do this or else’ can create more fear and anxiety, and impairs the human-animal bond. Ok, so the first page of their website has a button for Find a Trainer. That’s where you will want to go. Well, there were three CPDT-KA dog trainers not too far from me. I’d say within an hour‘s drive. But what if you can’t find a CPDT-KA trainer that is close to you, what should you do? Check out this Best Of page on SprucePets The top pick was the Karen Pryor Academy. Good choice! Veterinarian approved! Karen Pryor is author of the book Don’t Shoot the Dog. Did I mention that this book is on the reading list for apprentice zookeepers in Alberta? Maybe not. Either way, she is a model trainer for clicker training, not just for dogs, but for all species. Dogs do not understand human language. But a simple click-reward they catch on to VERY quickly. I have watched dog trainers with 8-week-old puppies mat trained and relaxed on their mats using clicker training. Read the book. It’s really short and easy to read. Learn how to use the clicker first so that you do not confuse your puppy. Need more guidance? The Karen Pryor Academy has a list of qualified trainers. For the most part, these dog trainers are going to be excellent for obedience, getting a dog to sit, stay, relax, and be able to walk on a leash without pulling. Now, on to a special group of dogs that I wrote briefly about: Dogs with Separation Anxiety. How do you reward your dog for being quiet home alone and not destroying things or themselves?! This is the most frustrating part of training, training your dog to be ok with being alone. If you have a dog with separation anxiety, get yourself to a veterinary behaviorist. Then find yourself a dog trainer using Julie Naismith’s search tool. The beauty of separation anxiety training is that they do not need to be local. You can use a trainer from across the world!
Allergic skin disease in dogs
I was looking up stay sutures this morning, but came across this quick and dirty summary of allergic skin disease management for dogs. We also call it atopic dermatitis, if you are looking for the medical terminology. It’s written by The Derm Vet, and if you aren’t aware of Dr. Ashley Bourgeois, check out her Instagram and podcast. As the article says, it is not a one size fits all treatment protocol for allergic skin disease in dogs. It can be one of the most frustrating things for pet owners because it is not always easy to manage, nor is it inexpensive. But when you get a dedicated owner it can be one of the most rewarding outcomes. My most memorable was an owner coming in for a QOL (quality of life) discussion asking me if she should put her dog down because he was suffering. Six months later the owner tells me I am the dog’s godmother. I saved his life. He was the saddest little white foo-foo with severe redness, lichenification and crusting from the tips of his toes to the hocks and elbows. He was bleeding in his skin folds. He just lay on the exam table while I scrubbed the crusts out from between his toes. We agreed to a short course of steroids because it was this or a dose of euthanyl. I managed to talk the owner into trying Cytopoint, despite its expensive price tag. Then the owner was diligent with shampooing daily. I love the Douxo Pyo products for the pro-ceramide in it. But also use the DermaChlor 4% chlorhexidine shampoo, and the DermaChlor conditioner spray for spot treating. The key is contact time. Everyone should know now in the days of COVID, you need to have the soap on your hands for a minimum amount of time to address any infectious organisms. The owners need to lather up those problem spots and then set a timer for 5 to 10 minutes before rinsing. Do not forget to dry them thoroughly! Yeast and bacteria love a warm moist environment! The last time I saw my ‘God son’ he was in a stroller, tail-wagging, coming in happily for his Cytopoint booster. He looked white and fluffy, no longer red and greasy. If you are a pet owner with an atopic dog. My sincerest condolences. You are not alone!! The key is to understand that it is multimodal therapy. To the veterinary students. The one thing that I need to say is… do not try one thing, and then tell the owner to come back if it doesn’t work. Start with multimodal therapy and wean down or off the ones that aren’t needed. 1) Control the itch. This is a vicious cycle. Itchy skin leads to the break down of a healthy skin barrier, more allergens, bacteria and yeast move and penetrate this barrier causing more cytokine release from inflammatory cells. More inflammation and itchy skin. Repeat. I have seen allergy tests for dogs where they are allergic to Malassezia, a yeast organism that naturally occurs on the skin. We need to break that itchiness pathway to give the skin time to heal. Even if you can get the owner to commit to a short course of Apoquel. Yes, there are other less expensive options. You just need to ensure that the owner is aware of the risks and side effects of your prescriptions. 2) Treat the infections. While you may want cytology to confirm infection, using topical 3-4% chlorhexidine is helpful for those crusting pyodermas. I like topicals if the owner can do it. Then I know I’m being diligent with my antimicrobial use. In severe cases, or cases where the owner just cannot bathe the tail crusting off their angry maltese cross, I have prescribed a first-generation cephalosporin. The last thing the dog needs is a multi-drug resistant bacteria. 3) Rule out fleas and mites. Even if you cannot see fleas, they may be allergic to the saliva in a fleas mouth. Skin scrape, cytology, treat accordingly. 4) Diet. I have clients fight me on this one. This is the hardest one for me to convince owners on. They have read on X forum that kibble is bad. They have read on such and such blog that raw is better. When I ask dog owners the reasoning behind their decision for raw #1 is allergies, #2 they thought it was healthier. The one thing that I can convince them on however is increasing the DHA/EPA content of what their dog consumes. Omega 3 fatty acids, fish oils (not flax) are both anti-inflammatory and help improve the phospholipid bilayer of the skin. It should be given at a higher dose than is provided in commercial dog food diets. The veterinary prescribed skin diets are meant to have these in higher levels. There are a lot of products out there. I usually use Eiocosaderm which comes with a convenient pump. I have seen a lot of recommendations on the Nordic Pet Omega product as well. Check for quality control. We want low heavy metals/mercury and toxins. You do want to check for concurrent food allergy. You cannot use a raw diet as an elimination diet, but you can use a home cooked elimination diet. Try looking at the recipes on BalanceIT.com go to the EZ balancer for vet patients and select skin conditions. Try a pork based diet as it seems to be one of the least allergenic proteins. The page should look like this… Just let the owners know that they will have to send your clinic a request for approval. Then you can log in, adjust the calories that the pet should be consuming, and approve the supplements. As always, the opinions in this blog are my own! I do not benefit from any of my product recommendations in this post. They are for your knowledge and for you to understand the wide array of treatment plans to address atopic dermatitis.
Merck Veterinary Manual app
Today I was looking up malignant hyperthermia because I couldn’t remember all the details. My source for those random diseases is the Merck Veterinary Manual. I just discovered that they have an app version that you can easily access on your phone. That is of course if you have a smart phone! There are a couple calculators in the app. There is a chocolate toxicity calculator. You enter the body weight of your patient, the amount of chocolate they consumed and then the type of chocolate. Then it will tell you how much methylxanthines were consumed and whether this is a toxic dose and the patient needs to seek emergency care. I typically use the chocolate calculate on VIN, because it has fun drawings. But VIN* you have to pay for and the Merck Veterinary Manual is free online, and the app! The Merck vet manual is like the bible of vet medicine. You can’t go wrong studying anything in there if you are studying for board exams.
It’s very easy to search a disease that you want to read about. In the app you can search as well, or use their category list to locate a topic. I do have a hard copy of the book, which I got prior to vet school. This would be a good book to find if you happen to be in a remote area and do not have internet or mobile services. The online version will be the most up-to-date, but some of the information has stayed the same so even if you find an older version it will still be useful. Do NOT read it front to back, and don’t think that you have to memorize every detail for your boards either! In fact, if you are studying for the NAVLE, there is a seminar series for NAVLE on VIN that is very useful. I think it is offered every spring and fall. Worthwhile so that you can focus your studying more. Anyway! Check out the Merck Vet Manual app and let me know what you think! *Just a note on VIN. VIN membership is FREE for veterinary students. Sign up and enjoy the membership while you’re in vet school!
Nasal Flushing in Cats
This week was extremely busy. We had a few dog bite wounds, sick sugar gliders, a GDV, a leopard gecko that had been regurgitating, a sneezing guinea pig, and that was just half of our Thursday! Aside from those, I actually wanted to write about a common presenting concern: the wheezing cat. When we have a cat owner call in to say that their cat is coughing and wheezing, since the airway is important for life, we want to see them as soon as achievable. Remember that your signalment is important when you are creating your list of differentials! Once we get that cat patient in, we need to determine if their signs are lower airway or upper airway. Part of the physical exam will include auscultation of the chest. One thing that I extrapolated from my days in the large animal medicine service in vet school was to also listen over the trachea at the neck. This is one way to help you decipher lower airway from upper airway. Is the wheezing louder over the trachea than it is over the bifurcation of the bronchi? Then it is most likely referred from the upper airway. Cats are not obligate nasal breathers. But it does take them a lot to be breathing through their mouths! A differential for the wheezing cat is allergic bronchitis or feline asthma. But before you put this coughing cat on steroids, know that feline asthma isn’t all that common, and the upper airway wheezing in cats is very common. There are a lot of resources online for feline asthma. So here are a few links if you need a refresher! Merck Veterinary Manual on Bronchitis Cornell Feline Health Center Case Study: 5-year-old male neuter DSH presenting for coughing Initially when we saw this patient he was being referred to us for bronchoscopy. It was thought he had a feather stuck in his lower airway or potentially feline asthma, depending on who you spoke with. We only have one DVM trained to do bronchoscopy at our hospital. So instead of scheduling on a day this DVM was working, I got the case. The first thing I thought after my physical exam was that the wheezing noises were louder in the upper airway than in the lower airway. X-rays had already been taken a couple days prior at the cat’s rDVM. So, I did a sedated laryngeal and oral cavity assessment. I saw a significant amount of mucous at the caudal aspect of the soft palate and on the arytenoids. I aspirated what I could get and swabbed for a culture. I started the cat on Doxycycline while we waited for the culture results. Surprising to me was that the culture came back negative. I guess that just goes to show you that not every green and yellow clump of mucous needs antibiotics. However, Chlamydophila is difficult to culture, and we still had not ruled this out. So a PCR may have been more fruitful. The cat’s symptoms waxed and waned. Sometimes improving, sometimes not. The owner was using some nasal drops provided to her by a friend and maybe these helped a little. This week, the cat came in for a therapeutic nasal flush. Since it had been months between his visits. I reassessed him. He was reverse sneezing in fits. His lungs auscultated normal and he had pink mucous membranes. We anesthetized and I used proparacaine for local anesthetic in the nostrils. I chose an 8Fr red rubber but could have gone wider for this particular cat. I measured the tip of the catheter to the medial canthus as I didn’t want it going in too far. Sterile saline was used for the flushing. You want to use sterile saline for a few reasons. If you want to culture the sample, you don’t want to be introducing anything into the nose. But also, because you’re flushing retrograde, you don’t want to flush anything into the airway. Yes, we anesthetized and the airway is protected by the ET tube, and our patient is tipped rostrally so it drains cranially and not caudally, but it is better to be cautious. I do have to say, pulling 2 ml of mucous from the back of the cat’s nasal cavity was satisfying and likely the cat will feel better! So what do we do now? You can do cytology, culture, and/or PCR on the sample. The owner declined diagnostics due to cost. So I told the owner she can continue with the nasal drops, or we can do extra-label Cerenia for its anti-inflammatory properties. He should at least feel better! Next steps if it doesn’t resolve would include a CT and/or a rhinoscopy.