Download ADR (Ain`t Doin` Right) Shar-Pei – Or What To Do When The Blood

ADR (Ain’t Doin’ Right) Shar-Pei – Or What To Do When The Blood Work Is
Normal.
Pardon me while I preface this discussion with the following disclaimer. I often get
inquiries about sick Shar-Pei and “the blood work is normal”. I will be talking about
what I do in such cases. The material contained herein is based on my experience, what
I’ve read in the veterinary literature, opinions and observations. Any comments,
criticism or questions should be directed to me. I also look at this as a work in progress
and fully expect to add to it as experience, new information and discussions with
colleagues further enlightens me. I present this material now to provide some insight into
what to do with the difficult Shar-Pei case.
I look at the diagnostic workup in any sick animal in terms of levels. These levels may
be thought of as the floors of a building and divide out based on the availability of tests,
costs of tests, ease of obtaining the test samples, the equipment needed to run the
diagnostic tests and the experience and comfort level of the veterinarian in interpreting
the test results. The higher you go up in the building the more specific, more specialized
and more expensive the tests become.
The first level of diagnostics consists of the history and physical examination. This
level is extremely important and requires the owner’s accurate information and
observations. Many times a tentative diagnosis is reached at this level but if not, the
information collected here often determines whether to proceed with the rest of the work
up or consider a therapeutic trial.
The second level of diagnostic testing is the basic workup consisting of a complete
blood count (CBC), a blood chemistry screen, a urinalysis, a stool sample check and
usually a chest and abdominal radiograph or radiographs. The purpose of the basic
workup is to provide a sense of direction for additional testing, if needed. Many times
the basic workup provides enough information for a diagnosis. The fact that the basic
workup doesn’t provide a diagnosis should not be interpreted to mean that the dog is
normal or that there is nothing wrong. Normal results more often mean additional testing
needs to be done. Another possibility is that the workup was done too early in the course
of the disease process before significant changes have occurred. This workup doesn’t
adequately evaluate the gastrointestinal system, the endocrine system, the neurological
system, the cardiopulmonary system or the musculoskeletal system. It often does not
help when evaluating for infectious diseases or immune-mediated disease.
Once the basic workup is complete and has not provided a definitive diagnosis, the
third level of diagnostics come into play. In my scheme of things, this is the level in
which the options for diagnostic testing increase dramatically. Hopefully, the
information gathered at the first and second levels provides enough information to narrow
down the testing choices in this third level. In this category I place serologic testing for
leptospirosis, testing for systemic mycoses such as blastomycosis and histoplasmosis,
testing for tick-borne diseases such as Lyme’s disease, ehrlichiosis, and others. Other
blood tests in this category would include testing for immune-mediated diseases such as
autoimmune hemolytic anemia, systemic lupus erythematosus, immune-mediated
thrombocytopenia, myasthenia gravis, masticatory myositis, etc. Bacterial culture and
sensitivity testing would be included here as would uncommon tests such as urine
protein: creatinine ratios and urine cortisol: creatinine ratios. Additional testing could
also include tests of the endocrine system such as the ACTH stimulation test and
dexamethasone suppression tests for Cushing’s disease, thyroid function tests, insulin
levels, etc. Testing of pancreatic digestive function utilizing the TLI (trypsin-like
immunoreactivity test) may also fit in this level. Tests of the gastrointestinal system like a
B12/Folate blood test or the newer fecal α1- proteinase inhibitor test fit in this level as
well. There are quite a few blood tests at this level but bear in mind that the information
obtained from the first two levels will provide a direction for the testing here. Other
testing here would include contrast radiographic studies, which utilize iodine-containing
solutions or barium to highlight the gastrointestinal tract, the urinary bladder, the kidneys,
the spinal canal, etc. Electrocardiography and blood pressure measurement might also be
used at this level.
A definitive diagnosis may still be elusive and fourth level diagnostics may be
required. Diagnostic tests here include ultrasonography, contrast radiography, MRI, CT
scans, laparoscopy and fiberoptic endoscopy. Various biopsy techniques including the
exploratory laparotomy are placed at this level.
Please remember this classification is my own way of explaining diagnostic testing.
The levels are not written in granite and vary with the availability of equipment and
laboratory services. For example, a veterinarian with ultrasound experience and
equipment may do an ultrasonographic examination very early in the workup. Likewise a
veterinary internist may proceed directly to specialized testing that a general practitioner
may not have access to or not do very often.
With the “ain’t doin’ right” Shar-Pei the following disease categories need to be
considered specifically:
1.
Inflammatory Bowel Disease
Gastrointestinal disease often is not demonstrated in the general workup, but I do pay
particular attention to the albumin and total protein levels. These are often slightly
low due to loss of protein in the GI tract which occurs with IBD. Additional tests
which may help to further define the problem include a direct fecal smear to rule out
Giardia, a fecal floatation to rule out intestinal parasitism, a trypsin-like
immunoreactivity test (TLI) to rule out exocrine pancreatic insufficiency or lack of
digestive enzymes, a B12/Folate blood test to rule in protein-losing enteropathy and a
relatively new test called a fecal alpha-1 protease inhibitor test which also helps to
diagnose protein-losing enteropathy. These tests can be done at many local
veterinary labs or more information can be obtained from the Gastrointestinal
Function Test Laboratory, College of Veterinary Medicine, TAMU 4474, College
Station, TX 77843-4474, phone (979) 862-2861. They also have a web site at
www.cvm.tamu.edu/gilab. Ultimately, IBD is a diagnosis based on intestinal
biopsies via exploratory abdominal surgery or fiberoptic endoscopy.
2. Familial Shar-Pei Fever
A multitude of abnormalities can show up in the blood work in cases of FSF
depending on when during the episode blood tests are taken. Usually a moderate to
severe stress leukogram is present characterized by a neutrophilia or increase in the
neutrophil count. Often there is an increase in the liver function test results due to the
release of acute phase reactant proteins. Other changes can include increases in
kidney function tests due to dehydration and electrolyte abnormalities due to
vomiting and diarrhea. The diagnosis is based on the characteristic fever and fairly
quick response to therapy. Complications of FSF need to be considered such as DIC
(disseminated intravascular coagulation), STSS (streptococcal toxic shock syndrome),
splenic torsion or thrombosis, thromboembolism in general, SIRS (systemic
inflammatory response syndrome) and MODS (multiple organ dysfunction
syndrome).
3.
Cancer, in general, can result in clinical signs of weight loss, changes in
behavior, decreased appetite, lethargy, depression, etc. Primary cancer types to think
about in Shar-Pei include lymphoma and mast cell cancer. Radiographs often are
helpful as are additional diagnostics such as ultrasound, CT scans, MRI and
exploratory surgery with biopsy. As an aside, gastrointestinal lymphoma can present
with clinical signs similar to IBD.
4.
Endocrine diseases are a fourth category in which vague and nonspecific
clinical signs often predominate. Hypothyroidism, Cushing’s disease
(hyperadrenocorticism), Addison’s disease (hypoadrenocorticism) are diseases, which
may not easily show up on routine blood testing and require additional tests to
diagnose them.
5.
Infectious diseases including tick-borne diseases can also have vague signs and
require additional blood testing beyond the routine workup. These diseases include
Lyme’s disease, ehrlichiosis, babesiosis, leptospirosis, and others. Systemic mycoses
(fungal infections) such as blastomycosis, histoplasmosis and, in some parts of the
country, cocciodiodomycosis would be included in this category as well. Chronic
bacterial disease such as brucellosis should be considered in appropriate
circumstances. Further pursuit of these diseases involves the use of serologic blood
testing.
6.
Immune-mediated disease including immune-mediated hemolytic anemia,
immune-mediated thrombocytopenia, immune-mediate skin disease such as
pemphigus variants, hepatitis, glomerulonephritis, and various neuromuscular
disorders such as myasthenia gravis and masticatory myositis fit in this category.
Specialized tests are necessary such as various immune panels, acetylcholine receptor
antibody levels, 2M muscle antibody levels, etc.
7. The cardiopulmonary system can be further evaluated with the use of an
electrocardiogram, cardiac ultrasound. I have seen primary and metastatic (cancer
spread from another area to the lungs) neoplasia to the lungs, heart-based tumors and
primary heart disease in Shar-Pei. Early in the course of these diseases coughing and
breathing problems may not be part of the clinical picture and only decreased activity,
weight loss, loss of appetite may be noted.
8. The neurologic system is notorious for being difficult to evaluate. Additional
testing involves CSF (cerebrospinal fluid) tap, myelograms, CAT scans and MRI
studies. Diseases to rule out include various types for cancer including lymphoma,
and discrete tumors involving the brain and spinal cord. Inflammatory disease such
as granulomatous meningoencephalomyelitis (GME) and otitis media or middle ear
infection need to be considered. Another condition to be considered here in the SharPei is glaucoma or an increase in intraocular pressure. In some Shar-Pei I’ve seen an
early intermittent glaucoma characterized by temporary blindness and pain which
may last for only a few hours and then return to normal. Checking intraocular
pressure during an episode would be the means of diagnosis. Another aspect of this
subject involves Cognitive Dysfunction Syndrome (CDS) also called canine
Alzheimer’s disease. Many vague symptoms can fit this syndrome in the older
patient. Lastly, emotional and behavioral upsets can often reflect as vague and nonspecific signs such as loss of appetite, weight loss, lethargy, etc.
9.
The musculoskeletal system is also not evaluated very well in the routine
workup. Pain related to degenerative joint disease (arthritis) and/or muscle/ligament
strains and sprains can be reflected in vague signs such as decreased activity,
decreased appetite, lethargy and changes in behavior. Often diagnosis is based on
additional radiographs and, more importantly, response to therapy with pain-relieving
medications. Anterior cruciate ligament rupture and luxating patella involve the
stifle, hip dysplasia and elbow dysplasia are orthopedic problems seen in Shar-Pei.
10. Lastly, in intact animals, the reproductive system can be a source of vague
symptoms. In males, I worry about prostate disease whether it be prostatitis, benign
prostatic hypertrophy, prostatic abscesses or cysts, testicular torsion or prostatic
cancer. In females we need to consider ovarian disease such as ovarian cysts or
ovarian cancer and uterine diseases such as endometritis, pyometritis, uterine cancer,
etc.
One of the major points in the workup is to do it within a reasonable period of time.
Too often therapeutic trials are tried as the pet continues to deteriorate and by the
time additional testing and/or biopsies are recommended it’s too late. The Shar-Pei
owner must decide early in the course of the workup how far to go in terms of
finances, time, commitment to the pet, etc. Often the delays in the progression of the
workup are due to wavering on the owner’s part.
My intent has been to illustrate the complexities of the workup and the range of
diagnostic tests and procedures, which are available to the pet owner and the
veterinarian. There are other testing procedures I may have missed and others, which
will be available in the future. One thing is always certain – cutting edge technology
will never stand still.