Assimilating my knowledge about Aspergillus

I’ve been wanting to write this post for awhile, because I view part of the purpose of this blog to share what I’m currently learning about. I have been working on a case that has been puzzling and frustrating me, and I think part of my frustration has to do with my inefficiency in looking up important information in a timely manner. In any case, I’m learning a lot from this situation, although some of it should not need to be re-learned in this way.

The patient I’m writing about is a 25-year old Timneh African Grey parrot. The owner acquired him from her father, and although the bird has been well-loved, it has not been particularly well cared for. I’m the first vet the bird has ever seen. She brought it to me because his nostrils keep getting clogged up (one was completely closed with dried debris). He’s been on an all-seed diet his whole life. That right there is a big problem.

I’ll cut to the chase, because there’s no sense in sharing my experiences step by step, when I can do a summarized version. The bird has localized nasal aspergillosis. No, I did not know that right off the bat. For almost two months, I’ve been seeing the bird every 2-3 weeks because I’ve been struggling with reaching a definitive diagnosis and finding effective treatment. It seems like anytime cost is a concern, I try so hard to avoid unnecessarily spending a client’s money, that I probably end up wasting more of their money in the long run. This because I’m trying to do things so piece-meal (one little thing at a time), that I waste valuable time in reaching a diagnosis and implementing effective treatment. This is just as frustrating for me as it is the owner (perhaps more so).

Here’s a general summary of how this case has played out:

• Visit #1: Flushed the nares, performed a gram stain on the very gross, white goopy discharge (yes, that’s the technical term!) from the nares, had no idea what I was looking at (see below) but sent in a sample for aerobic culture and sensitivity, performed a Standard Avian Profile blood panel (through Antech Laboratories), and started on drops of gentamicin ophthalmic solution in the nostrils twice daily and crushed Baytril (enrofloxacin) tablets in the water because the owner was concerned she coudn’t get the meds in his mouth (mistake #1).
• Visit #2: Zero improvement, repeated the sinus flush, tons more white goop, switched to baytril given directly by mouth. The culture had grown: Providencia rettgeri (never heard of it before), Serratia Marcescens, Klebsiella Oxytoca, and Enterococcus species. (Mistake #2 = not requesting a fungal culture.)  We had discussed doing an aspergillus titer on the first visit, but since the WBC was normal (total count 4100, heterophils 2700), I didn’t think asper was likely our culprit (mistake #3), so I elected to have us stay the course with oral meds (rather than in the water, where he likely wasn’t getting enough).
• Visit #3: Slight improvement (nostrils not as clogged up). Flushed nares and was absolutely horrified at how much debris I dislodged. I mean, I couldn’t believe it. And afterwards, you could see clear through one nostril to the other–that is not normal, I repeat, not normal! I was thinking to myself, what on earth is going on here?! I am missing something really important and obvious! So I made another slide of the discharge using diff-quick. I also convinced the owner to spend the money on an asper titer (mistake #4). Here is what I saw on my slide and why I didn’t need to waste the owner’s money on an asper titer:

Branching aspergillus hyphae from African Grey's nasal discharge

The picture is one I took through the microscope at 40x, and at 100x, you can actually see the little conidiophores (sorry, I don’t have that picture). After having looked at that slide multiple times over the course of several days, I finally began to make sense of it. I built up my confidence in knowing what I was looking at. I can now say, yes, that’s asper.

However, when the aspergillus titer came back, it was totally normal. And now I know (though I should have already known) that when a bird has such a localized infection like my patient had, they usually don’t get the heterophilia/leukocytosis and can have normal titers. Now I also know how to better recognize asper on cytology.

Luckily, when I called the bird’s owner to inform her that I had confirmed asper, she reported that his nostrils were finally staying clear! We’ve been working on the diet, among other things, and I think we’re finally on the right track. Unlike systemic aspergillosis, which is much more serious and life-threatening, I don’t think (at this time anyway) that I will need to use systemic anti-fungals for this bird. I switched from using topical gentamicin to topical clotrimazole (an anti-fungal), and increased the baytril dose from 10 mg/kg to 15 mg/kg PO BID. I’m looking forward to our next recheck because I finally have a sense that we’re headed in the right direction.

If you want, you can read another blogger’s account of aspergillus in their African Grey Parrot, Coco. She had a more serious form of the disease and nearly died (but made a full recovery!).

Why I Love Veterinary Medicine: Reason #3

Photo Credit: Nomed Senkrad

The first patient I saw this morning came in as an emergency. The presenting complaint was “not moving”. She turned out to be a 12-year old domestic shorthair. She usually follows her owner around everywhere, always wanting to cuddle, so her owner knew something was wrong last night when she just stayed in one spot and didn’t want to get up or even eat.

My exam revealed a quiet, lethargic, febrile (T = 104) senior kitty with a fairly distended abdomen, but I found it difficult to discern what I was palpating in her abdomen. Important question I should have asked at this point: Has your cat been spayed? (We had only seen the cat at our hospital one other time, almost a year ago, for a broken foot. We’d never seen the cat for routine wellness care where we tend to address the fundamentals a little more diligently. Another reason why routine wellness care is so important! So even though her record didn’t indicate spayed, I didn’t know if it was because she wasn’t spayed or we just forgot to ask her specifically.)

I put together a treatment plan, which included comprehensive in-house blood work, a UA, IV catheterization, fluids, antibiotics and hospitalization. The owner was clearly concerned as she looked at the total of $550 and heard me say, “This is a starting point for us.”

Blood work revealed marked neutrophilia (WBC 35,000 – though I don’t remember specifics off the top of my head), elevated BUN (moderate–likely due to dehydration), hyperglycemia, and some mildly elevated liver enzymes. When I placed our ultrasound probe on her belly to collect my cystocentesis urine sample, I was a little surprised by what I saw. At first, it just looked like a really large bladder. I mean realllly large–but the bladder isn’t supposed to extend up past the kidneys! And this was more of a tubular fluid-filled structure. I stuck it with my syringe and needle anyway and aspirated 3 cc of dark green, turbid nastiness. I had just (accidentally) expressed the cat’s bladder moments before and it looked like normal, yellow pee–so clearly this material was not from her bladder.

You’d think I should be starting to think pyometra by this point, but I’m a little dense (and I always assume my patients are spayed, because they almost always are–and what 12 year old cat wouldn’t be spayed?!). I had my associate come over and take a quick look and she immediately asked if the cat was spayed or not.

When I called the owner with an update on the blood work, I of course asked her this very important question. She said no, the cat had never been spayed. I could then confidently tell her that her cat had pyometra and needed immediate life-saving surgery. Naturally, she wanted to know how much it would cost and I told her it would be about another $1000-1500.

I was afraid she would call me back with a decision to end the cat’s life, but she applied for CareCredit and was approved, so we got the green light to do surgery. Thankfully, surgery went very smoothly–better than I could have ever hoped for, really. No bleeding, no tearing, no spillage. Pretty easy, actually. She weighed a half-pound less afterwards!

Calling the owner after surgery to tell her the good news felt rewarding. We had just saved the cat’s life! But what the owner said next moved me to tears, and reaffirmed why I love to help people and their animals. I can’t repeat what she said because, although some details have been changed to protect identity and this is posted semi-anonymously, it’s still too personal in nature to share. Needless to say, this cat has seen her through some dark times, times when she felt like she had no friends at all in the world. Her cat has always stayed by her side. She felt like she had to save her. And I’m so glad we did. The kitty may be “senior” but hopefully has many, many years ahead of her.

Why I Love Veterinary Medicine: Reason #2

Photo Credit: Georgia State University Library

I love veterinary medicine because I love learning.  This quote by Mahatma Gandhi captures my sentiment best:

“Live as if you were to die tomorrow. Learn as if you were to live forever.”

 

I didn’t always feel this way. Ironically, while I was in school, I would say I bordered more on hating school. But school and learning are different. Vet school in particular, as they say, is like “trying to drink water from a fire hose”. It is NOT enjoyable. Vet school represents a finite amount of pain and suffering, which you must endure so you can have the rest of your life to love learning.

Even before vet school–elementary school through high school and college–I never considered myself (and still don’t) one of the “smarties” who always had her head in a book, latched onto every science show, and wanted to learn and understand everything. I only need to spend five minutes around someone who’s really smart to be reminded of how little, in fact, I know.

Except for maybe a handful of moments that occur every year, where I am surrounded by ultra-smart people who unintentionally make me feel abysmally average, I am comfortable with not knowing all that much. If I were too caught up in feeling inadequate, I would feel less motivated to learn, not more. As it is, I’ve come to love learning, and I am always learning something new every day. (Hence the name of this blog, see? )

Behavior Consult: Protocol for Relaxation

Along the same lines as my last post (Say Please by Sitting), and from the same behavior consultation, I thought I’d share my discussion of what the Protocol for Relaxation is, and how it can help anxious dogs. Again, I’m not saying this is the best way to present it, but it’s one fly-on-the-wall perspective of how one veterinarian does it.

The Protocol for Relaxation that I use is adapted from Dr. Karen Overall and her book, Clinical Behavioral Medicine for Small Animals.

My explanation of the Protocol for Relaxation – helping dogs with anxiety from Learning Vet on Vimeo.

Behavior Consult: Say Please by Sitting

One of my goals with this blog is to share examples of exam room conversation. Afterall, reading and understanding (in theory) various medical problems and solutions doesn’t necessarily mean it’s easy to communicate said knowledge to a pet owner. Once again, I emphatically pronounce my disclaimer that, just because I say it doesn’t mean it’s so, and I by no means think I have done the best job possible in presenting information to the client in the following video. Like I’ve said before, this blog is an experiment, and one of my goals is not only to show a “fly-on-the-wall” perspective of this conversation, but I also hope to gain feedback in how I can improve my presentation.

That said, and with a big swallowing gulp of my pride, here’s my “Say Please by Sitting” dicussion:

My explanation of “Say Please by Sitting” – Dog training from Learning Vet on Vimeo.

Note: I should probably include some discussion on why the “Say Please by Sitting” protocol (also known as “Nothing in Life is Free”) is so useful and helpful, but perhaps that’s for another time. Or if you know of a great resource, post it in the comments section below. I really love Dr. Sophia Yin’s website and information, but she’s recently revamped her website and I can’t find any singular discussion on this exact topic.)

Why I Love Veterinary Medicine: Reason #1

Photo Credit: Bernie Ledesma

The number one reason I love being a veterinarian is because I can help people and animals. As a child, I always knew I wanted to be a vet, but I didn’t really know why. Sure, I thought it was because I loved animals and wanted to help them. How many young vets-to-be picture a poor puppy dog with a broken leg, and think, “I want to save him!”

Not surprisingly, veterinary medicine is so much more than helping that poor puppy with a broken leg. It’s medicine. It’s an art. And, for right or wrong, it’s a business. A veterinarian can’t provide quality medical care if he/she doesn’t charge appropriately for it. If the practice isn’t run like a business–if it’s run like a subsidized clinic providing low-cost or even free care because the staff “just wants to help”–then no one can make a living, and the people who love animals so much will be forced into other professions where they can make a living. (And yes, this happens all the time.)

My point with this apparent digression is, there’s a person attached to that animal. And in order to help the animal, you have to help that person understand what’s wrong and how you can help. It is this exchange that allows me to learn so much about people, and humanity, and to be thankful for my opportunity to help. Because during these conversations about diagnostic and treatment options for a family’s beloved, sick guinea pig, I feel the anguish. I feel the love. I feel the anxiety about the uncertainty of the outcome. I don’t just want to help the guinea pig (or whatever the patient may be)–I want to help that family get their pet back. And if it’s not in the cards, and I can’t save the pet, then you can bet your life that those children will remember what comes next for the rest of their life. My purpose then becomes one of guidance. I want them to remember how kindly and gently their pet was treated, that their vet really does love this pet too, and that we’re saying good-bye because we love him so much.

It’s true, there are times when you can hear me say, “I hate people.” But the real reason I love veterinary medicine is because I do love people, and their animals. If I didn’t, I would be in the wrong profession.

Super Bowl and musings

As I write this, Packers are ahead by 4. A little background: I used to be unable to stand football, let alone watch a whole game. When we got a large screen HD TV a few years ago, I began watching more sports and actually enjoy it now! And yes, I watched some of the Puppy Bowl too! In fact, I helped our hospital host a “tailgating” puppy bowl party yesterday afternoon, and it was really fun. I mean REALLY fun!! We had a total of 7 dogs and 12 people, which far surpassed my expectations.

Why were my expectations so low? I had done essentially nothing to promote the event. Even the decision to host the event was rather last-minute, and little to no preparations were made. My main impetus for doing the puppy bowl party at all was to show our support for the American Animal Hospital Association (AAHA). Ever since AAHA started their “Practice of the Year Awards”, I can’t let go of the feeling that we have such a great hospital and I want AAHA (and everyone else) to know it! Even if we were to win some kind of award, I wouldn’t want that to change our behavior–we should always strive to be the best and demonstrate our commitment to AAHA.

We announced our plans to host the tailgating party in a mass email that went out approximately 2 weeks beforehand and on our Facebook page. Didn’t ask for an RSVP (which probably wouldn’t have made a difference anyway–people either RSVP and don’t show up or show up without RSVPing). I was afraid no one would come and that my two volunteers would be bored and annoyed that I asked for their help. But as it turned out, we were busy taking pictures, guarding the cake table (most of the dogs were too short, but some noses were trying to get up there!) and having fun watching the dogs play. In retrospect, I’m glad we didn’t have more attendees because it might have been too much.

Lesson learned: minimal preparation + AAHA-supported event = easy fun!

I’d be interested to hear from my counterparts (in school and out) what your thoughts are on the Puppy Bowl, AAHA, and social events held at the hospital.

I Couldn’t Live Without: Cerenia

I’ve decided to start a new category, “What I Couldn’t Live Without,” and I’d like to post a product or useful device that makes my life as a small animal veterinarian easier on a daily basis. Today’s can’t-live-without item is Cerenia.

Cerenia, or maropitant, is a wonderful anti-emetic. It comes in two forms: oral tablets and injectable solution. I feel safe and confident using it in many of my vomiting cases. In fact, that’s one way I know something is seriously wrong–I gave them cerenia and they’re still vomiting. Of course, xrays/ultrasound are important for investigating causes of vomiting, but I don’t see any reason why a patient shouldn’t get a Cerenia injection if they’re feeling nauseated.

VIN (the Veterinary Information Network) had a Rounds discussion not so long ago on this very topic, entitled, “Cerenia: Is It The New Anti-Inflammatory, Anti-Allergy, Analgesic, Anti-Emetic, Anti-Obesity, And Antidepressant Wonder Drug?” (if you’re a VIN subscriber, you can access that link; if you’re not a VIN subscriber, then I ask you, “Why not???“).

A summary of the Rounds is as follows:

• Cerenia (maropitant) is a tachykinin antagonist which acts by inhibiting the binding of substance P.
• Cerenia is labeled only for treatment of nausea and vomiting, but can potentially be used extra-label for pain, inflammation, GI disturbances, allergies and immune diseases, bladder inflammation, CNS and spinal cord injury, and mast cell diseases.
• Treatment schedules should be 5 days on, 2 days off or every other day as continuous dosing depletes substance P which leads to tremors.

With all these benefits, why wouldn’t it be one of my favorite drugs? The VIN discussion includes a lot of other really useful and interesting information (way more than I ever thought I wanted to know about Cerenia but am now glad to know!), and I encourage you to read it over.

Cerenia is labeled for dogs, but it can be used in cats too. In fact, I gave it to two different cats in one day recently. It’s also touted as a useful aid for motion sickness in dogs. It doesn’t cause drowsiness, unlike Dramamine, which I’ve also suggested for dogs who get sick while riding in the car.

Practice Tip: Cerenia stings, but it stings less if cold–so wee keep the bottle in the refrigerator! We’ll also give it with SC fluids (when indicated) to help reduce the sting.

The Hallway Consultation

Do you engage in hallway consultations? That’s when someone you know–colleague, friend, family member–casually asks you advice for a potentially serious problem. As in, “By the way, do you have any suggestions on what I should do about Dezzie? He has absolutely destroyed our door frame, sofa, and blinds, and I don’t know what his deal is. But my dad is really mad and wants me to get rid of him. I’m willing to try anything!”

Or maybe the request relates to inappropriate elimination, or aggression, or excessive barking, or anxiety. Whatever the problem is, the one thing I can guarantee you is, I can’t solve it in that setting.

I find behavior fascinating, and I appreciate the opportunity to help restore or improve a family’s bond with its pets, but taking on behavior cases can also be extremely frustrating and unrewarding. That’s because, too often, I’m brought into the picture too late. (Example: Client called about her 8 month old Great Dane who is so anxious when left alone that she becomes extremely destructive. The owner was requesting some anti-anxiety medication so they could see if the dog would improve enough to warrant keeping her and thus paying for her spay surgery. If she’s not going to get better, they don’t want to spend any more money on her and want to find her a new home. My repeated explanation that meds alone are not going to help her improve, that she needs intense behavior modification, which will take weeks to months, fell on deaf ears. For right or wrong, I prescribed some fluoxetine for the dog, knowing full well that they won’t implement any kind of behavior modification and the dog will ultimately need to be rehomed. Where did I miss my opportunity to really help these people? Why do I feel so responsible that I can’t help them more?)

I do try to make a habit of bringing up behavior in the exam room, so I can try to help “nip problems in the bud” before they spiral out of control, but I have to do it in such a way that I can address an owner’s concerns during a routine office visit. Often, what this means is I have to say, “This sounds like a serious concern. I’d like to help you with it, but I need some more information, and it’s more than we can cover during our appointment today. I’m going to send you home with a behavior evaluation form. Please fill it out and return it to me, and we’ll go from there.”

That’s what I’ve had to do for my hallway consultations, too. I try to explain, as helpfully as possible, that to adequately address their concerns, I need a full history, in a written format (otherwise, people try to give me an entire history verbally, and that is REALLY not a good idea–unless you have all the time in the world and a perfect memory, and I certainly have neither). I also like to schedule a time to sit down and review the history and concerns with them. If THEY can’t find the time to meet with me for said consultation, then I know they aren’t likely to follow a prescribed behavior modification plan, either. If it’s a priority for you, it’s a priority for me. If it’s not a priority for you, it’s not fair to make it a priority for me–and no matter how many times this happens to me, I still feel bad and partially personally responsible when therapy fails and a pet has to be rehomed or, worse, euthanized as a result of its behavior.

What do you do when family/friends ask for your help or input on a case where you don’t have all the information?

Veterinary Radiology

I love teaching and learning about veterinary medicine, so when I find another website with the same theme, you can bet I want to share it!

The website I want to share is VeterinaryRadiology.net. It’s run by Allison Zwingenberger DVM DACVR DECVDI (enough initials for ya?!) in Davis, CA.

You simply can’t ask for a better website in terms of learning about veterinary radiology. She generally posts a new case each week (pretty much all small animal), gives you some time to mull it over, then she posts the answers later in the week or the following week. The images range from standard survey films to CT and MRI images.

I love this opportunity to test my skills and learn, and I encourage all Learning Vet readers to join the discussion! Considering I missed a GI perforation on survey films of a ferret I radiographed earlier today (thank goodness we have a radiologist review our films, and extra-thank goodness she took a look at them today), I know I am always needing help interpreting films. Hmm, perhaps I should forward the films to Dr. Zwingenberger and see if she’d like to post them??

Has a radiologist’s review saved your butt? What was the case? Do share!