I Gotta Go! I Gotta Go!

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Mercy Clark
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1 I Gtta G! I Gtta G! Identifying Infectius Causes f Diarrhea in the Dg and Cat Kristi L. Graham DVM, MS, DACVIM (SAIM) Internal Medicine Cnsultant IDEXX Labratries Kristi-Graham@idexx.cm Take a Standard Apprach Prblem riented apprach Gather infrmatin Histry Physical examinatin Identify and list all prblems Establish rule-uts (DAMNIT scheme) Design a diagnstic plan fr each prblem Priritize the wrkup and initiate diagnstics Update the prblem list Diagnsis reached r Prblem refined Fllw up n each prblem Histry: characterize the diarrhea Small bwel diarrhea 2 4 times per day Weight lss Large vlumes Liquid diarrhea Melena Large bwel diarrhea 4 10 times per day Tenesmus Dyschezia Mucus Frank hemrrhage Fecal incntinence (mre s than small-bwel diarrhea) Histry: additinal infrmatin Vaccinatin status Envirnmental and dietary histry Duratin and frequency f nrmal vs. abnrmal stls Nrmal in mrning and prgressively becmes abnrmal Clr f stl Mre variable in small-bwel diarrhea Green, yellw, gray, black Cntent f stl Undigested fd Freign material

2 Physical examinatin Attitude, behavir and psture (unrestrained) Weight, bdy cnditin scre Hydratin Other systems Lymphadenpathy Cardipulmnary Reprductive Musculskeletal Abdminal palpatin Rectal palpatin Fecal evaluatin Mass, stricture, freign bdy Fistula/hernia/anal sacs Minimum database Cmplete bld cunt (CBC) Serum chemistry panel with electrlytes Urinalysis Fecal fltatin by centrifugatin Giardia ELISA Direct smear Cat: include FeLV, FIV, cnsider T 4 The Cmpanin Animal Parasite Cuncil (CAPC) The missin f the CAPC is t fster animal and human health thrugh recmmendatins fr diagnsis, treatment, preventin, and cntrl f parasitic infectins. CAPC recmmendatins: Year-rund treatment with brad-spectrum heartwrm/anthelmintics Apprpriate fecal exams perfrmed: 2 4 times/year fr puppies and kittens 1 2 times/year fr adult pets, t mnitr cmpliance with mnthly preventives CAPC recmmends that feces be rutinely screened by a centrifugal fltatin methd, which is cnsistently mre sensitive than simple fltatin. Envirnmental cntrl preventing/cntrlling cntaminatin Staff, pet wner and cmmunity awareness Year rund parasite cntrl Recmmend and prescribe year-rund heartwrm/anthelmintic treatment Medicatins like Heartgard Plus and Sentinel Spectrum nt nly prevent heartwrm infectins, they als prvide cntrl f gastrintestinal parasites Place dgs and cats n preventive flea/tick prducts as sn after birth as pssible (cnsistent with label claims) Annual heartwrm retesting is ideal t ensure cmpliance with mnthly preventives Small bwel diarrhea additinal diagnstics Imaging: radigraphs, ultrasund r bth Fecal ELISA tests Fecal cultures r PCR testing Fecal ccult bld Fecal alpha-1 prtease testing

3 Pancreatic functin tests Trypsin-like immunreactivity (TLI) Spec cpl /Spec fpl Tests Small-intestinal bacterial vergrwth (SIBO) Cbalamin (Vit B 12)/flate Identify underlying cause Intestinal bipsy Fecal ELISA tests In-huse and/r reference labratry Parvvirus Giardia Clstridium spp. entertxin Cryptspridium Fecal culture Specific bacteria: Salmnella, Campylbacter, Yersinia, etc. Sme bacteria can be islated in small numbers frm nrmal animals Cmparative numbers Heavy, pure grwth mre significant Fecal culture transprt media Turnarund time: 3 12 days Nt all pathgenic rganisms can be cultured Fecal RealPCR Only specific rganisms available (i.e., nt all pathgens) Sme bacteria can be islated in small numbers frm nrmal animals Cmparative numbers Feces in sterile cntainer Turnarund time: 1 3 days Panels include viral and prtzal rganisms IDEXX diarrhea RealPCR panels Feline Clstridium perfringens entertxin A gene Cryptspridium spp. Feline crnavirus Feline panleukpenia virus Giardia spp. Salmnella spp. Txplasma gndii Tritrichmnas fetus Canine Canine distemper virus Canine enteric crnavirus Canine parvvirus type 2 (CPV-2) Canine circvirus Clstridium perfringens entertxin A gene Cryptspridium spp. Campylbacter spp. Giardia spp. Salmnella spp.

4 Benefits f RealPCR panels Cst-effective Quick turnarund time Easy sample submissin N special transprt media needed Identificatin f cinfectins ALWAYS interpret in light f clinical signs! Large bwel diarrhea additinal diagnstics Fecal smears and rectal scraping Giardia Entameba histlytica Histplasma rganisms Inflammatry cells Clstridium spp. spres Abdminal radigraphs Mre imprtant when tenesmus present Fecal cultures and/r RealPCR testing may be indicated Intestinal bipsy Case Discussins Willie 5 m ld MN glden retriever Chief cmplaint: chrnically sft stls, episdes f liquid diarrhea Histry Adpted at 2 mnths f age Always sft stls, n bld r mucus Nrmal appetite and grwth Onging dietary indiscretin Cccidia diagnsed at 2 mnths f age n respnse t Albn and pyrantel pamate Fecal fltatin by centrifugatin and Giardia ELISAs negative at 3 and 4 mnths Flea, tick and heartwrm prphylaxes administered mnthly Physical examinatin Bright, alert and respnsive (BAR) Bdy cnditin scre (BCS): 5/9 Nrmal temperature, pulse and respiratin Thracic auscultatin within nrmal limits Abdminal palpatin within nrmal limits Assessment Small- vs. large-bwel diarrhea? 4 6 bwel mvements per day N bld r mucus bserved Nrmal BCS and grwth Large-bwel diarrhea Differential Diagnsis Anatmic: bstructin, freign bdy Metablic Infectius: parasitic, prtzal, bacterial, fungal, viral Inflammatry

5 Txin Diagnstic plan CBC As expected fr age Chemistry panel ALP and P as expected fr age Mild hypalbuminemia Urinalysis Recmmended but declined Fecal fltatin by centrifugatin N parasites seen Giardia ELISA Negative Time passes: Grws nrmally, remains BAR Sft stls wax and wane, peridically becming mre liquid but never watery diarrhea Empiric therapy with metrnidazle, prbitics and bland diet Attributed t dietary indiscretin Basically ignred since dg clinically ding well Vaccinated as per rutine schedule Heartgard Plus mnthly, Advantage /Frntline Nw 2 years ld: Cntinues t have sft-t-runny stls Respnds t metrnidazle but relapses when ff treatment N respnse t dietary trials Repeat fecal fltatin by centrifugatin and Giardia tests: negative Physical examinatin: nrmal grwth, BCS 5/9, unremarkable Differential diagnsis: Infectius: parasitic, prtzal, bacterial, fungal, viral Inflammatry: fd intlerance, inflammatry bwel disease Diarrhea RealPCR panel Cryptspridium psitive Treatment plan: Azithrmycin, 10 mg/kg rally twice daily fr 10 days Respnse t therapy Stls nrmal within 3 days and cntinue t remain nrmal 1 year later! Kestra 11 year ld FS Tnkinese Chief cmplaint: diarrhea Frank bld Tenesmus 5 r mre bwel mvements per day Several weeks duratin Vmiting fd ff/n N dietary changes, previusly healthy

6 Quiet, alert and respnsive (QAR); unremarkable physical exam Tw new Tnkinese kittens have been added t the huse Assessment Small- vs. large-bwel diarrhea? Frank hemrrhage Tenesmus 5 r mre bwel mvements per day Large-bwel diarrhea Vmiting Differential Diagnsis Metablic Infectius: parasitic, prtzal, bacterial, viral Inflammatry Neplastic Diagnstic plan Fecal fltatin by centrifugatin: negative CBC: stress leukgram Chemistry panel: nrmal T 4 and free T 4 by equilibrium dialysis (ED): nrmal Diarrhea RealPCR Panel Feline Diarrhea RealPCR Panel Tritrichmnas fetus Giardia spp Bth psitive Tritrichmnas fetus Prtzal flagellates, similar in size t Giardia Challenging t diagnse Direct fecal examinatin (14% sensitivity) Fecal culture using InPuch TM TF Feline (56% sensitivity) RealPCR test (94% sensitivity) A negative test never rules ut Tritrichmnas fetus Challenging t treat Metrnidazle and fenbendazle ften fail Rnidazle (30 mg/kg rally nce daily fr 14 days) Spntaneus clinical reslutin median 9 mnths (4 mnths 2 years) Treatment Metrnidazle Kestra and kittens N respnse Rnidazle Kestra nly 30 mg/kg rally twice daily fr 14 days Clinical reslutin Stls nrmal fr apprximately 3 weeks, then relapse f symptms Retreated Kestra and bth kittens (ne develped symptms) Nrmal stls fr mre than 3 mnths

7 Pearls Cnsider husemates (even asymptmatic nes) and the envirnment as a surce f infectius disease. An advantage f the RealPCR panels is identificatin f cinfectins. Tritrichmnas fetus can be challenging t diagnse and treat. Terra 10 m ld FS Labradr retriever Chief cmplaint: lethargy; sft, dark stls fr 1 week Stls became lse and dark brwn t black ver past 7 10 days Appetite decreased past 3 4 days N weight lss r vmiting Previusly healthy; up-t-date vaccinatins Frequently visits dg park Physical examinatin QAR Temperature: F; pulse: 150 beats per minute; respiratin: pant Pale pink mucus membranes; capillary refill time (CRT): 2 secnds Slightly tense with abdminal palpatin Fecal staining arund perineum Rectal examinatin Dark, tarry stls Flecks f frank bld Assessment Small- vs. large-bwel diarrhea? Black, tarry stls (melena) Frank bld n rectal exam Mixed: bth small- and large-bwel diarrhea Differential diagnsis? Anatmic: freign bdy, bstructin Metablic Infectius: parasitic, prtzal, viral, bacterial, fungal Inflammatry Txin Diagnstic plan CBC Regenerative anemia Leukcytsis characterized by a mature neutrphilia, esinphilia, and basphilia Chemistry panel Panhypprteinemia Elevated BUN with nrmal creatinine Urinalysis Fecal fltatin by centrifugatin Hkwrm va Remember: ZOONOTIC ptential Abdminal radigraphs Fecal material present N abnrmal gas pattern Treatment Fenbendazle: 50 mg/kg rally fr 5 days

8 Mnthly prphylaxis initiated Respnse t therapy Stls nrmalized Fllw-up Recheck packed cell vlume (PCV)/ttal slids (TS) after 2 weeks: nrmal Recheck fecal fltatin by centrifugatin after 1 mnth: negative Buster 11 week ld intact male mixed breed dg Tw puppies adpted and bth develped vmiting and diarrhea 2 days later Cccidia and Giardia diagnsed n the ther puppy Bth puppies treated with Albn and metrnidazle Sibling imprved Buster re-presents 4 days later with cntinued diarrhea, vmiting and anrexia Vluminus stls, fetid dr, brwn-green-yellw clr Bth puppies vaccinated 1 day prir t adptin Physical examinatin Quiet, respnsive Temperature: F; pulse: 180 beats per minute; respiratin: 50 breaths per minute; BCS: 5/9 Mucus membranes: pale pink, slightly tacky; CRT: 2 secnds Thracic auscultatin: within nrmal limits Abdmen tense with palpatin, thickened bwel lps Buster vmited during palpatin Feces-stained perineum Assessment Small- vs. large-bwel diarrhea? Vluminus stls Varius clrs Small-bwel diarrhea Differential diagnsis? Anatmic: freign bdy, bstructin Metablic Infectius: parasitic, prtzal, bacterial, viral Inflammatry Txin Diagnstic plan CBC Essentially nrmal; mild thrmbcytsis Chemistry panel (mini-panel) Hypprteinemia Mild hyperglycemia (stress) Urinalysis declined Fecal fltatin by centrifugatin - declined SNAP Parv Test Psitive Abdminal radigraphs: declined Initial therapy Hspitalizatin fr 6 days Intravenus fluid therapy

9 Antibitics ampicillin and enrflxacin Antiemetics metclpramide CRI Nutritinal supprt nasesphageal tube Placed day 3 Vivnex CRI Little t n interest in slid fd during mst f hspitalizatin Leukpenia develped during hspitalizatin Pearls Nt all parvvirus patients are leukpenic at presentatin What abut recent vaccinatin and the SNAP Parv Test? Abstract presented at IVECCS 2008: Effects f Mdified Live Canine Parvvirus Vaccine n the SNAP ELISA Antigen Assay 1 If SNAP ELISA psitive, indicates infectin with wild type canine parvvirus type 2 (CPV-2) 1. Schultz RD, Larsn LJ, Lrentzen LP. Effects f mdified live canine parvvirus vaccine n the SNAP ELISA antigen assay. J Vet Emerg Crit Care. 2008;18(4):

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