HEART OF TEXAS. Continuing Education Day

Transcription

1 HEART OF TEXAS Continuing Education Day May 7, 2017

2 2017 HEART OF TEXAS CE Primary Care Veterinarian Appreciation Day May 7 th, 2017 AGENDA 8:00 8:45 Registration and Breakfast 8:45 9:00 Opening Remarks 9:00 10:00 Benjamin Perry, DVM, DACVS-SA "Knots in Your Stomach: Taking the Stress out of GI Surgery" 10:00 10:10 Break Visit sponsor tables 10:10 11:10 Lauren Cunningham, DVM, DACVIM Infectious Causes of Gastrointestinal Disease 11:10 12:10 Melissa Parsons, DVM, DACVIM-Oncology Treatment of Mast Cell Tumors: Guidelines for Success 12:10 1:10 Lunch Buffet 1:10 2:10 Laura Hinton, DVM, DACVS Biliary Surgery Sludge or Mucocele? 2:10 2:20 Break Visit sponsor tables 2:20 3:20 Brooke Clark, DVM, DACVECC Acute Kidney Injury 3:20 4:20 Richard Stone, DVM, DACVIM "Environmental Air Quality and Chronic Respiratory Disease, a one-health approach 4:20 4:30 Break visit sponsor tables 4:30 5:30 Brian Poteet, MS, DVM, DACVR, DABSNM Meandering Thoughts on Veterinary Imaging 5:30 5:40 Closing Remarks 5:40 6:30 Happy Hour The Woodlands Resort and Conference Center

3 Dr. Benjamin Perry Knot s in your Stomach: Taking the Stress out of GI Surgery

4 Infectious causes of chronic GI disease May 7, 2017 Lauren Cunningham, DVM, DACVIM COPYRIGHT MARS INCORPORATED Outline Localizing GI disease Utility of broad GI PCR panels Specific Infectious agents Tritrichomonas Histiocytic ulcerative colitis Histoplasmosis Heterobilharzia COPYRIGHT MARS INCORPORATED Primary complaint vomiting Esophageal, gastric or small intestinal Esophagus Regurgitation typically Spirocerca lupi Gastric Helicobacter spp. Physaloptera Small intestinal Round/ hook worms Pythium

5 COPYRIGHT MARS INCORPORATED Primary complaint diarrhea Small Intestinal Vomiting Weight loss Large volume feces Minimal to no straining Dark or tarry stools Large Intestinal Hematochezia Straining/urgency Mucoid feces Minimal weight loss Broad GI PCR profiles Feline Feline Panleukopenia Tritrichomonas PCR Profile Cont. Non enveloped DNA virus CPV 2b and CPV c most common Viremia for 1 5 days, shed for 3 14 days In house rapid fecal antigen

6 PCR Profile Cont. Single stranded enveloped RNA Cytoplasm of SI epithelial cells Unusual in puppies > 6 weeks of age Incubation period of 1 4 days <100% PPV due to healthy carriers PCR Profile Cont. Gram neg facultative rod shaped anaerobic bacteria Common + Culture 30% dogs, 18% cats Enteroinvasive, mucosal sloughing, High risk of septicemia Tx: Enro, amoxi and TMS PCR sensitivity of ~100%, Spec 97% PCR Profile Cont. Flagellate protozoan Lives on surface of enterocyte (duodenum dogs and ileum cats) Prevalence 15.6% Dogs, 10.8% cats Dx: SNAP ELISA fecal antigen Monoclonal IFA lab basedcross reacts with crypto PCR fails to amplify DNA from 20% of cases Tx: days 50mg/kg fenbendazole as tx of choice

7 PCR Profile Cont. C. jejunum, C. coli Gram negative curved shaped rods Resides in mucus filled crypts of SI and colon. Prev. non diarrhea feces 49% (c. j) 5% (c.c) dogs 46% (c. j) 1% (c.c) cats Gram stain fresh fecal smear Tx: Not often advised but treatment of choice erythromycin PCR Profile Cont. Cryptosporidium Protozoan C. felis (cats), C. canis (dogs) Reside within the small intestine Cats> susceptibility than dogs 3.8% Dx: Acid fast staining of fecal smear (70%) IFA shows poor sens (due to C. parvum being antigen) and poor spec (cross reacts with giardia) PCR method of choice, but still doesn t help with healthy carriers Tx: Tylosin, azithromycin, paromomycin and nitazoxanide

8 PCR profile Cont. Clostridium Gram + spore forming anaerobe C. perfringens 4 different strains based on toxin alpha, beta, epilson, iota Part of natural flora PCR is looking for CPE (C. perfringens enterotoxin) C. difficile Toxin A E: Only A and B studied and both cytotoxic less commonly part of natural flora Dx: Fecal gram stain, fecal culture (not useful due to carrier state) Enterotoxin ELISA/ Enterotoxin PCR Tx: Ampicillin(124/131 C. perfringens sensitive) Tritrichomonas T. foetus Flagellate protozoan Direct transmission of trophozoites Crypts of distal ileum and colon Large bowel, diarrhea with hematochezia 88% considered self limiting w/in 2 yrs

9 Tritrichomonas Dx: Direct saline smear <2% sensitivity Works best with mucus in feces InPouch culture Grown at 37 Celsius F <0.1 gm feces (1 to 10 organisms) Results within 1 6 days Inhibits bacterial growth and did not increase G. lambia or Pentatrich. hominus PCR Single tube nested PCR Detection limit of 10 organisms per 200mg of feces Tritrichomonas Tx Ronidazole Ronidazole/timidazole 10mg/kg resolved diarrhea for about 85 days prior to relapse 30 50mg/kg SID x 14 days 10/10 cats neg at weeks Neurotoxicity JVIM 2007 case series 5 Hyperesthesia, ataxia, trembling Onset day 3 to day 9 Resolution 8 days to 6 weeks Histiocytic Ulcerative Colitis Young dog disease Diarrhea as young as 8 weeks of age, majority < 2 yrs Severe large bowel diarrhea, with significant weight loss, anorexia, hematochezia Similarity to Crohn s E. Coli LF82

10 Histiocytic Ulcerative Colitis Adherent invasive E.coli (AIEC)within colonic macrophages PAS staining FISH analysis Infec Immun 2006 ID E.coli as both Unique in their genetic makeup Unique in their in vitro ability to invade cells Histiocytic ulcerative colitis Treatment: Baytril at 5mg/kg PO SID However: JVIM 2009, JVIM /14 ulcerative colitis e, coli strains were enrofloxacin resistant Treatment with Baytril prior to culture, lead to poorer outcome Histoplasmosis Histoplasma capsulatum Dimorphic soil bourne fungus Mycelial fungus within the soil Yeast phase at body temp Confined to Mississippi river valley High organic matter Aerosolized and inhaled

11 Histoplasmosis Life Cycle Inhalation of microconidia Uptake by macrophages, neutrophils and dendritic cells Prevents acidification of the phagolysosome Transformation into yeast phase Reproduction by budding Dissemination Histoplasmosis Feline (lung/joint) (GI, lung) Gastrointestinal manifestations Mimics PLE, including Extreme weight loss, severe hematochezia/melena, ascites Panhypoproteinemia 53 samples 43% Clinical GI Manifestations 23% gross normal GI tract 83% lymphohistiocytic inflammation Thankfully.. 89% organism was found on histopath Histoplasmosis Diagnosis Serology Cannot diff between active and previous infection (exposure) Complement fixation (64.3%) and Immunodiffusion (17.2%) Organism ID Histopathology Actually harder to find organisms with some stains PAS vs H&E RECTAL SCRAPE! Culture 2 4 week turn around time with sig human health risk Antigen EIA Urine, serum or BAL Cats Urine 94.4% Dogs Urine 89.5% False neg usually patients with GI disease as presenting complaint

12 Histoplasmosis Treatment Azoles Fluconazole vs Itraconazole No significant differences in % treatment response or relapse between the two Itraconazole MUST be brand name Sporonox Itraconazole fat soluble and administered with fatty meal Supportive care Steroids Cobalamin Probiotics Prognosis Even with treatment overall mortality around 33% (cats, no data in dogs) OK State study 2/15 non responders, 2/15 relapse at ~40 weeks. Heterobilharzia Trematode parasite Family: Schistosomatidae Agent of canine schistosomiasis Closely related to human fluke causative agent of swimmer itch Found within the gulf coast/south Atlantic regions, KS, OK Heterobilharzia Life cycle Infected hosts sheds eggs containing formed miracidium, which when exposed to fresh water causes miracidium to hatch Miracidium infect snail. Sporocysts develop within the snail. Cercariae develop within sporocysts and emerge from host Cercariae penetrate (intact) skin of canine and migrate through lungs and liver. During migration, mature to adults Adults travel from portal to mesenteric veins, deposit eggs Eggs penetrate mesenteric veins and intestine, shed in feces

13 Heterobilharzia Disease manifestations Severe granulomatous inflammation Immune response Primarily in response to the antigens present on the eggs produced Macrophage activation pro inflammatory Acute Diarrhea, melena, wt loss, anorexia Less commonly hepatic fibrosis, PU/PD, etc Heterobilharzia Diagnosis Fecal saline sedimentation (sodium chloride) Fecal PCR Cost effective Sensitivity and specificity not studied Only pathogenic Schistosomiasis spec 100% Minimal limit of detection is 1.5eggs per gram feces Repeated testing 10x with 100% reproducibility Tissue PCR Egg or adult seen on histopath Heterobilharzia Treatment Fenbendazole 50mg/kg PO q 24 x 10 days Praziquantel 25mg/kg PO/SQ q 8 x 3 days Hypercalcemia does not resolve without addition of Prazi SQ has been documented to cause epidermal necrosis Biltricide name brand Wang, et al Parasitology Research 2012 both experimental and field resistance to Prazi

14 References T. Geurdena, D. Berkvensb, S. Casaerta, J. Vercruyssea, E. Claerebout. A Bayesian evaluation of three diagnostic assays for the detection of Giardia duodenalis in symptomatic and asymptomatic dogs. V Parasit, 2008 André P. Burnens, Barbara Angéloz Wick, Jacques Nicolet. Comparison of Campylobacter Carriage Rates in Diarrheic and Healthy Pet Animals. Zoonosis and public health Ronald Fayera, Mónica Santína, James M. Trouta, J.P. Dubeyb. Detection of Cryptosporidium felis and Giardia duodenalis Assemblage F in a cat colony. Vet parasite, 2006 Sophia Tzannes, Daniel J. Batchelor, et al. Prevele nce of Cryptosporidium, Giardia and Isospora species in pet cats with clinical signs of gastrointestinal disease. JFMS A. V. Scorza, M. M. Brewer, M. R. Lappin. Polymerase Chain Reaction for the Detection of Cryptosporidium Spp. in Cat Feces. J. Vet Parasit Bruce R. Madewell, Joel K. Bea, Susan A. Kraegel, et al. Clostridium Difficile: A Survey of Fecal Carriage in Cats in a Veterinary Medical Teaching Hospital. Journal of Veterinary Diagnostic Investigation, vol. 11, 1: pp TAKASHI UEMURA, Incidence of Enterotoxigenic Clostridium perfringens in Healthy Humans in relation to the Enhancement of Enterotoxin Production by Heat Treatment. Applied microbiology, June Stanley L. Marks, Elizabeth J Kather. Antimicrobial susceptibilities of canine Clostridium difficile and Clostridium perfringens isolates to commonly utilized antimicrobial drugs. Veterinary Microbiology, Heather D. Stockdalea, M. Daniel Givensb, Christine C. Dykstrab, Byron L. Blagburn. Tritrichomonas foetus infections in surveyed pet cats. Vet Parasi References Cont. Jody L. Gookin, DVM, PhD, DACVIM Derek M. Foster, BS Matthew F. Poore, BS, et al. Use of a commercially available culture system for diagnosis of Tritrichomonas foetus infection in cats. JAVMA Jody L. Gookin, Adam J. Birkenheuer, Edward B. Breitschwerdt and Michael G. Levy. Single Tube Nested PCR for Detection of Tritrichomonas foetus in Feline Feces. J Clinical Microbio Nov 2002 Jody L. Gookin,Christina N. Copple,Mark G. Papich,et al. Efficacy of Ronidazole for Treatment of Feline Tritrichomonas foetus Infection. Terri W. Rosado, Andrew Specht, and Stanley L. Marks. Neurotoxicosis in 4 Cats Receiving Ronidazole. J Vet Intern Med 2007;21: Simpson KW, Dogan B, Rishniw M, et al. Adherent and invasive Escherchia coli is assocaited with granuloamtous colitis in boxer dogs. Infec Immun. 74:4778, C.S. Mansfield, F.E. James, et al. Remission of Histiocytic Ulcerative Colitis in Boxer Dogs Correlates with Eradication of Invasive Intramucosal Escherichia coli. JVIM Craven, M, Dogan, B, Schukken, A, et al. Antimicrobial Resistance Impacts Clinical Outcome of Granulomatous Colitis in Boxer Dogs. JVIM Laura W. Lamps, MD, Claudia P. Molina,MD, A. Brian West, MD, et al. The Pathologic Spectrum of Gastrointestinal and Hepatic Histoplasmosis. A Jou Path, Audrey K Cook, Lauren Y Cunningham, et al. Clinical evaluation of urine Histoplasma capsulatum antigen measurement in cats with suspected disseminated histoplasmosis. JFMS 2012; Lauren Cunningham, Audrey Cook, et al. Sensitivity and Specificity of Histoplasma Antigen Detection by Enzyme Immunoassay. JAAHA; References Cont. Fabrick, C, A. Bugbee, G.Fosgate. Clinical Features and Outcome of Heterobilharzia americanum infection in dogs. JVIM, 2010; Rodriguez, J. B. Lewis, K Snowden. Distribution and characterization of Heteronbilharzia Americana in dogs in Texas. Vet Parasit Schitosomiasis (Heterobilharzia americanum). schistosomiasis heterobilharzia americana

15 COPYRIGHT MARS INCORPORATED Questions?

16 Dr. Lauren Cunningham Infectious Causes of Gastrointestinal Disease

17 Infectious causes of chronic GI disease May 7, 2017 Lauren Cunningham, DVM, DACVIM COPYRIGHT MARS INCORPORATED Outline Localizing GI disease Utility of broad GI PCR panels Specific Infectious agents Tritrichomonas Histiocytic ulcerative colitis Histoplasmosis Heterobilharzia COPYRIGHT MARS INCORPORATED Primary complaint vomiting Esophageal, gastric or small intestinal Esophagus Regurgitation typically Spirocerca lupi Gastric Helicobacter spp. Physaloptera Small intestinal Round/ hook worms Pythium

18 COPYRIGHT MARS INCORPORATED Primary complaint diarrhea Small Intestinal Vomiting Weight loss Large volume feces Minimal to no straining Dark or tarry stools Large Intestinal Hematochezia Straining/urgency Mucoid feces Minimal weight loss Broad GI PCR profiles Feline Feline Panleukopenia Tritrichomonas PCR Profile Cont. Non enveloped DNA virus CPV 2b and CPV c most common Viremia for 1 5 days, shed for 3 14 days In house rapid fecal antigen

19 PCR Profile Cont. Single stranded enveloped RNA Cytoplasm of SI epithelial cells Unusual in puppies > 6 weeks of age Incubation period of 1 4 days <100% PPV due to healthy carriers PCR Profile Cont. Gram neg facultative rod shaped anaerobic bacteria Common + Culture 30% dogs, 18% cats Enteroinvasive, mucosal sloughing, High risk of septicemia Tx: Enro, amoxi and TMS PCR sensitivity of ~100%, Spec 97% PCR Profile Cont. Flagellate protozoan Lives on surface of enterocyte (duodenum dogs and ileum cats) Prevalence 15.6% Dogs, 10.8% cats Dx: SNAP ELISA fecal antigen Monoclonal IFA lab basedcross reacts with crypto PCR fails to amplify DNA from 20% of cases Tx: days 50mg/kg fenbendazole as tx of choice

20 PCR Profile Cont. C. jejunum, C. coli Gram negative curved shaped rods Resides in mucus filled crypts of SI and colon. Prev. non diarrhea feces 49% (c. j) 5% (c.c) dogs 46% (c. j) 1% (c.c) cats Gram stain fresh fecal smear Tx: Not often advised but treatment of choice erythromycin PCR Profile Cont. Cryptosporidium Protozoan C. felis (cats), C. canis (dogs) Reside within the small intestine Cats> susceptibility than dogs 3.8% Dx: Acid fast staining of fecal smear (70%) IFA shows poor sens (due to C. parvum being antigen) and poor spec (cross reacts with giardia) PCR method of choice, but still doesn t help with healthy carriers Tx: Tylosin, azithromycin, paromomycin and nitazoxanide

21 PCR profile Cont. Clostridium Gram + spore forming anaerobe C. perfringens 4 different strains based on toxin alpha, beta, epilson, iota Part of natural flora PCR is looking for CPE (C. perfringens enterotoxin) C. difficile Toxin A E: Only A and B studied and both cytotoxic less commonly part of natural flora Dx: Fecal gram stain, fecal culture (not useful due to carrier state) Enterotoxin ELISA/ Enterotoxin PCR Tx: Ampicillin(124/131 C. perfringens sensitive) Tritrichomonas T. foetus Flagellate protozoan Direct transmission of trophozoites Crypts of distal ileum and colon Large bowel, diarrhea with hematochezia 88% considered self limiting w/in 2 yrs

22 Tritrichomonas Dx: Direct saline smear <2% sensitivity Works best with mucus in feces InPouch culture Grown at 37 Celsius F <0.1 gm feces (1 to 10 organisms) Results within 1 6 days Inhibits bacterial growth and did not increase G. lambia or Pentatrich. hominus PCR Single tube nested PCR Detection limit of 10 organisms per 200mg of feces Tritrichomonas Tx Ronidazole Ronidazole/timidazole 10mg/kg resolved diarrhea for about 85 days prior to relapse 30 50mg/kg SID x 14 days 10/10 cats neg at weeks Neurotoxicity JVIM 2007 case series 5 Hyperesthesia, ataxia, trembling Onset day 3 to day 9 Resolution 8 days to 6 weeks Histiocytic Ulcerative Colitis Young dog disease Diarrhea as young as 8 weeks of age, majority < 2 yrs Severe large bowel diarrhea, with significant weight loss, anorexia, hematochezia Similarity to Crohn s E. Coli LF82

23 Histiocytic Ulcerative Colitis Adherent invasive E.coli (AIEC)within colonic macrophages PAS staining FISH analysis Infec Immun 2006 ID E.coli as both Unique in their genetic makeup Unique in their in vitro ability to invade cells Histiocytic ulcerative colitis Treatment: Baytril at 5mg/kg PO SID However: JVIM 2009, JVIM /14 ulcerative colitis e, coli strains were enrofloxacin resistant Treatment with Baytril prior to culture, lead to poorer outcome Histoplasmosis Histoplasma capsulatum Dimorphic soil bourne fungus Mycelial fungus within the soil Yeast phase at body temp Confined to Mississippi river valley High organic matter Aerosolized and inhaled

24 Histoplasmosis Life Cycle Inhalation of microconidia Uptake by macrophages, neutrophils and dendritic cells Prevents acidification of the phagolysosome Transformation into yeast phase Reproduction by budding Dissemination Histoplasmosis Feline (lung/joint) (GI, lung) Gastrointestinal manifestations Mimics PLE, including Extreme weight loss, severe hematochezia/melena, ascites Panhypoproteinemia 53 samples 43% Clinical GI Manifestations 23% gross normal GI tract 83% lymphohistiocytic inflammation Thankfully.. 89% organism was found on histopath Histoplasmosis Diagnosis Serology Cannot diff between active and previous infection (exposure) Complement fixation (64.3%) and Immunodiffusion (17.2%) Organism ID Histopathology Actually harder to find organisms with some stains PAS vs H&E RECTAL SCRAPE! Culture 2 4 week turn around time with sig human health risk Antigen EIA Urine, serum or BAL Cats Urine 94.4% Dogs Urine 89.5% False neg usually patients with GI disease as presenting complaint

25 Histoplasmosis Treatment Azoles Fluconazole vs Itraconazole No significant differences in % treatment response or relapse between the two Itraconazole MUST be brand name Sporonox Itraconazole fat soluble and administered with fatty meal Supportive care Steroids Cobalamin Probiotics Prognosis Even with treatment overall mortality around 33% (cats, no data in dogs) OK State study 2/15 non responders, 2/15 relapse at ~40 weeks. Heterobilharzia Trematode parasite Family: Schistosomatidae Agent of canine schistosomiasis Closely related to human fluke causative agent of swimmer itch Found within the gulf coast/south Atlantic regions, KS, OK Heterobilharzia Life cycle Infected hosts sheds eggs containing formed miracidium, which when exposed to fresh water causes miracidium to hatch Miracidium infect snail. Sporocysts develop within the snail. Cercariae develop within sporocysts and emerge from host Cercariae penetrate (intact) skin of canine and migrate through lungs and liver. During migration, mature to adults Adults travel from portal to mesenteric veins, deposit eggs Eggs penetrate mesenteric veins and intestine, shed in feces

26 Heterobilharzia Disease manifestations Severe granulomatous inflammation Immune response Primarily in response to the antigens present on the eggs produced Macrophage activation pro inflammatory Acute Diarrhea, melena, wt loss, anorexia Less commonly hepatic fibrosis, PU/PD, etc Heterobilharzia Diagnosis Fecal saline sedimentation (sodium chloride) Fecal PCR Cost effective Sensitivity and specificity not studied Only pathogenic Schistosomiasis spec 100% Minimal limit of detection is 1.5eggs per gram feces Repeated testing 10x with 100% reproducibility Tissue PCR Egg or adult seen on histopath Heterobilharzia Treatment Fenbendazole 50mg/kg PO q 24 x 10 days Praziquantel 25mg/kg PO/SQ q 8 x 3 days Hypercalcemia does not resolve without addition of Prazi SQ has been documented to cause epidermal necrosis Biltricide name brand Wang, et al Parasitology Research 2012 both experimental and field resistance to Prazi

27 References T. Geurdena, D. Berkvensb, S. Casaerta, J. Vercruyssea, E. Claerebout. A Bayesian evaluation of three diagnostic assays for the detection of Giardia duodenalis in symptomatic and asymptomatic dogs. V Parasit, 2008 André P. Burnens, Barbara Angéloz Wick, Jacques Nicolet. Comparison of Campylobacter Carriage Rates in Diarrheic and Healthy Pet Animals. Zoonosis and public health Ronald Fayera, Mónica Santína, James M. Trouta, J.P. Dubeyb. Detection of Cryptosporidium felis and Giardia duodenalis Assemblage F in a cat colony. Vet parasite, 2006 Sophia Tzannes, Daniel J. Batchelor, et al. Prevele nce of Cryptosporidium, Giardia and Isospora species in pet cats with clinical signs of gastrointestinal disease. JFMS A. V. Scorza, M. M. Brewer, M. R. Lappin. Polymerase Chain Reaction for the Detection of Cryptosporidium Spp. in Cat Feces. J. Vet Parasit Bruce R. Madewell, Joel K. Bea, Susan A. Kraegel, et al. Clostridium Difficile: A Survey of Fecal Carriage in Cats in a Veterinary Medical Teaching Hospital. Journal of Veterinary Diagnostic Investigation, vol. 11, 1: pp TAKASHI UEMURA, Incidence of Enterotoxigenic Clostridium perfringens in Healthy Humans in relation to the Enhancement of Enterotoxin Production by Heat Treatment. Applied microbiology, June Stanley L. Marks, Elizabeth J Kather. Antimicrobial susceptibilities of canine Clostridium difficile and Clostridium perfringens isolates to commonly utilized antimicrobial drugs. Veterinary Microbiology, Heather D. Stockdalea, M. Daniel Givensb, Christine C. Dykstrab, Byron L. Blagburn. Tritrichomonas foetus infections in surveyed pet cats. Vet Parasi References Cont. Jody L. Gookin, DVM, PhD, DACVIM Derek M. Foster, BS Matthew F. Poore, BS, et al. Use of a commercially available culture system for diagnosis of Tritrichomonas foetus infection in cats. JAVMA Jody L. Gookin, Adam J. Birkenheuer, Edward B. Breitschwerdt and Michael G. Levy. Single Tube Nested PCR for Detection of Tritrichomonas foetus in Feline Feces. J Clinical Microbio Nov 2002 Jody L. Gookin,Christina N. Copple,Mark G. Papich,et al. Efficacy of Ronidazole for Treatment of Feline Tritrichomonas foetus Infection. Terri W. Rosado, Andrew Specht, and Stanley L. Marks. Neurotoxicosis in 4 Cats Receiving Ronidazole. J Vet Intern Med 2007;21: Simpson KW, Dogan B, Rishniw M, et al. Adherent and invasive Escherchia coli is assocaited with granuloamtous colitis in boxer dogs. Infec Immun. 74:4778, C.S. Mansfield, F.E. James, et al. Remission of Histiocytic Ulcerative Colitis in Boxer Dogs Correlates with Eradication of Invasive Intramucosal Escherichia coli. JVIM Craven, M, Dogan, B, Schukken, A, et al. Antimicrobial Resistance Impacts Clinical Outcome of Granulomatous Colitis in Boxer Dogs. JVIM Laura W. Lamps, MD, Claudia P. Molina,MD, A. Brian West, MD, et al. The Pathologic Spectrum of Gastrointestinal and Hepatic Histoplasmosis. A Jou Path, Audrey K Cook, Lauren Y Cunningham, et al. Clinical evaluation of urine Histoplasma capsulatum antigen measurement in cats with suspected disseminated histoplasmosis. JFMS 2012; Lauren Cunningham, Audrey Cook, et al. Sensitivity and Specificity of Histoplasma Antigen Detection by Enzyme Immunoassay. JAAHA; References Cont. Fabrick, C, A. Bugbee, G.Fosgate. Clinical Features and Outcome of Heterobilharzia americanum infection in dogs. JVIM, 2010; Rodriguez, J. B. Lewis, K Snowden. Distribution and characterization of Heteronbilharzia Americana in dogs in Texas. Vet Parasit Schitosomiasis (Heterobilharzia americanum). schistosomiasis heterobilharzia americana

28 COPYRIGHT MARS INCORPORATED Questions?