Day 1: Ryder Barrett is a 2-year-old neutered male Border Collie whom presented to our emergency department for lethargy, vomiting, and decreased mobility. Earlier that morning, he appeared more lethargic than usual; however, he had just been picked up from doggie daycare. Ryder’s owners had noted a lesion on his left elbow which was typical of his normal skin lesions. Ryder is also a patient of our dermatology department and is being managed with steroids for Cutaneous Histiocytosis, an immune-mediated skin disease. Ryder’s owners reported he had missed his last two doses of his steroid medication.
On physical examination, Ryder was clinically dehydrated and exhibiting signs of shock. He was mentally dull and unable to stand or walk. Ryder’s left elbow was swollen, painful, and had a small amount of clear red discharge seeping from a wound. Emergency consent was obtained to allow for initial diagnostics and stabilization. Ryder’s blood glucose and blood pressure were both low and he received supplemental dextrose and intravenous fluids to improve his blood glucose and blood pressure. An emergency focused ultrasound demonstrated no evidence of free fluid in his chest or abdomen. His pupils were noted to be different sizes and he also vomited a large amount of bright yellow fluid. Initial bloodwork confirmed severe dehydration, electrolyte abnormalities, and an acid-base imbalance. His blood glucose had improved, but his blood pressure remained low so additional intravenous fluids were administered. He also received an injection of anti-nausea medication to help with his vomiting. Ryder’s owners were updated he was in critical condition and would require advanced diagnostics and aggressive stabilization. His owners elected to continue with additional care.
Blood and urine samples were obtained for comprehensive evaluation of organ function, electrolytes, and cell counts. Ryder’s blood pressure remained low and intravenous fluids were continued. An intravenous injection of a steroid was administered to help supplement Ryder’s steroid hormone levels in case they were depleted due to his severe stress. On evaluation of Ryder’s bloodwork, his liver and kidney values were also elevated. His red and white blood cell counts were normal; however, there was an increased number of immature white blood cells indicating infection or inflammation. The urine sample collected was suggestive of a possible urinary tract infection. An in-house test for common tick-borne diseases was negative. The severity of Ryder’s condition was again discussed with the owners. Increased concern for multiple organ dysfunction versus secondary elevations due to his history of steroid administration and current dehydrated state were discussed. Potential causes such as a toxin exposure (snake/spider bite, other), severe allergic reaction, sepsis (severe infection), complication with another underlying immune-mediated disease due to pet’s history, tick-borne disease, cancer, or another undiagnosed condition were discussed. His owners reported no known trauma, medication or toxin exposure, or any obvious exposure to a snake or spider in their home.
Ryder’s elbow continued to become more swollen and painful. Radiographs and ultrasound of the elbow demonstrated soft tissue swelling and no other abnormalities. Chest and abdominal radiographs demonstrated no thoracic abnormalities; however, his stomach was noted to be air-filled and his bladder distended. The detail on his abdominal radiograph was decreased and another ultrasound confirmed no evidence of free abdominal fluid. On repeat evaluation, Ryder’s spleen had an abnormal appearance with no obvious mass, but concern for possible cancer was discussed. Ryder was admitted to the hospital for continued aggressive stabilization consisting of intravenous fluids, dextrose supplementation, broad-spectrum antibiotic therapy, pain medications, and serial monitoring. His ongoing diagnostic plan consisted of a urine culture, serial blood glucose monitoring, comprehensive ultrasound with our internist the following day, and continued vital monitoring. A urinary catheter was also placed to monitor his urine production and help keep Ryder clean.
Overnight, Ryder’s left elbow became more bruised and his right elbow started to become swollen and painful. Possible vasculitis associated with blood vessel inflammation and subsequent leakage of fluid was discussed as an underling cause. Ryder developed a fever and became more uncomfortable, requiring additional pain medications. Additional antibiotic therapy was initiated to cover for possible tick-borne diseases associated with vasculitis. His blood pressure appeared to stabilize until early the next morning when his values started to trend low again. Ryder’s blood glucose and urine production were normal overnight.
Day 2: Ryder’s blood pressure remained low and he had gained almost 2 pounds since admission. On examination, he had signs of fluid overload and severe swelling and bruising over his left and right elbow regions which extended up and down his limbs. His mentation had improved, but he was still weak and non-ambulatory. A repeat ultrasound demonstrated a large, fluid-filled stomach with limited motility. A nasogastric tube (tube inserted into the nose and passed into the stomach) was placed to allow decompression of his stomach and promotility therapy was initiated. His owners were updated on his clinical status and his diagnostic/therapeutic plan was discussed. Recheck bloodwork demonstrated improved kidney values, stable liver value elevations and improved hydration and acid/base status. A blood smear submitted for cytological review by our clinical pathologist confirmed an inflammatory process with no obvious infectious or neoplastic agent. An abdominal ultrasound with our internal medicine department demonstrated mild liver enlargement consistent with most likely his history of steroid administration and an irregular spleen with no obvious mass effect. An ultrasound-guided splenic aspirate was submitted for cytological review and findings were consistent with an inflammatory process as no infectious or neoplastic agents were identified. His owners were updated on his case and blood pressure support was recommended due to his persistent hypotension and clinical signs of fluid overload. Ryder’s fluid therapy was decreased and he was started on a blood pressure support medication. Throughout the day, his mentation improved and he started drinking small amounts of water on his own. Ryder was started on nutritional supplementation and his other supportive care was continued. Overnight, Ryder’s blood glucose and blood pressure improved. His dextrose supplementation and blood pressure support was decreased. Unfortunately, his nutritional supplementation had to be discontinued as his stomach had persistent decreased motility causing the liquid nutrition to remain within the stomach instead of moving into his small intestines.
Day 3: Ryder continued to make small improvements and his dextrose supplementation was discontinued. He was transitioned to step-down pain medications as we were concerned the stronger opioid medications were slowing down his gastrointestinal motility. His blood pressures continued to improve and his blood pressure medication was decreased slowly. Due to his severe swelling and edema formation in both of his front limbs, laser therapy was initiated to improve blood circulation and healing of the affected areas. Ryder started to take more initiative to move his peripheral limbs and attempted to stand. Using the exercise ball from our rehabilitation department, we provided standing support to Ryder and performed range of motion exercises. He was also taken outside for short visits using a mobile gurney to allow for mental stimulation and emotional support. Ryder’s nausea improved and his nutritional supplementation was restarted. We were excited to update his owners on the positive advancement in Ryder’s case and include his family during his physical therapy exercises. Unfortunately, that afternoon Ryder was noted to have small bruises along his abdominal area and the inside of his hind limbs. Bloodwork demonstrated a low platelet count with signs that his body was attempting to make new platelets. We discussed our concerns that Ryder’s suspect vasculitis had also caused his platelet count to decrease secondary to bleeding versus a secondary immune mediated disease causing destruction of his platelets. We elected to increase his steroid dose and continue supportive care. Overnight, Ryder continued to show small improvements with stable blood pressures and his blood pressure medication was discontinued. His intravenous fluid support was also decreased due to persistent signs of fluid overload and his urine production had normalized.
Day 4: Ryder appeared brighter and more interactive during his physical examination, he was even interested in playing with a tennis ball during his morning physical therapy. He was holding his head more stable and attempting to take steps with support. He was fitted with a harness over his chest and hind end area to allow for additional support when walking. Ryder started to eat small amounts of food and drink water more readily. As he became more ambulatory, Ryder developed head tremors and an increased concern for an ischemic event to his brain secondary to decreased oxygen delivery from his low blood pressure was discussed. Our neurology department was consulted regarding his neurological tremors and the neurologist agreed the tremors were most likely associated with brain hypoxia. His signs of fluid overload continued to improve and his fluid therapy was discontinued. His left elbow region continued to produce small amounts of fluid and there was concern for possible abscessation and necrosis of the tissue due to decreased blood flow to the area.
Day 5: Ryder continued to significantly improve, interacting more with our hospital staff and becoming more strongly ambulatory with sling support. He now supported approximately 50% of his own weight in his fore limbs and supported his hind limbs almost completely by himself. During physical therapy, he stood on his own for a few seconds and played tug of war with one of his toys! His appetite continued to improve with no additional signs of nausea. He was transitioned to all oral medications and we discussed possibly discharging Ryder to his owners the next day if he continued to improve.
Day 6: Ryder greeted us this morning with tail wags and kisses! During his morning exam, we noted his left elbow wound appeared infected and was draining large amounts of fluid. The skin over his left elbow appeared ulcerated with sections of necrotic skin. Our surgery department was consulted and we elected to perform serial bandage changes hoping the wound would heal without surgical intervention. We did not feel Ryder was a good surgical candidate due to his low platelet count and increased risk of bleeding and immunosuppressed state from his steroid therapy. Our exam findings were discussed with Ryder’s family and that he would require daily bandages changes for an extended period. As the wound started to heal, he may be able to have the bandage changed less frequently; however, the wounds would need to be treated for several months. His owners were determined and dedicated to helping Ryder make a full recovery. Luckily Ryder’s owner was also a human nurse and able to help with some of Ryder’s care at home. Overnight, Ryder continued to improve and even walked outside on his own.
Day 7: Ryder’s strength and mobility continued to improve; however, he was noted to fatigue easily. His left elbow wound was still actively draining, but the surrounding tissue appeared less inflamed and more comfortable during palpation. The right elbow also appeared to be more bruised and the tissue compromised. A new bandage was placed on the left front limb when his owner visited. To allow Ryder to go home for continued long-term therapy, wound care and bandage application were demonstrated to his owner. Ryder would be evaluated by our surgery department once a week with his owner performing daily bandages changes in between his recheck visits.
Day 8: Ryder had another great night, walking with minimal support. He had a great appetite and a vibrant personality. He appeared to thoroughly enjoy all the attention and was warming the hearts of our entire hospital. During his bandage change, his left elbow wound had less drainage and healthy tissue appeared to be forming under the necrotic tissue indicating healing. Unfortunately, the skin over his right elbow appeared to be dying and his owners were warned that he would require serial bandage changes for his limb soon. Ryder’s family were excited about his overall progress and were not discouraged by this new information. They were excited to take him home and Ryder was discharged that afternoon for continued care.
9/30/2017 Case Update: Ryder is doing very well at home with no recurrent episodes. His right elbow has healed well; however, he wears a padded brace to relieve elbow pressure when he lays down. Ryder’s left elbow has continued to heal; however, the process has been very slow. He is still being re-evaluated by our surgery department for bandage changes due to a persistent ulcerated area on his left elbow. Ryder is not letting his prolonged recovery dampen his spirits and greets our team with tail wags and kisses during his visits. He is so famous at our hospital, his paw print even made it onto our “Wall of Fame” in the ICU!
Ryder’s case is an excellent example of RVRC’s emergency and critical care team in action. His case demonstrates how a patient in shock can deteriorate rapidly and require aggressive medical intervention. The case also illustrates the complexities in managing all body systems during a critical illness. Ryder’s case also demonstrates the collaboration of multiple specialty departments within RVRC to ensure he was provided excellent veterinary care. Ryder is incredibly lucky to also have such a dedicated family whom never gave up on him, rallying behind the care he would need to successfully recover.