Volume 3 | Issue 1 (January 2001)


Veterinary Neurology and Neurosurgery Journal (VNNJ) Case Study 6

Vet Neurol Neurosurg J. January 2001;3(1):1.
Veterinary Neurology and Neurosurgery Journal (VNNJ)

Full Text Article (What's Your Diagnosis?)

July, 2001

Signalment, History, Physical Examination   Neurological Examination   Tests Performed   Case Summary

Signalment, History, Physical Examination

 Signalment: This patient is a three-year-old, spayed female, domestic short-haired cat with a five month history of progressive pelvic limb weakness and reluctance to jump. Previously the patient had similar clinical signs which responded to a steroid injection.

 Past Medical History: Previous history of popliteal lymphadenopathy, fine needle aspirates were suggestive of reactive lymph nodes. No other history of previous trauma or illness was reported.

 Medications: No medications are being given at this time

Physical Examination:

 General: Weight 7.58 lbs, Temperature 103, Pulse 140/BPM, Regular rhythm with pulses equal & synchronous, Respiratory rate 40/min, eupneic and mucous membranes pink, Capillary refill time < 2 sec. Alert & Responsive, Body Condition Score 5.5 / 9

 Musculoskeletal: Mild to moderate discomfort with flexion & extension of both hocks, stifles and carpi. Mild effusion both tibiotarsal joints.

 Lymph Nodes: Both Popliteal lymph nodes were 2.5- 3 cm non-painful to palpation

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Neurological Examination

 State of Consciousness: Alert & Responsive

 Gait: The cat's gait could not be fully examined but it was believed there was at least a suggestion of generalized weakness in all limbs with the pelvic limbs somewhat more affected then the thoracic limbs.
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Placing and Postural Reactions

 Proprioceptive Placing Reactions (N=normal, S=slow, VS = very slow, A=Absent)
Thoracic limb/ Pelvic limb
Left - S Right - S/ Left - S Right - S

 Hopping & Hemistand / Walk
Thoracic limb Pelvic limb
Left - S Right - S Left - VS Right - VS

 Wheelbarrow
Thoracic limbs - Unable to complete / evaluate

 Extensor Postural Thrust
Pelvic limb
Left - Right

 Visual & Tactile Placing Reactions
Thoracic limb
Visual Left - Right
Tactile Left - Right

Spinal Reflexes: (Left/Right) (N=Normal, D=Decreased, I=Increased, A=Absent)

 Thoracic Limb
Tendon Reflexes
Biceps N/N
Triceps N/N
Flexor Reflex N/N
Crossed Extensor Reflex A/A

 Pelvic Limb
Tendon Reflexes
Patellar N/N
Gastrocnemius N/N
Flexor Reflex N/N
Crossed-extensor Reflex A/A

 Perineal Reflex N

 Cutaneous Trunci N (If abnormal will indicate level that the reflex is first identified when testing is begun in sacral region and carried rostrally)

Somatosensory examination: (N=Normal, D=Decreased, I=Increased, A=Absent)

 Thoracic limb, Pelvic limb: all normal

Cranial Nerves:

 I: Not tested.

 II: Normal visual fields. PLR - Equal pupils with intact direct and consensual responses.

 III, IV, VI: Normal physiological nystagmus present without positional nystagmus or strabismus.

 V: Normal motor and sensory function present on both sides.

 VII: Normal facial symmetry and normal movement of the muscles of facial expression.

 VIII: Normal clinical response to auditory stimuli each ear. No head tilt was noted and normal conjugate eye movements were noted. No positional nystagmus or strabismus was noted.

 IX, X, XI: Normal swallowing action was noted with stimulation.

 XII: The tongue musculature was symmetrical and tongue movements were normal.

Palpation of the head/neck/spine: Normal range of motion with very little reaction to palpation of the cervical region. No hyperpathia demonstrated over the thoracic or lumbosacral junction.

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Tests Performed

Hematology, Chemistry and Urinalysis

Clinical Chemistry Laboratory Results

Constituent

Patient's Results

Units

Reference Range (Dog)

Alk. Phosphatase

10

U/L

15-127 U/L

ALT (SGPT)

24

U/L

19-70

Ammonia

 

mg/dl

0-92

AST (SGOT)

22

U/L

15-43

Bile acids:

fasting

 

micromol/L

0-12

post-prandial

 

micromol/L

0-16

Bilirubin: direct

 

mg/dl

0-0.1

Bilirubin: total

0.1

mg/dl

0-0.4

Blood urea nitrogen (BUN)

24

mg/dl

8-31

BUN/creatinine ratio

20

 

6-25

Calcium

10.2

mg/dl

9.9-11.4

Cholesterol

81

mg/dl

135-345

Creatine kinase

 

U/L

46-320

Clotting:

PT

 

SEC

7.5-19.5

PTT

 

SEC

9-12

PIVKA

 

SEC

15-18

FDP

   

<10

Creatinine

1.1

mg/dl

0.8-1.6

Glucose

139

mg/dl

70-118

Electrolytes:

Anion gap

 

mmol/l

12-25

Chloride

 

mmol/l

105-116

CO2, total

 

mmol/l

16-26

Potassium

 

mmol/l

4.1-5.3

Sodium

 

mmol/l

145-154

Lipase

 

U/L

0-500

Magnesium

 

mg/dl

1.2-2.4

Phosphorus, inorganic

6.1

mg/dl

3.0-6.2

Proteins:

Albumin

2.3

g/dl

2.9-4.2

A/G ratio

0,5

 

0.6-1.2

Globulin

4.8

g/dl

2.3-4.4

Total protein

7.1

g/dl

5.4-7.4

Thyroid:

Thyroxine T4

 

micrograms/dl

1.0-3.6

Free T4-EQ.D.

 

ng/ml

1.0-3.5

TSH-Canine

 

mU/L

2-30

Tri-iodothyro. T3

 

ng/dl

75-150

Triglycerides

 

mg/dl

19-133

Hemogram Results

Parameter

Patient's results

Reference Values (Dog)

Erythrocytes

9.3

5.5-8.5 million

Hemoglobin (Hb)

12.3

12.0-18.0 g/dl

Hematocrit

41

37-55%

Mean corpuscular volume

44.0

62-77 fl

Mean corpusc. Hb

13.3pgm

33-37 g/d

Mean corpusc. Hb conc.

30gm/dl

21.5-26.5 pg

Reticulocytes

-

0.5-1 %

Leucocytes

22,200

6000-17000/microliter

Band

232

0-300/microliter

Neutrophils

18,792

3000-11500/microliter

Lymphocytes

2552

1000-4800/microliter

Monocytes

696

150-1350/microliter

Eosinophils

928

100-1250/microliter

Basophils

0

Rare

Platelets

1,026.000

200-500x1000

Icteric Index

 

2.0-5.0

Plasma proteins

7.4

6.0-8.0

Fibrinogen

300

200-400 mg/dl

Protein:fibrinogen

 

>15:1

Urinalysis

Parameter

Result

Method/Units

Turbidity

Clear

Visual

Color

Yellow

Visual

Specific gravity

1.070

Refractometer

pH

6.5

Reagent strip

Protein

1+

Acid PPT

Glucose

Negative

Reagent strip

Ketones

Negative

Reagent strip

Bilirubin

Negative

Reagent strip

Occult blood

Negative

Reagent strip

Sediment

   

Leucocytes

None observed

range/high power microscope field

Erythrocytes

None observed

range/high power microscope field

Epithelial Cells

   

transitional

none seen

range/high power microscope field

squamous

none seen

range/high power microscope field

renal

none seen

range/high power microscope field

Casts

None observed

range/low power microscope field

Crystals

 

range: rare/few/moderate/many

Bacteria

 

range: rare/few/moderate/many

Lipid droplets

 

range: rare/few/moderate/many

Sperm

 

range: rare/few/moderate/many

Immunology, Serology and Microbiology

Antinuclear Antibody Test: ANA Serology UC Davis Lab I0010 I 57 - Positive 1: 40

Toxoplasmosis Serology: IgG: Negative, IgN: Negative

Imaging

Radiographs

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Radiograph 1.
Click to view larger image
 
Radiograph 2.
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Joint Fluid Examinations

 Left tibiotarsal joint aspirate: Smears (2) contain blood and abundant mucoproteinaceous background precipitate typical of synovial fluid. Estimated leucocyte count: 80,000/microliter; leucocytes are neutrophils, the majority of which are nondegenerated; no organisms seen.

 Right tibiotarsal joint aspirate: Smears (5) contain blood and abundant mucoproteinaceous background precipitate typical of synovial fluid. Estimated leucocyte count: 60,000/microliter; leucocytes are neutrophils, the majority of which are nondegenerated; no organisms seen.

 Right femorotibial joint aspirate: Smears (2) contain blood and abundant mucoproteinaceous background precipitate typical of synovial fluid. Estimated leucocyte count: 2,000-4,000/microliter; leucocytes are neutrophils, the majority of which are nondegenerated; no organisms seen.

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Case Summary

The signalment, clinical signs, radiographic studies and joint fluid cytology in this case were all consistent with immune-mediated polyarthritis.

The clinical presentation of this case suggested an orthopedic disorder or polyarthritis. The imaging studies did not reveal erosive changes involving the articular joint surfaces. The synovial fluid cytology was also consistent with a polyarthritis. These changes in conjunction with a positive ANA serology suggest that this case fits the category of systemic lupus erythematosus of the immune-mediated polyarthropathies.

There are at least four classes of immune-mediated polyarthropathy described in the cat, including rheumatoid arthritis, progressive proliferative polyarthropathy, systemic lupus erythematosus and idiopathic polyarthritis. Rheumatoid arthritis and progressive proliferative polyarthropathy develop distinguishing radiographic features and can be further classified by the presence or absence of rheumatoid factor. While systemic lupus erythematosus and idiopathic polyarthritis are two nonerosive arthropathies that cause synovial effusion but do not develop any distinguishing radiographic features.

Rheumatoid arthritis and progressive proliferative polyarthropathy are progressive disorders that mainly affect young male cats less than 5 years of age. The carpi and tarsi are the joints mostly likely to be involved, however other joints have been reported with a smaller frequency. The relationship of concurrent viral infections (feline syncytium-forming virus and feline leukemia virus), has been questioned as not all affected cats are positive for feline leukemia virus. These two arthropathies can be further divided into destructive and proliferative forms based on the typical radiographic features that are found.

The last two classes of immune-mediated polyarthropathy, systemic lupus erythematosus and idiopathic polyarthritis, do not produce any distinctive radiographic changes but do present with a symmetric distribution of joint swelling. Systemic lupus erythematosus is distinguished from idiopathic polyarthritis by the presence of a positive antinuclear antibody test. Because of an association between feline idiopathic polyarthritis and myeloproliferative disease, a bone marrow biopsy is recommended for any cat identified with a nonerosive , immune-mediated polyarthritis.

Progressive orthopedic problems in animals can sometimes be very difficult to recognize until they are well advanced. Such cases are sometimes referred to veterinary neurologists because of the vague and often varying nature of the clinical signs.

References

1.  Pedersen, NC, Pool, RR, O Brien, T. Feline Chronic Progressive Polyarthritis. J Am Vet Res 1992; Vol 41, No. 4: 522-535.

2.  Allan, GS. Radiographic Features of Feline Joint Diseases: in Veterinary Clinics of North America: Small Animal Practice. 2000; Vol 30, No. 2: 281-301

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