OCM Case C

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OCM Case C
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HISTORICAL CLINICAL FINDINGSFOR REVIEW PRIOR
TO EXAM

• A 2½day-old AQH colt is presented for evaluation
  of depression and bleeding from mouth and eyes
  (conjunctiva).
• History
• Normal foaling (placenta passed within 30
  minutes. Foal stood and nursed colostrum from the
  mare within 2 hours) after 331 days of gestation.
• Examination of the colt and the mare (including
  placenta and umbilicus) by the referring
  veterinarian revealed no abnormalities
• The foal appeared normal until 48 hours after
  birth, when blood-colored fluid oozing from the
  colt's conjunctiva and mouth, as well as
  depression and decreased nursing were noted. The
  colt was bottle-fed with milk from the mare but
  drank only 2-3 liters during the 12 hours before
  presentation. Due to progressive depression it
  was referred to you about 60 hours after birth
• The 13 year-old mare (healthy, in good body
  condition 4 previous foals by different sires
  without neonatal problems) was vaccinated against
  tetanus influenza but not against equine herpes
  viruses. Preventive deworming every 8 weeks
  (alternating pyrantel pamoate and benzimidazoles)
  was the only medication administered during
  pregnancy. No problems were reported with other
  neonatal foals on the farm.

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HISTORICAL CLINICAL FINDINGSFOR REVIEW PRIOR
TO EXAM

• Clinical examination
• The foal was depressed and required assistance to
  walk.
• Body weight was 71.5 kg with normal body
  condition and no evidence of dysmaturity
• Rectal temperature was 38.4C, heart rate 108
  beats per minute and respiratory rate 40 breaths
  per minute.
• Tan feces on the thermometer supported complete
  meconium passage.
• Dehydration was estimated at 5 of body weight
  based on pink, but slightly tacky (thick saliva)
  oral mucous membranes and history of decreased
  nursing. Capillary refill time was less than 2
  seconds and extremities were warm.
• Digital stimulation provoked both a suckle
  response and swallowing.
• Excessive salivation was apparent. An oral exam
  revealed normal anatomical structures, but the
  tongue and gingiva showed five ulcers (3 x 3 to
  20 x 45 mm) that were painful to palpation.

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HISTORICAL CLINICAL FINDINGSFOR REVIEW PRIOR
TO EXAM

• No fresh bleeding or no petechiation were
  observed on the sclera, pinnae, or oral,
  conjunctival, penile or anal mucous membranes.
• However, the skin around the muzzle and eyes, as
  well as in the axillary and inguinal regions, was
  covered with sero-sanguinous crusts and showed
  partial superficial ulceration.
• No effusion was palpated in any joint and the
  umbilicus was dry and normal on palpation.
• Except for depression, a complete neurological
  exam revealed no further abnormalities. No
  abnormalities of the eyes, including fundi, were
  detected on direct ophthalmoscopy.

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HISTORICAL CLINICAL FINDINGSFOR REVIEW PRIOR TO
EXAM
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Laboratory data on admissionFOR REVIEW PRIOR TO
EXAM

• Parameter Normal Values
• PCV 30-45 36
• RBC x 106/ul 6.91-10.36 9.65
• MCV fl 38.1-52.7 37.7
• MCH pg 12.7-18.8 14.3
• MCHC 32.6-37.2 38
• RBC Morphology
• ( slight
• slight to moderate
• moderate
• marked) echino-cytes

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Laboratory data on admissionFOR REVIEW PRIOR TO
EXAM

• Parameter Normal Values
• WBCs x 103/ul 5.10-13.1 22.34
• Metamyelocytesx 103/ul
• Band Neutrophils x 103/ul 0-0 0.02
• Seg. Neutrophils x 103/ul 1.94-7.40 1.03
• Lymphocytes x 103/ul 0.96-5.74 0.96
• Monocytes x 103/ul 0.01-0.35 0.33
• Eosinophils x 103/ul 0.00-1.07 0
• Basophils x 103/ul 0.03-0.26 0
• Leukocyte Morphology
• ( few, slight moderate many)
  basophilaand Dohlebodies

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Laboratory data on admissionFOR REVIEW PRIOR TO
EXAM

• Parameter Normal Values
• Platelets x 103/ul 97-309 46
• Fibrinogen mg/dl 100-500 231
• PT sec. 10.0-12.3 11.2
• APTT sec. Control horses
• 94.7 66.66 7.7
• Fibrin degradation
• Products ug/ml lt5 lt5

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Laboratory data on admissionFOR REVIEW PRIOR TO
EXAM

• Parameter Normal Values
• BUN mg/dl 11-31 11
• Creatinine mg/dl 0.8-1.8 1.2
• Alk. Phos. IU/L 90-295 781
• SGOT (AST) IU/L 210-380 221
• GGT IU/L 6-17 31
• SDH IU/L 4.1-20.4 7.3
• CPK IU/L 156-417 135
• Total bilirubin mg/dl 0.1-2.1 3.3

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Laboratory data on admissionFOR REVIEW PRIOR TO
EXAM

• Parameter Normal Values
• Glucose mg/dl 75-119 178
• Na mEq/L 128-158 133
• K mEq/L 2.6-4.9 4.0
• Cl mEq/L 91-110 99
• Ca mg/dl 10.1-13.7 10.8
• P mg/dl 1.2-4.6 4.8
• Mg mg/dl 1.3-2.1 1.5

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Laboratory data on admissionFOR REVIEW PRIOR TO
EXAM

• Parameter Normal Values
• Total protein gm/dl 6.1-8.9 5.4
• Albumin gm/dl 3.5-4.7 2.6
• Globulin gm/dl 2.4-5.1 2.8
• Cholesterol mg/dl 51-117 110

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Laboratory data on admissionFOR REVIEW PRIOR TO
EXAM

• Parameter Normal Values
• Anion Gap mmol/l 6-15 10.0
• PH 7.373-7.241 7.39
• pO2mm Hg 19.8-42.5 86.2
• pCO2mm Hg 40.0-57.2 49.0
• HCO3mEq/L 24.6-34.1 26.5
• Total CO2mEq/L 22-30 28
• Base Excess mEq/L 0.7
• Equine IgG mg/dL gt725 1262

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Urinalysis data on admissionFOR REVIEW PRIOR TO
EXAM

• Parameter Normal Values
• Source (e.g. Cath/void cysto) Void
• Color Pale yellow
• Appearance Transparent
• Specific gravity 1.001-1.012 1.008
• Ph 6-7 7
• Protein Negative-Trace Negative
• Glucose Negative Negative
• Acetone Negative Negative
• Bilirubin Negative Negative
• Blood Negative Negative
• Urobilinogen Normal Normal

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Sepsis score on admissionFOR REVIEW PRIOR TO EXAM

• Sepsis score (based on Koterba 1990) was 7

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Further investigation of thrombocytopenia
manual counts of citrate and heparin
bloodcoagulation and mucosal bleeding timesbone
marrow aspirate

• Manual and machine counts of blood collected in
  sodium citrate and heparin tubes maintained
  warmed at 37C confirmed thrombocytopenia.
• Coagulation times still within normal ranges
• Prolonged mucosal bleeding time (9 minutes)
  repeated one day later 5 minutes
• A bone marrow aspirate was deemed justifiable
  since the bleedingtime was almost normal one day
  later histopathology report
• CommentsThe slides submitted were from bone
  marrow aspirates but no hematopoieticelements
  were encountered in the sea of RBCs.
• DiagnosisPeripheral blood.

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Punch (6 mm) skin biopsies for histological
evaluation were taken from the muzzle and
pectoral area.

• Histopathology report
• CommentsThe sections were characterized by
  prominent regions of deep epidermal erosion and
  ulceration alternating with zones of epidermal
  hyperplasia. Associated with these affected zones
  were extensive serocellular crusts consisting of
  degenerate neutrophils, keratin, cellular debris
  and bacterial colonies. Also noted were marked
  epidermal spongiosis and scattered individual
  necrotic keratinocytes involving all epidermal
  layers. Dermal alterations consisted of fibrinoid
  necrosis of dermal pegs obscuring the associated
  superficial dermal blood vessels, as well as mild
  inflammatory cell infiltrations surrounding
  remaining viable superficial dermal vessels.
  Neutrophils were the primary cell type noted.
  Remaining viable superficial vessels exhibited
  moderate endothelial cell swelling. Deep dermal
  vessels were generally spared.
• Diagnosis Mild to marked acute
  erosive/ulcerative and crusting dermatitis, with
  superficial dermal necrosis, vasculitis and mild
  parakeratosis

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Bacteriological blood cultures

• Bacteriological results
• Specimen Whole blood (1000 pm Day 1)
• Bacteriology culture no growth or aerobic or
  anaerobic bacteria
• Specimen Whole blood (1130 pm Day 1)
• Bacteriology culture no growth or aerobic or
  anaerobic bacteria
• Specimen Catheter tip (Day 3)
• Bacteriology culture no growth or aerobic or
  anaerobic bacteria

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ABDOMINAL ULTRASONOGRAPHY

• Ultrasonographicfindings
• On admission
• Normal ultrasonographic appearance of liver,
  intestines (good motility), spleen, bladder and
  all umbilical structures (umbilical vein 6-9 mm
  umbilical arteries no fluid in urachus) and no
  free peritoneal fluid.
• Follow-up on consecutive days
• Normal ultrasonographic appearance of umbilical
  structures (umbilical vein and arterieslt10mm no
  fluid in urachus) and no other abnormalities
  noted.

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CHEST RADIOGRAPHSThorax, lateral standing
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FURTHER CLINICAL COURSE

• The colt quickly became more alert, started
  nursing the mare, first with assistance, then on
  its own and was normoglycemic. Urination and
  defecation were normal.
• Consequently, IV fluid therapy and supplemental
  bottle feedings were discontinued after 12 hours.
• Close monitoring showed the colt even more
  vigorous and alert with vital signs and PCV, TS
  and blood glucose concentrations within normal
  ranges over the next 4 days. It continued to
  nurse well and had gained weight. The oral ulcers
  and skin lesions appeared less painful and
  started to heal. NSAIDs were discontinued, the
  catheter was pulled, and antibiosis was continued
  orally.
• The colt was discharged with recommendations for
  close monitoring, restricted exercise and
  continued antibiotic prophylaxis (oral
  trimethoprim-sulfonamide for 4 more days) until
  the referring veterinarian re-examined the foal.
• Follow-up CBCs showed increasing platelet numbers
  (62000/µl5 days and 316000/µl10 days after
  discharge) and no other abnormalities. The colt
  continued to do well.