Assessment of misdiagnosis in small animal intensive care patients using the Modified Goldman criteria.

The postmortem examination can be used as a means of quality control for clinical diagnoses. A retrospective study on 300 dogs and cats that had been admitted to a small animal intensive care unit was performed comparing the clinical and postmortem findings, using the Modified Goldman criteria. All patient files were reevaluated for clinical diagnoses and all postmortem material was reevaluated for pathological diagnoses. After this, the Modified Goldman criteria were applied to score the discrepancies between them, and factors associated with the occurrence of an undiagnosed major unexpected finding were analyzed. The postmortem examination revealed additional findings in 65% of the cases. Major discrepancies, defined as those affecting treatment and possibly outcome of the patient, were present in 21.3% of the cases. The most frequently missed diagnoses detected at necropsy were pneumonia of various etiologies, meningitis/meningoencephalitis, myocarditis and generalized vasculitis. A shorter ICU stay was associated with increased odds of a major discrepancy. Conditions affecting the urinary or gastrointestinal system were negatively associated with major discrepancy.

The clinical significance of Cyniclomyces guttulatus in dogs with chronic diarrhoea, a survey and a prospective treatment study.

This study surveyed the prevalence of massive numbers of Cyniclomyces guttulatus in faecal samples from healthy dogs (18%) and dogs with chronic diarrhoea (14%) suggesting that this yeast has no clinical significance. Subsequently, a total of 57 referred dogs with chronic diarrhoea were selected because they excreted massive numbers of C. guttulatus and their initial diagnostic work-up yielded no other direct clues explaining their diarrhoea. Treatment with nystatin did not result in any clinical response in 36 out of these 57 dogs (63%), although they no longer shed the yeast. However, a response was noted in the remaining 21 (37%) dogs: 13 were 'responders', in that their diarrhoea subsided for more than two weeks and the faeces were cleared of the yeast. However, three of these dogs relapsed repeatedly, with signs of diarrhoea and massive shedding of the yeast. The other eight dogs were 'incomplete responders', whereby faecal quality initially normalised, but diarrhoea relapsed within two weeks, whilst still not shedding the yeast. In these cases, further diagnostic work up revealed other co-causes of diarrhoea. It was concluded that there was no direct evidence that C. guttulatus is a primary pathogen. However, the results of the prospective treatment study suggest that a possible role in a minority of cases, perhaps as an opportunist, cannot be ruled out.

Copper-associated hepatic cirrhosis in a Friesian horse.

A 6-year-old Friesian stallion was examined because of signs of exercise intolerance, stiff gait and symmetrical hind weakness, and increased serum liver enzymes. On presentation, the horse showed muscle atrophy of the hindquarters. Neurological investigation showed no abnormalities. Laboratory findings revealed a prolonged prothrombin time and increased levels of alkaline phosphatase (AF), aspartate aminotransferase (ASAT), gamma-glutamyl-transferase (GGT), lactate dehydrogenase (LDH), and bile acids. Histological evaluation of the liver revealed severe cirrhosis and intracytoplasmic greyish brown granules in almost all hepatocytes, sinusoidal Kuppfer cells, and macrophages. These granules stained strongly for copper. Treatment to slow hepatic fibrosis was advised and included oral prednisolone administration for at least 1 month. A diet to support liver function was formulated by a nutritional specialist, and vitamin E was advised as dietary supplement to support neuromuscular function. Soon after diagnosis, the animal showed signs of intravascular haemolysis, with the presence of Heinz bodies in peripheral blood smears, and haemoglobinuria. On the basis of this haemolytic crisis and the poor prognosis of the chronic hepatic disease, the horse was euthanized at the owners' request. Although we could not establish the cause of the hepatic copper accumulation, this case report highlights that excessive copper in the liver should be considered in the differential diagnosis of hepatic cirrhosis and Heinz body anaemia in the horse.