[Calcitriol induced hypercalcemia in a hunting dog with a disseminated Paecilomyces variotii infection]. / Calcitriol-bedingte Hyperkalzämie bei einem Jagdhund mit disseminierter Paecilomyces variotii-Infektion.

INTRODUCTION: A 5-year old hunting dog was presented with reduced appetite, weight loss and polyuria/polydipsia. Hematology and clinical chemistry revealed anemia, leukocytosis, increased liver enzymes, hypoalbuminemia and hypercalcemia. The cytological, pathohistological and microbiological examination identified a disseminated infection with the saprophytic mould fungus Paecilomyces variotii in the biopsies of the spleen and a lymph node. Determination of vitamin D metabolites confirmed a calcitriol induced hypercalcemia.

[Syncope, falls and vertigo]. / Synkope, Sturz, Schwindel.

Dizziness/vertigo, falls and syncope are among the most common reasons for seeking medical care. As clinical entities they share common pathogenetic and clinical features and differences. The diagnostic work-up can often be initiated in a general practitioner's or internist's practice and, if necessary, completed in an interdisciplinary emergency unit. Simple diagnostic tools can be used in an outpatient setting to obtain valuable diagnostic information. First and foremost, it is important to differentiate between prognostically favorable clinical events and potentially serious disease. In younger patients diagnostic procedures should primarily focus on potential structural cardiac disease and/or primary arrhythmia. The same applies to elderly patients in whom, however, multicausal clinical symptoms and severe complications in the case of falls are characteristic. Elderly patients frequently require the involvement of various clinical specialties to investigate a broad spectrum of potential differential diagnoses in an interdisciplinary diagnostic approach, which is not always available in practice. In the emergency unit, decisions regarding inpatient care need to be made individually. In elderly patients, inpatient care is sometimes necessary not only due to acute disease, but also in order to ensure social care. Geriatric day hospitals may be a suitable option for some of these patients.

First application of a new portable, miniaturized system for extracorporeal membrane oxygenation.

Extracorporeal assist systems for respiratory and circulatory failure are increasingly used in intensive care medicine. Important technical innovations over the past years have resulted in improved biocompatibility and, consequently, reduced complication rates. Extracorporeal membrane oxygenation (ECMO) technology experienced a surge of use during the influenza A (H1N1) pandemic, but transport of unstable patients with life-threatening ARDS is still hazardous. We describe the first successful application of a newly developed, compact and easily portable ECMO device in a patient with severe ARDS due to influenza A (H1N1). Support with the miniaturized ECMO resulted in immediate improvement of gas exchange and a highly protective ventilation. Inspiratory pressure was decreased from 40 to 29 cmH(2)O and tidal volume per kilogram of predicted bodyweight could be reduced from 6.5 to 3.3 mL. Small and efficient heart-lung assist systems will become a tool of growing importance in intensive care medicine, both for profound respiratory and cardiac failure in the future. The reduced weight and compact design of the device greatly facilitates transport and handling of unstable patients on ECMO.

[Juvenile sterile granulomatous dermatitis and lymphadenitis in the dog]. / Juvenile sterile granulomatöse Dermatitis und Lymphadenitis beim Hund.

Juvenile sterile granulomatous dermatitis and lymphadenitis is a rare immune-mediated skin disease in young dogs. History, signalment, diagnostics, treatment, and outcome in 10 dogs are described. The age ranged from 8 - 36 weeks. The lymph nodes were enlarged in all dogs, especially the mandibular and prescapular lymph nodes. Systemic signs including fever were present in 8 dogs. Seven dogs suffered from blepharitis and painful edema of the muzzle with hemorrhagic discharge, pustules and papules. Cytology of pustules and lymph node aspirates revealed a pyogranulomatous inflammation. In 7 cases the diagnosis of juvenile sterile granulomatous dermatitis and lymphadenitis was confirmed by histology. Nine dogs were treated with prednisolone (0.5 - 1.25 mg/kg BID), H2-receptor antagonists and analgetics; all dogs were treated with antibiotics. Four dogs were treated with eye ointment containing antibiotics and glucocorticoids. The prednisolone dosage was tapered over 3 - 8 weeks. One dog had a relapse.

Chocolate ingestion in dogs: 156 events (2015-2019).

OBJECTIVES: To describe the clinical features and outcome of dogs after chocolate ingestion. MATERIAL AND METHODS: Retrospective evaluation of clinical signs, clinical pathological findings, therapy and outcome of 156 dogs after chocolate ingestion. The concentration of methylxanthines (theobromine, caffeine) was calculated based on the type of chocolate and the amount ingested. RESULTS: One hundred and twelve dogs had no clinical signs. Forty-four dogs had clinical signs of chocolate intoxication. Twenty-eight of these 44 dogs ingested dark and bitter chocolate. Reasons for presentation were agitation (33), tremor (22), vomiting (21), panting (11), polyuria/polydipsia (seven) and diarrhea (two). Common clinical findings were sinus tachycardia (28), tachypnea/panting (14), hyperthermia (10) and dehydration (seven). Clinical pathological findings in 34 of 44 dogs consisted of hyperlactataemia (23), hypokalaemia (16), mild hyperglycaemia (16) and mild alanine aminotransferase (ALT) and aspartate aminotransferase (AST) elevation (14). After decontamination (apomorphine, activated carbon) and symptomatic treatment (fluid therapy, esmolol, forced diuresis, sedatives), 43 of the 44 dogs survived. CLINICAL SIGNIFICANCE: In dogs with potential chocolate intoxication, the type and amount of chocolate and the time of ingestion are important factors. Cardiovascular, neurological and gastrointestinal signs are the most common clinical signs. In this case series, the prognosis after decontamination and symptomatic therapy was good, with a mortality rate of less than 3%.

Septic polyarthritis caused by Erysipelothrix rhusiopathiae in a dog.

A 14-month-old, male German Shepherd dog was admitted with a six-week history of lameness and swelling of the right hindlimb. Clinical examination revealed polyarthritis, fever, petechiae and ecchymoses of the abdominal skin and prepuce. The haematology and blood chemistry were indicative of sepsis. Mediolateral radiographic views of both of the stifle joints revealed signs of bilateral articular capsule swelling. The radiographical, bacteriological and necropsy findings confirmed a diagnosis of septic polyarthritis due to infection with Erysipelothrix rhusiopathiae.

[Zinc intoxication in a Yorkshire Terrier due to Euro cent ingestion]. / Zinkintoxikation bei einem Yorkshire Terrier nach Aufnahme von Euro-Cent-Münzen.

A 5-year old, intact male Yorkshire Terrier was presented due to lethargy, vomiting and diarrhea. Clinical signs included shock, icterus and a painful abdomen. Laboratory examination revealed a severe intravascular hemolytic anemia, a thrombocytopenia and a leukocytosis. The radiographic examination revealed the presence of metallic foreign bodies in the stomach and in the intestine. After stabilisation of the patient with crystalloids, packed red blood cells, ranitidine, metamizole, amoxicilline/clavulanic acid and marbofloxacine, surgery was performed and 5 coins (10 cent, 5 cent, 2 cent) were removed via esophagus and via enterotomy. In the course of disease the dog developed acute renal failure and pancreatitis. The zinc concentration in the serum was 2200 microg/dl, which was 30 times higher compared to a healthy control dog. After 21 days the dog was discharged from the hospital. On day 28 all laboratory values were within the reference range.

Primary immune-mediated haemolytic anaemia: a retrospective long-term study in 61 dogs.

OBJECTIVES: The objective of this study is to describe the course of disease of dogs with primary immune-mediated haemolytic anaemia (pIMHA) with an observation period longer than 90 days in regard to clinical signs, laboratory results and treatment response. MATERIAL AND METHODS: Clinical records between January 2003 and December 2011 were reviewed. Diagnosis of pIMHA was based on the presence of haemolytic anaemia with a packed cell volume of <0.35 L/L, a positive Coombs' test and/or erythrocyte agglutination, spherocytosis and exclusion of an underlying disease. Included were dogs which could be monitored for more than 90 days after initial presentation. RESULTS: Sixty-one dogs with pIMHA were included. The initial packed cell volume ranged from 0.08 to 0.30 L/L (median 0.16). Immunosuppressive treatment included prednisolone in all the cases; 32 dogs successively received cyclosporine (28), cyclophosphamide (5), leflunomide (2) or human intravenous immunoglobulins (2) in addition. In 33/61 dogs, the drugs were discontinued 67-3372 days (median 334) after beginning of therapy; in 28 dogs, the drug dosage was reduced, but not discontinued until the end of the study. Three dogs developed immune-mediated thrombocytopenia (days 132, 156 and 680). The observation period ranged from 96 to 4147 days (median 628). A total of 22.9% (14/61) of the dogs developed a relapse after 94-3972 days (median 517). Five dogs were euthanased due to a relapse after 96-1188 days (median 628). CLINICAL SIGNIFICANCE: Long-term prognosis in dogs with pIMHA is favourable. However, a relapse can occur after many years. Relapse was the most common cause of death in dogs with pIMHA that survive more than 90 days.

Increase in renal vascular resistance after intake of cyclosporin A and tacrolimus and reversal by nitroglycerin spray: a study in patients with stable renal allograft function.

PURPOSE: Acute effects of drug administration on renal arterial resistance index (RI) are still discussed controversially. In our study we investigated the immediate effects of cyclosporin A (CyA) and tacrolimus (FK-506) on renal arterial resistance indices in patients with stable graft function after renal transplantation. Additionally we studied the effects of nitroglycerin spray on resistance indices. METHODS: RI was measured by color Doppler sonography at baseline, at 1 and 2 hours after intake of medication and 30 minutes after administration of nitroglycerin spray which followed the 2-hour measurement. 34 renal transplant recipients were examined. 16 patients received CyA, 18 patients received FK-506. Whole blood levels of calcineurin inhibitors were taken at each time point. Arterial blood pressure and heart rate were measured to assess possible systemic hemodynamic effects. RESULTS: Mean RI values increased significantly in both groups 1 hour after calcineurin inhibitor intake and remained still significantly elevated after 2 hours. There was no significant increase of mean arterial blood pressure nor was there any correlation between whole blood levels of calcineurin inhibitors and mean RI. 30 minutes after administration of nitroglycerin spray, mean RI values decreased significantly to a level even below baseline. Mean arterial blood pressure also decreased after administration of nitroglycerin. CONCLUSION: Renal RI values are markedly influenced by a recent intake of calcineurin inhibitors and vasoactive substances such as nitrates. This demonstrates the necessity of keeping standardized conditions when using RI as a tool in followup investigations after renal transplantation.

The Oldest Old in the Emergency Department: Impact of Renal Function.

OBJECTIVES: The ageing population implicates an increasing numbers of older adults attending Emergency Departments (ED). We assessed the effect of estimated glomerular filtration rate as a predictor of clinical outcomes in oldest-old patients ≥ 85 years attending the ED in an university teaching hospital. DESIGN: Within three years, 81831 patient contacts were made in our ED. 7799 (9.5%) were older than 85 years, in whom we analyzed the impact of renal function on various outcome parameters. Furthermore, this patient group was compared to the patients < 85 years. RESULTS: Within the group of patients ≥ 85 years, not older age, but as denominator decreased glomerular filtration rate led to significant longer hospital stays. In addition, impaired kidney function was associated with lower heart rates, lower blood pressure, lower oxygenation, a higher rate of established ambulant care setting, as well as higher mortality. Compared to younger patients, the oldest-old significantly differed with regard to medical attribution (e.g. internal medicine, surgery), sex distribution, length of hospital stay, Manchester triage score, Glasgow Coma Scale, visual analogue pain scale, heart rate, blood pressure, oxygen saturation as well as fall prophylaxis, outpatient care, and presence of relatives. CONCLUSION: In conclusion, in this large collective of oldest-old patients, impaired kidney function seems to be a more important determinant in adverse outcome and thus increased health care costs than age per se. Adapted strategies in EDs to adjust diagnostic and treatment strategies for this population are thus warranted.

Haemorrhage in seven cats with suspected anticoagulant rodenticide intoxication.

Clinical features were evaluated in seven adult cats (six males, one female) with haemorrhage and presumptive anticoagulant rodenticide intoxication. Haemorrhage appeared as thoracic haemorrhage, otic bleeding, haematoma, melena, haematochezia, and petechiation. The most common other presenting signs were lethargy, anorexia, and tachypnoea or dyspnoea. Six cats were anaemic, four cats were mildly thrombocytopenic (58000-161000/ microL), and three had slightly decreased plasma protein or albumin values. The prothrombin time (30.3->100 s, reference range: 16.5-27.5 s) and activated partial thromboplastin time values (32.6->100 s; reference range: 14-25 s) were markedly prolonged in all cats. All cats received vitamin K(1)subcutaneously or orally (3.7-5 mg/kg body weight initially) and depending on severity of signs five cats were transfused with fresh whole blood. Plasma coagulation times improved in all cats and returned to normal in 1-5 days. Rodenticide poisons represent an important but relatively rare cause of haemorrhage in cats and can be effectively treated.

Whole blood transfusions in 91 cats: a clinical evaluation.

This survey assessed the feline transfusion practices at the University of Berlin from 1998 to 2001 in regard to patient population, indications, efficacy, and transfusion reactions. Blood was obtained from seven healthy in-house donors and 127 mostly indoor client-owned pet cats. Over a 3-year period 91 cats were transfused with blood type compatible blood. The blood was fresh (within 8 h of collection) or stored no longer than 15 days. Transfusions were required because of blood loss anaemia (n=40), haemolytic anaemia (n=13), ineffective erythropoiesis (n=35), hypoproteinaemia (n=2) or coagulopathy (n=2). The anaemic cats had a pretransfusion haematocrit of 5-20% (m [median]=13), and received one to six transfusions (m=1). The survival rates of the anaemic cats at 1 and 10 days after transfusion were 84 and 64%, respectively. None of the deaths appeared to be related to transfusion reactions. The major crossmatch, undertaken before 117 transfusions, was incompatible for eight cats. All except for one had previously been transfused. Lysis of transfused cells in six cases resulted in a less than expected haematocrit rise and an increase in serum bilirubin. Transient mild transfusion reactions were only noted in two cats during the second or third transfusion. In conclusion, with proper donor selection and appropriate compatibility screening, blood transfusions are well tolerated, appear effective, and may increase chances of survival.

An emerging pulmonary haemorrhagic syndrome in dogs: similar to the human leptospiral pulmonary haemorrhagic syndrome?

Severe pulmonary haemorrhage is a rare necropsy finding in dogs but the leptospiral pulmonary haemorrhagic syndrome (LPHS) is a well recognized disease in humans. Here we report a pulmonary haemorrhagic syndrome in dogs that closely resembles the human disease. All 15 dogs had massive, pulmonary haemorrhage affecting all lung lobes while haemorrhage in other organs was minimal. Histologically, pulmonary lesions were characterized by acute, alveolar haemorrhage without identifiable vascular lesions. Seven dogs had mild alveolar wall necrosis with hyaline membranes and minimal intraalveolar fibrin. In addition, eight dogs had acute renal tubular necrosis. Six dogs had a clinical diagnosis of leptospirosis based on renal and hepatic failure, positive microscopic agglutination test (MAT) and/or positive blood/urine Leptospira-specific PCR. Leptospira could not be cultured post mortem from the lungs or kidneys. However, Leptospira-specific PCR was positive in lung, liver or kidneys of three dogs. In summary, a novel pulmonary haemorrhagic syndrome was identified in dogs but the mechanism of the massive pulmonary erythrocyte extravasation remains elusive. The lack of a consistent post mortem identification of Leptospira spp. in dogs with pulmonary haemorrhage raise questions as to whether additional factors besides Leptospira may cause this as yet unrecognized entity in dogs.

Bordetella pertussis virulence factors affect phagocytosis by human neutrophils.

The interaction between human neutrophils and wild-type Bordetella pertussis or mutants expressing altered lipopolysaccharide or lacking virulence factors-pertussis toxin, adenylate cyclase toxin, dermonecrotic toxin, filamentous hemagglutinin (FHA), pertactin, or BrkA-was examined. In the absence of antibodies, the wild-type strain and the mutants, with the exception of mutants lacking FHA, attached efficiently to neutrophils. The addition of opsonizing antibodies caused a significant reduction (approximately 50%) in attachment of the wild-type strain and most of the mutants expressing FHA, suggesting that bacterium-mediated attachment is more efficient than Fc-mediated attachment. Phagocytosis was also examined. In the absence of antibodies, about 12% of the wild-type bacteria were phagocytosed. Opsonization caused a statistically significant reduction in phagocytosis (to 3%), possibly a consequence of reduced attachment. Phagocytosis of most of the mutants was similar to that of the wild type, with the exception of the mutants lacking adenylate cyclase toxin. About 70% of the adenylate cyclase toxin mutants were phagocytosed, but only in the presence of opsonizing antibody, suggesting that Fc receptor-mediated signaling may be needed for phagocytosis. These studies indicate that FHA mediates attachment of B. pertussis to neutrophils, but adenylate cyclase toxin blocks phagocytosis.

Regulation of expression of the nonhemolytic phospholipase C of Burkholderia cepacia.

Burkholderia cepacia is an opportunistic pathogen that causes serious pulmonary infections in cystic fibrosis patients. We have purified and partially characterized one potential virulence factor for the organism-a nonhemolytic phospholipase C-and we studied the effect of iron restriction and choline and phosphate concentrations on the expression of phospholipase C. Iron limitation did not affect expression, the effect of choline was variable, and high phosphate concentrations repressed expression. Experiments with heat-treated spent culture supernatants suggested that autoinducers affected the expression of the phospholipase and two other potential virulence factors, a protease and a lipase. We screened 26 B. cepacia isolates for autoinducer activity: 11 induced violacein production in the autoinducer-deficient mutant Chromobacterium violaceum CV026. Spent supernatants from two strains, one that was positive in the C. violaceum assay and one that was negative, were tested for inducing early expression of phospholipase C, protease, and lipase in homologous and heterologous cultures. Expression of all three enzymes was increased or induced at an earlier stage in the growth curve in every case, suggesting not only that autoinducers were involved in the regulation of the expression of these enzymes, but also that the autoinducers were of two different classes.

A nonhemolytic phospholipase C from Burkholderia cepacia.

Burkholderia cepacia is an opportunistic pathogen that causes serious pulmonary infections in cystic fibrosis patients. Although several potential virulence factors-a protease, lipase, and two phospholipases C (one hemolytic and one nonhemolytic)-have been identified, only two, the protease and the lipase, have been described in detail. The goal of this study was to purify and characterize a nonhemolytic phospholipase C secreted by B. cepacia strain Pc224c. The enzyme was concentrated from culture supernatants and purified by polyacrylamide gel electrophoresis. The 54-kDa protein was stable in the presence of sodium dodecyl sulfate (up to 10%) and at 4 degrees, 22 degrees, and 37 degrees C; it was, however, inactivated at 100 degrees C. The enzyme bound to glass, chromatography matrices, and polyvinylidene difluoride and cellulose membranes, suggesting that it is hydrophobic. In a genetic approach, primers based on conserved sequences of a B. cepacia Pc69 hemolytic phospholipase C and both the Pseudomonas aeruginosa hemolytic and nonhemolytic proteins were designed to identify the Pc224c nonhemolytic phospholipase C gene. One polymerase chain reaction product was identified; it was sequenced and the sequence compared with sequences in the BLAST database. The best match was the Pseudomonas aeruginosa hemolytic phospholipase C. Ten additional B. cepacia strains were screened for the gene by Southern hybridization; five had the 4-kb band, suggesting that these strains have a similar form of the PLC gene. Nine of the ten strains reacted with the probe, suggesting that similar sequences were present, but in another form.

Phagocytosed Bordetella pertussis fails to survive in human neutrophils.

Previous studies have reported that phagocytosed Bordetella pertussis survives in human neutrophils. This issue has been reexamined. Opsonized or unopsonized bacteria expressing green fluorescent protein (GFP) were incubated with adherent human neutrophils. Phagocytosis was quantified by fluorescence microscopy, and the viability of phagocytosed bacteria was determined by colony counts following treatment with polymyxin B to kill extracellular bacteria. Only 1 to 2% of the phagocytosed bacteria remained viable. Opsonization with heat-inactivated immune serum reduced the amount of attachment and phagocytosis of the bacteria but did not alter survival rates. In contrast to previous reports, these data suggest that phagocytosed B. pertussis bacteria are killed by human neutrophils.

Characterization of bactericidal immune responses following vaccination with acellular pertussis vaccines in adults.

Sera from six adults, collected before and after acellular pertussis vaccination, and from a placebo control were examined for the ability to elicit two bactericidal immune defenses, (i) antibody-dependent complement-mediated bacterial lysis and (ii) opsonization and phagocytosis by human neutrophils. The samples were chosen based on low preimmunization titers and strong postimmunization responses to various combinations of vaccine antigens. All but two prevaccination samples demonstrated activity indicative of complement-mediated lysis. Preimmunization activity could have been due to prior infection or childhood immunization. Immunization did not result in improved bactericidal activity for any of the individuals, and in two cases immunization caused a statistically significant decrease in complement-mediated lysis. Similarly, opsonization with the postimmunization sera failed to enhance attachment or phagocytosis of bacteria by neutrophils, and one postimmunization sample with a strong response to filamentous hemagglutinin caused an inhibition of phagocytosis that was statistically significant compared to that observed for the no-serum control. In summary, booster immunization of adults with acellular pertussis vaccines was not found to increase bactericidal activity over preimmunization levels. Identifying ways to promote bactericidal immune responses might improve the efficacy of acellular pertussis vaccines.

Fluorescent labels influence phagocytosis of Bordetella pertussis by human neutrophils.

To explore the role of neutrophil phagocytosis in host defense against Bordetella pertussis, bacteria were labeled extrinsically with fluorescein isothiocyanate (FITC) or genetically with green fluorescent protein (GFP) and incubated with adherent human neutrophils in the presence or absence of heat-inactivated human immune serum. In the absence of antibodies, FITC-labeled bacteria were located primarily on the surface of the neutrophils with few bacteria ingested. However, after opsonization, about seven times more bacteria were located intracellularly, indicating that antibodies promoted phagocytosis. In contrast, bacteria labeled intrinsically with GFP were not efficiently phagocytosed even in the presence of opsonizing antibodies, suggesting that FITC interfered with a bacterial defense. Because FITC covalently modifies proteins and could affect their function, we tested the effect of FITC on adenylate cyclase toxin activity, an important extracellular virulence factor. FITC-labeled bacteria had fivefold-less adenylate cyclase toxin activity than did unlabeled wild-type bacteria or GFP-expressing bacteria, suggesting that FITC compromised adenylate cyclase toxin activity. These data demonstrated that at least one extracellular virulence factor was affected by FITC labeling and that GFP is a more appropriate label for B. pertussis.