ANCA-associated scleritis: impact of ANCA on presentation, response to therapy and outcome.

OBJECTIVES: To describe the characteristics, treatment and outcome of isolated ANCA-associated scleritis at diagnosis compared with idiopathic scleritis with negative ANCA tests. METHODS: This retrospective multicentre case-control study was performed within the French Vasculitis Study Group (FVSG) network and in three French tertiary ophthalmologic centres. Data from patients with scleritis without any systemic manifestation and with positive ANCA results were compared with those of a control group of patients with idiopathic scleritis with negative ANCA tests. RESULTS: A total of 120 patients, including 38 patients with ANCA-associated scleritis and 82 control patients, diagnosed between January 2007 and April 2022 were included. The median follow-up was 28 months (IQR 10-60). The median age at diagnosis was 48 years (IQR 33-60) and 75% were females. Scleromalacia was more frequent in ANCA-positive patients (P = 0.027) and 54% had associated ophthalmologic manifestations, without significant differences. ANCA-associated scleritis more frequently required systemic medications, including glucocorticoids (76% vs 34%; P < 0.001), and rituximab (P = 0.03) and had a lower remission rate after the first- and second-line treatment. Systemic ANCA-associated vasculitis (AAV) occurred in 30.7% of patients with PR3- or MPO-ANCA, after a median interval of 30 months (IQR 16.3-44). Increased CRP >5 mg/l at diagnosis was the only significant risk factor of progression to systemic AAV [adjusted hazard ratio 5.85 (95% CI 1.10, 31.01), P = 0.038]. CONCLUSION: Isolated ANCA-associated scleritis is mostly anterior scleritis with a higher risk of scleromalacia than ANCA-negative idiopathic scleritis and is more often difficult to treat. One-third of patients with PR3- or MPO-ANCA scleritis progressed to systemic AAV.

Lung lobe torsion in 15 dogs: Peripheral band sign on ultrasound.

The diagnosis of lung lobe torsion in dogs is usually based on radiological, endoscopic, and CT features. Few ultrasonographic descriptions have been published. The purpose of this multicenter, retrospective, and prospective observational study was to investigate the presence of a hypoechoic area forming a pulmonary band or line at the periphery of the twisted lobe on ultrasonography and assess its significance by comparing it to CT and histological findings. Fifteen dogs with lung lobe torsion confirmed surgically or postmortem were included. All had received ultrasonography and CT examinations; 13 had additional histopathological examination performed. In 14 cases, thoracic ultrasonography revealed a peripheral hypoechoic band, overlying areas of scattered, hyperreflecting interfaces in the affected lobe. On CT, central emphysema was surrounded by a peripheral, soft tissue attenuation band, affecting the periphery in 14 cases. No band was observed in one case, in which the lobe was entirely consolidated. Histological examination yielded a comparable peripheral band, consisting of a thickened visceral pleura with or without hemorrhagic necrosis of the underlying pulmonary parenchyma. This peripheral band may be related to the specific fractal organization of airways and vessels, which plays an important role in lung perfusion and ventilation and makes the lung periphery more prone to ischemia. Our findings suggest that the presence of a peripheral hypoechoic band, associated with central emphysema in a noncollapsed lung lobe on ultrasonography, is suggestive of compromised blood supply and air flow, and lung lobe torsion should therefore be suspected.

Malakoplakia of the Bladder in a 4-Month-Old Puppy.

A 4 mo old female Staffordshire bull terrier puppy was presented with chronic Escherichia coli cystitis. Ultrasound and cystoscopic examination revealed innumerable, intraluminal, finger-like proliferations arising from the dorsal urinary bladder (UB) wall. Histological examination of mucosal biopsies obtained by cystoscopy was suggestive of granulomatous cystitis. The proliferative lesions were removed surgically and submitted for histological examination. The UB submucosa was heavily infiltrated by macrophages with periodic acid-Schiff-positive cytoplasm exhibiting rare Michaelis-Gutmann bodies, leading to the diagnosis of malakoplakia. The puppy was prescribed with sulfamethoxazole-trimethoprim. The urinary signs disappeared despite the persistent UB wall thickening revealed by abdominal ultrasound. Urine culture performed during the ninth week of treatment showed a persistent infection by E coli resistant to sulfamethoxazole-trimethoprim. The dog was switched to doxycycline but was then lost to follow-up. Malakoplakia is a chronic granulomatous inflammation well documented in humans. Its pathophysiology is not fully understood, but bacterial infection, immunodepression, and a defective lysosomal function may lead to the intracytoplasmic accumulation of partially degraded bacteria that can subsequently mineralize to form the Michaelis-Gutmann bodies. Malakoplakia should be suspected when UB mass lesions are identified in a young dog with bacterial cystitis.

Machine-learning algorithm as a prognostic tool in non-obstructive acute-on-chronic kidney disease in the cat.

OBJECTIVES: The aim of this study was to develop an algorithm capable of predicting short- and medium-term survival in cases of intrinsic acute-on-chronic kidney disease (ACKD) in cats. METHODS: The medical record database was searched to identify cats hospitalised for acute clinical signs and azotaemia of at least 48 h duration and diagnosed to have underlying chronic kidney disease based on ultrasonographic renal abnormalities or previously documented azotaemia. Cases with postrenal azotaemia, exposure to nephrotoxicants, feline infectious peritonitis or neoplasia were excluded. Clinical variables were combined in a clinical severity score (CSS). Clinicopathological and ultrasonographic variables were also collected. The following variables were tested as inputs in a machine learning system: age, body weight (BW), CSS, identification of small kidneys or nephroliths by ultrasonography, serum creatinine at 48 h (Crea48), spontaneous feeding at 48 h (SpF48) and aetiology. Outputs were outcomes at 7, 30, 90 and 180 days. The machine-learning system was trained to develop decision tree algorithms capable of predicting outputs from inputs. Finally, the diagnostic performance of the algorithms was calculated. RESULTS: Crea48 was the best predictor of survival at 7 days (threshold 1043 µmol/l, sensitivity 0.96, specificity 0.53), 30 days (threshold 566 µmol/l, sensitivity 0.70, specificity 0.89) and 90 days (threshold 566 µmol/l, sensitivity 0.76, specificity 0.80), with fewer cats still alive when their Crea48 was above these thresholds. A short decision tree, including age and Crea48, predicted the 180-day outcome best. When Crea48 was excluded from the analysis, the generated decision trees included CSS, age, BW, SpF48 and identification of small kidneys with an overall diagnostic performance similar to that using Crea48. CONCLUSIONS AND RELEVANCE: Crea48 helps predict short- and medium-term survival in cats with ACKD. Secondary variables that helped predict outcomes were age, CSS, BW, SpF48 and identification of small kidneys.

Use of endoscopic-guided electrocautery ablation for treatment of tracheal liposarcoma in a dog.

CASE DESCRIPTION A 7-year-old 44-kg (97-lb) neutered male Great Pyrenees was referred for evaluation because of episodic dyspnea with cyanosis of 1 to 2 weeks' duration. Three days prior to evaluation, the clinical signs had worsened, including 1 episode of collapse. CLINICAL FINDINGS Thoracic radiography and CT revealed a well-delineated soft tissue mass, located approximately 1.5 cm cranial to the carina and occupying almost 90% of the tracheal lumen. A CBC and serum biochemical analysis were performed, and all results were within reference limits. TREATMENT AND OUTCOME Tracheoscopy confirmed the presence of a broad-based bilobate mass that was protruding from the right dorsal aspect of the trachea and occupied almost the entire tracheal lumen. The mass was successfully resected by endoscopic-guided electrocautery ablation. Findings of histologic evaluation were consistent with a diagnosis of liposarcoma. Immediately following the ablation procedure, the previously noted clinical signs of respiratory tract disease resolved. On follow-up examination 12 months later, no regrowth of the mass was evident on thoracic helical CT and tracheoscopy. CLINICAL RELEVANCE Endoscopic-guided electrocautery ablation of tracheal liposarcoma was a safe and effective minimally invasive treatment for the dog of this report. The procedure was brief and appeared to be well tolerated, resulting in immediate improvement of clinical signs.

Minimally Invasive Drainage of a Post-Laminectomy Subfascial Seroma with Cervical Spinal Cord Compression.

A 14 mo old female neutered Doberman pinscher was evaluated for difficulty in rising, a wide based stance, pelvic limb gait abnormalities, and cervical pain of 2 mo duration. Neurologic examination revealed pelvic limb ataxia and cervical spinal hyperesthesia. Spinal reflexes and cranial nerve examination were normal. The pathology was localized to the C1-C5 or C6-T2 spinal cord segments. Computed tomography (CT) findings indicated bony proliferation of the caudal articular processes of C6 and the cranial articular processes of C7, resulting in bilateral dorsolateral spinal cord compression that was more pronounced on the left side. A limited dorsal laminectomy was performed at C6-C7. Due to progressive neurological deterioration, follow-up CT examination was performed 4 days postoperatively. At the level of the laminectomy defect, a subfacial seroma had developed, entering the spinal canal and causing significant spinal cord compression. Under ultrasonographic guidance a closed-suction wound catheter was placed. Drainage of the seroma successfully relieved its compressive effects on the spinal cord and the patient's neurological status improved. CT was a valuable tool in assessing spinal cord compression as a result of a postoperative subfascial seroma. Minimally invasive application of a wound catheter can be successfully used to manage this condition.

Ultrasonographical examination of feline adrenal glands: intra- and inter-observer variability.

Interpretation of ultrasonographical measurements requires an understanding of the source and the magnitude of variation. A substantial part of the variation can be attributed to the observer, the equipment or the animal. The aim of this study was to evaluate which adrenal gland measurement is the least variable within and between observers. Three experienced ultrasonographers examined six cats at three different times on the same day, more than 1 h apart, according to a strict scanning protocol. Seven ultrasonographical measurements were performed on each adrenal gland (maximal length on sagittal images, maximal height at the cranial and caudal poles on sagittal and transverse images, and maximal width of the cranial and caudal poles on transverse images). Height measurements in both planes showed the lowest variability within and between observers compared with length and width measurements. Descriptive ultrasonographical features, such as echogenicity of the gland, presence of hyperechoic spots or layering assessment, demonstrated satisfactory-to-good intra- and inter-observer agreement, whereas the shape assessment showed very poor inter-observer agreement. The results of this study describe a reliable scanning protocol that can be the basis for future adrenal ultrasonographical examinations for cats suspected of adrenal disease (eg, hyperaldosteronism, hyperadrenocorticism, sex hormone-producing tumours).

Renal dimensions at ultrasonography in healthy Ragdoll cats with normal kidney morphology: correlation with age, gender and bodyweight.

Fifty-six healthy Ragdoll cats underwent an ultrasonographical examination of the urinary tract to evaluate if gender, age, bodyweight and presence of a medullary rim sign had a significant influence on renal length and corticomedullary ratio (CM). Individual variation percentage was much more pronounced for renal length in comparison with CM ratio. Mean renal length measured 3.83 ± 0.45 cm (range 2.98-5.09 cm), mean cortical thickness 0.73 ± 0.15 cm (range 0.36-1.18 cm), mean medullary thickness 0.87 ± 0.19 cm (range 0.46-1.39 cm) and mean CM ratio 0.88 ± 0.29 (range 0.29-1.78). Renal length showed a significant positive correlation with bodyweight (P <0.0001), age (P = 0.0073) and male gender (P <0.0001). Therefore, these parameters have to be kept in mind when evaluating renal length on ultrasound. The CM ratio was solely influenced by the presence of a medullary rim sign (P <0.0001). Further research, however, is needed to investigate the usefulness of the CM ratio for the detection of kidney disease by ultrasonography.

Comparison of renal ultrasonographic measurements between healthy cats of three cat breeds: Ragdoll, British Shorthair and Sphynx.

Healthy cats of three cat breeds -- Sphynx (n = 11), British Shorthair (n = 15) and Ragdoll (n = 15) -- were included in this study. All cats underwent an ultrasonographic examination to assess renal length, cortical thickness, medullary thickness and corticomedullary ratio. Of all ultrasonographic measurements, renal length showed the highest variation. For all ultrasonographic dimensions, individual and kidney side (left vs right) variation were much more pronounced than interbreed variation. Sphynx cats tended to have larger kidneys (4.09 ± 0.33 cm) than British Shorthair (3.77 ± 0.43 cm) and Ragdoll cats (3.87 ± 0.41 cm). British Shorthair cats, however, tended to have a thinner cortex (0.67 ± 0.13 cm) and medulla (0.76 ± 0.18 cm) than Sphynx (0.76 ± 0.14 cm and 0.90 ± 0.25 cm, respectively) and Ragdoll cats (0.75 ± 0.13 cm and 0.91 ± 0.22 cm, respectively). However, statistical tests did not reveal significant differences between these cat breeds. The corticomedullary ratio was similar for the three cat breeds (Sphynx: 0.93 ± 0.43; British Shorthair: 0.91 ± 0.26; Ragdoll: 0.88 ± 0.31). The left kidney (3.83 ± 0.42 cm) was significantly smaller than the right kidney (3.99 ± 0.40 cm) and showed a thicker medulla (left: 0.93 ± 0.21 cm, right: 0.79 ± 0.22 cm), and thus a lower corticomedullary ratio (left: 0.80 ± 0.23, right: 1.01 ± 0.32). For the cortical thickness, no significant difference was observed between the left (0.71 ± 0.14 cm) and right kidney (0.74 ± 0.14 cm).

Prospective evaluation of healthy Ragdoll cats for chronic kidney disease by routine laboratory parameters and ultrasonography.

Ragdoll breeder organisations often forewarn Ragdoll cat owners that renal problems may develop as a result of polycystic kidney disease (PKD), chronic interstitial nephritis, familial renal dysplasia or nephrocalcinosis. Healthy Ragdoll and non-Ragdoll cats were prospectively evaluated by measuring serum creatinine and urea concentrations, routine urinalysis and abdominal ultrasonography. All Ragdoll cats also underwent genetic PKD testing. One hundred and thirty-three Ragdoll and 62 control cats were included. Ragdoll cats had significantly lower serum urea concentrations and higher urinary specific gravity. However, median creatinine concentration, median urinary protein-to-creatinine ratio, and the proportion of cats with serum creatinine or urea concentration exceeding the reference interval did not differ. One or more renal ultrasonographical changes were detected in 66/133 (49.6%) Ragdoll and in 25/62 (40%) control cats. Ragdoll cats showed significantly more frequent segmental cortical lesions (7.5% versus 0%), abnormal renal capsule (19.5% versus 8%) and echogenic urine (51.9% versus 25.8%). Chronic kidney disease (CKD) was ultrasonographically suspected in 7/133 (5.3%) Ragdoll and in none of the control cats, which approached significance. Laboratory parameters confirmed kidney dysfunction only in 1/7 of these Ragdoll cats. All Ragdoll cats were PKD negative. In conclusion, first, breed-specific serum creatinine reference intervals are not likely required for Ragdoll cats. Second, renal ultrasonographical abnormalities are common, both in Ragdoll and non-Ragdoll cats. Third, healthy young Ragdoll cats are uncommonly affected by PKD and CKD, but an increased susceptibility of Ragdoll cats to develop CKD cannot be excluded. Finally, Ragdoll cats are predisposed to segmental cortical lesions, which may indicate renal infarction or cortical scarring.

Transsplenic portal scintigraphy using 99mTc-pertechnetate for the diagnosis of portosystemic shunts in cats: a retrospective review of 12 patients.

Portosystemic shunts (PSS), congenital or acquired, occur uncommonly in the feline population. The diagnostic approach is similar to one in dogs suspected of a PSS based on the clinical signs and haematological and biochemical changes. Diagnostic imaging, however, is key for the confirmation of a PSS. Although abdominal ultrasound is the first-choice diagnostic imaging modality, the results are not always unequivocal. Transsplenic portal scintigraphy (TSPS) using (99m)Tc-pertechnetate is a well-established technique in canine medicine, providing relatively fast and easy confirmation of the presence or absence of a PSS. As the prevalence of PSS is much lower in the feline population, this technique has not been widely used in cats. This retrospective study of 12 cases gives an overview of the potential of TSPS in the diagnostic work-up of PSS in cats (2005-2012).

Ultrasonographic appearance of adrenal glands in healthy and sick cats.

The first part of the study aimed to describe prospectively the ultrasonographic features of the adrenal glands in 94 healthy cats and 51 chronically sick cats. It confirmed the feasibility of ultrasonography of adrenal glands in healthy and chronically sick cats, which were not statistically different. The typical hypoechoic appearance of the gland surrounded by hyperechoic fat made it recognisable. A sagittal plane of the gland, not in line with the aorta, may be necessary to obtain the largest adrenal measurements. The reference intervals of adrenal measurements were inferred from the values obtained in the healthy and chronically sick cats (mean ± 0.96 SD): adrenal length was 8.9-12.5 mm; cranial height was 3.0-4.8 mm; caudal height was 3.0-4.5 mm. The second part of the study consisted of a retrospective analysis of the ultrasonographic examination of the adrenal glands in cats with adrenal diseases (six had hyperaldosteronism and four had pituitary-dependent hyperadrenocorticism) and a descriptive comparison with the reference features obtained in the control groups from the prospective study. Cats with hyperaldosteronism presented with unilateral severely enlarged adrenal glands. However, a normal contralateral gland did not preclude a contralateral infiltration in benign or malignant adrenal neoplasms. The ultrasonographic appearance of the adrenal glands could not differentiate benign and malignant lesions. The ultrasonographic appearance of pituitary-dependent hyperadrenocorticism was mainly a symmetrical adrenal enlargement; however, a substantial number of cases were within the reference intervals of adrenal size.

Ultrasonographic measurements of adrenal glands in cats with hyperthyroidism.

Feline hyperthyroidism is potentially associated with exaggerated responsiveness of the adrenal gland cortex. The adrenal glands of 23 hyperthyroid cats were examined ultrasonographically and compared to the adrenal glands of 30 control cats. Ten hyperthyroid cats had received antithyroid drugs until 2 weeks before sonography, the other 13 were untreated. There was no difference in adrenal gland shape between healthy and hyperthyroid cats: bean-shaped, well-defined, hypoechoic structures surrounded by a hyperechoic halo in 43/60 (71.6%) healthy cats and 34/46 (73.9%) hyperthyroid cats; more ovoid in 13/60 (21.6%) healthy cats and 9/46 (19.6%) hyperthyroid cats while more elongated in 4/60 (6.7%) healthy cats, 3/46 (6.5%) hyperthyroid cats. Hyperechoic foci were present in 9/23 (39.1%) hyperthyroid cats and 2/30 (6.7%) healthy cats. The adrenal glands were significantly larger in hyperthyroid cats, although there was overlap in size range. The mean difference between hyperthyroid cats and healthy cats was 1.6 and 1.7 mm in left and right adrenal gland length, 0.8 and 0.9 mm in left and right cranial adrenal gland height, and 0.4 and 0.9 mm in left and right caudal adrenal gland height. There was no significant difference between the adrenal gland measurements in treated and untreated hyperthyroid cats. The adrenomegaly was most likely associated with the hypersecretion of the adrenal cortex documented in hyperthyroid cats. Hyperthyroidism should be an alternative to hyperadrenocorticism, hyperaldosteronism, and acromegaly in cats with bilateral moderate adrenomegaly.

Scintigraphic thyroid volume calculation in hyperthyroid cats.

A successful, euthyroid outcome after radioiodine therapy in hyperthyroid cats ranges from 83% to 95%. Thyroid volume has been reported as one of the factors influencing radioiodine therapy outcome in man and cats. The goal of this study was to describe the most reliable and practically applicable formula to determine thyroid volume using scintigraphy. The volume of each thyroid lobe of 32 hyperthyroid cats was determined by ultrasound and scintigraphy. The ultrasonographically determined volume (ellipsoid formula) for each thyroid lobe was compared with the scintigraphic volume that was calculated using eight different formulas: F1 [(π/6) × L × H × W], F2 [(π /2) × L × W(2)], F3 [0.33 × (area cm(2))(3/2)], F4 [1.08 × (π /6) × L × W(2)], F5 (area × H), F6 (0.27 × area × L), F7 (π × L × W(2)) and F8 [π × (4/3) × W(3)]. F1, F3, F4 and F6 did not differ statistically from the volumes measured on ultrasound, while F2, F5, F7 and F8 did. Subjective shape assessment of the thyroid lobes, assigned as cylindrical or spherical, and the use of corresponding formulas, did not appear to be useful.

Ultrasonography of the feline kidney: Technique, anatomy and changes associated with disease.

PRACTICAL RELEVANCE: Ultrasonography is an important tool for the detection of kidney disorders, which are among the most common health problems suffered by cats. It is more accurate than radiography for this purpose and is considered to be the reference modality for imaging the feline kidney, providing excellent visualisation of renal size, shape and internal architecture. Compared with more advanced imaging modalities, such as computed tomography or magnetic resonance imaging, ultrasonography is more accessible, less expensive, does not require general anaesthesia and allows real-time procedures to be performed. CLINICAL CHALLENGES: On ultrasound examination, focal or multifocal disorders may be readily identified, but diffuse changes are more challenging. B-mode ultrasonography is of limited use for differentiating between benign and malignant focal lesions. However, based on the presence and pattern of vascularity as an indicator of malignancy, contrast-enhanced ultrasonography allows distinction between benign and malignant focal renal lesions. AUDIENCE: This review provides a framework for the ultrasonographic approach to feline renal and perirenal disorders for the general practitioner. EVIDENCE BASE: Drawing on current literature relating to ultrasonographic examination of feline kidneys, the aim is to summarise ultrasonographic technique, anatomy and changes associated with renal and perirenal diseases.

Intra- and interobserver variability of ultrasonographic measurements of the adrenal glands in healthy Beagles.

The aim of the present study was to establish which adrenal gland measurement was characterized by the least variations. To do this, we quantified the variability of seven different size measurements of the canine adrenal gland (maximal length, maximal height at the cranial and caudal poles on longitudinal and transverse images, and maximal width of the cranial and caudal poles) within observer, between observer, and between dogs based on three different measurements made by each of the three observers in six healthy Beagle dogs. The height of the caudal pole of both adrenal glands measured on longitudinal images had the lowest intra- and interobserver variability, while measurements of the length had the highest intra- and interobserver variability. Other measurements that were characterized by low intra- and interobserver variability were: height and width of the caudal pole on transverse images and height of the cranial pole on longitudinal images only. These results provide a basis for further study of the changes in adrenal gland size in dogs with pituitary-dependent hyperadrenocorticism.