Yummy! Vegetative Endocarditis with a side of Pericarditis.

Before I start this post, I would encourage anyone who does NOT have a warped sense of appropriate dinner conversations, like many in the medical field, to not consume ANYTHING while reading this one… You have been warned. 

I was asked to perform a necropsy (animal autopsy) on a dry cow at one of my herd checks the other day. This cow was a middle aged cow that had been dried off a month ago.  She went down in the stall, looked thin, unthrifty and did not even seem to have the energy to get up to eat.  She was housed in a separate facility with all the other dry cows.  

Refresher: a dry cow is a cow that is due to have a baby in 2 months. The last two months before they calve, the cow stops milking and the udder is allowed to regenerate and renew itself for the next lactation. 

Since this cow seemed to be sick, she was brought up to the herdsman on the farm so that she could be treated with the appropriate medications.  The herdsman gave her a bottle of calcium in the vein, and pumped her stomach with alfalfa meal and energy to keep the bugs in the rumen alive.  She was kept outside on the lawn, where she would have adequate footing and wouldn’t be at risk to slipping on concrete and further injuring herself. When the herdsman went out to check her a couple hours later, she was found dead.

To start a necropsy, we lay the cow so that the left side is down on the ground. We then cut back the front leg, then the back leg to allow full exposure of the inside of the cow. The abdominal cavity is opened and the right rib cage is removed.  When I removed the rib cage of this cow, I noticed severe hemorrhaging and bruising around the lower lungs and heart.  There was excessive scarring of the heart, to the sternum. The lungs looked relatively healthy. Based on what I was seeing, I decided to take out the lungs and heart in one chunk.  The picture above is the pericardium of the heart in my cow. This is the sack that the heart sits in. Normally there is straw colored fluid in the sack, preventing friction as the heart beats. A normal pericardium is very thin and pictured to the left. 

When I peeled back the thick pericardium to gain access to the heart, I was greeted with the lovely picture below and to the left.  The yellowish stringy material is all scar tissue.  You can also see the severe bruising on the inside of the pericardium.

I then opened up the right ventricle and examined the atrial-ventricular (AV) valve, following with the left ventricle. These valves are also normally very thin and smooth. The long strings seen in the picture are normally there and help with the movement of the valve. What are not normal, are the large chunks on the valve, seen in the circles.  This is where the “vegetative” term comes into play. 

Circles are the vegetative lesions on the valves

These large vegetations are colonies of bacteria that have taken up residence on the AV valves. In order for the bacteria to get to the heart, the cow had to have had bacteria in her blood; a term we call septicemia.  In adult cows, diseases such as pneumonia, mastitis (infection of the udder), metritis (infection of the uterus), or acidosis (decreased pH in the rumen) can all result in septicemia.  The herdsman could not recall any of the previously mentioned diseases in this particular cow. 

Now as I mentioned, the pericardium was also diseased. This is termed pericarditis. Pericarditis alone is most commonly caused by “hardware;” sharp pieces of metal that have been ingested and have poked through the lining of the stomach, through the diaphragm and into the pericardium.  Cows are non-discriminate eaters, so they will not pick around a nail or scrap of metal, when they take a bite of food. To try to minimize hardware disease, many cows are given a magnet, which sits in the reticulum or bottom of the rumen to catch any metal they may eat. 

In this case, I could not find any signs of hardware when I examined the stomach and diaphragm.  I suspect that the septicemia that caused the endocarditis was severe enough to also cause the pericarditis.  
 

Endocarditis is usually treatable with long term antibiotic therapy. Because there are several different kinds of bacteria that can cause endocarditis, a blood culture would be needed, to find the right antibiotic for the job.  Treatment can take up to 3 weeks and can be very expensive. And sometimes we don't know what is really wrong with them, until we perform a necropsy and find this! 

As disgusting as you may, or may not, find this, it really is awesome when a necropsy reveals such wonderful lesions and an obvious cause of death.  Because I’m one of those with a warped sense of appropriate topics for discussion at the dinner table, all this talk of vegetation has made me hungry... Til next time!!!!  :-)

"Baby"; I can't pee!!!!

"Baby" still a little sleepy from anesthesia

“Baby” came to see me on Monday. He is an 8 year old, castrated, male goat, that was shivering, reluctant to stand up and would not eat. His owner is also a veterinarian, but works mostly on small animals and did not feel comfortable diagnosing and treating her own pet. When “Baby” arrived at the clinic, he was standing, had a temperature of 101F and was shivering. His stomach was working well and his heart and lungs sounded normal. During his physical exam, I heard him grinding his teeth, which is a common sign of pain in animals, as is shivering.  After discussion with the owner, and further assessment of “Baby,” we determined he was “blocked.” This means he has urinary stones or “calculi”, which have blocked the urethra, and prevented him from urinating.  

Urolithiasis (urine stones) is a severe, painful emergency situation. If the calculi are not cleared from the urethra, the urine backs up, can cause damage to the urethra, and if there is enough urine in the bladder, can even cause the bladder to rupture.  The penis of a male goat (buck) is similar to a male sheep (ram), but is very different from cows, horses, pigs, dogs and cats. Over to the side, is a picture of a male goat penis. The urethral process (#2 in the picture) is very small and is often the site of obstruction in blocked goats.  The presence of testosterone in intact, male goats allows for adequate development of the urethra from the bladder to the end of the urethral process. When male goats are castrated at a very young age, the urethra is not as developed therefore predisposing a wether (castrated male) to blockage.  Many times we recommend our goat clients to feed a urine acidifier along with the hay and grain. Ammonium chloride is the most common urine acidifier used, and it drops the pH of the urine to slow/prevent the formation of stones.

So after I diagnosed “Baby” with a urinary tract blockage it was time to have a discussion with the owner as to our next step. The most common first step to correcting the issue is to cut off the urethral process of the penis.  Many times, this is enough to provide immediate relief. We do not have an X-ray machine at the clinic, so I was not able to take a radiograph of the goat to see if there were more stones in the bladder.  We decided we would start with removal of the urethral process and if this did not solve the issue, then we would need to open up the abdomen, and the bladder, to try to flush out the stones with a catheter.

“Baby” was sedated with an injectable anesthetic. Because this is a very painful situation, the injectable sedation was not sufficient.  We also have a gas anesthesia machine at the clinic, so we completely anesthetized him with gas to perform the procedure.  After a little bit of effort, we were able to exteriorize the penis and cut off the urethral process. Immediately we were getting a steady stream of urine. Based on the apparent relief, we woke “Baby” up and did not proceed with the much more invasive procedure.  As soon as he was awake enough, he started chewing his cud; a much better sign than grinding his teeth!!!

The picture is of the urethral process that I cut off. You can see on the right hand side of the picture, a reddened portion of the urethral process. This is most likely where the blockage was.  “Baby” was sent home with a prescription of urine acidifier, pain medication and antibiotics. Hopefully he has no further issues and neither do the other 4 wethers on the farm!!!!

My Week in Review: Feeling like "Dr. Death."

The last week has been a rough one for my own confidence as a veterinarian. Don't let any vet fool you, we all have these days/weeks. Usually they are few and far between. There isn’t a particular case that stands out, so I thought I would just review my calls since last Thursday’s post. Brace yourself.... 

Friday: I had two smaller herd checks that went off without a hitch. J Then I had a call for a cow with a right sided DA. Upon examining this cow, her manure was very dark, almost black, and pasty and she truly did have a right DA. When cows have very dark, pasty manure, we often think of bleeding stomach ulcers.  The digested blood in the manure, make the appearance of black manure. Based on all her physical exam findings, I recommended that she be euthanized or sold for slaughter immediately as she was a very poor surgical candidate.

Saturday: I was on call over the Easter weekend and only had two calls on Saturday. Thank goodness! One was for a cow with nervous ketosis. I’ve talked about ketosis in a previous post. But a quick review… When cows are in a negative energy balance, which is very common post calving, they start to break down fat to supply the body with the energy it needs. Through this process ketone bodies are formed. Now the brain needs sugar and cannot use ketones for an energy source.  Certain cases of severe ketosis result in “Nervous ketosis.” These cows are exhibiting neurologic signs because they brain has been deprived of sugar. They start to lick walls, are unsteady when walking, will press their head into a corner and do all sorts of other crazy things that make you think she is drunk.  This cow had a baby two days prior and was exhibiting these crazy neurologic signs. Her treatment was dextrose in the vein, with Vitamin B complex added, calcium, and dexamethasone. The steroid (dexamethasone) injection is to help stimulate the liver in the process of gluconeogenesis (sugar formation).  The farmers were then instructed to continue her treatment with propylene glycol, orally, for the next couple days.  Usually these cows respond well.  I tried to find a video  of a nervous ketosis cow to show you, and this was the only one I could find. It's not the greatest, but gives you an idea. Nervous Ketosis Cow

The second call was for another right DA.  This cow was in much better shape than the cow on Friday so I performed surgery on her, which I thought was routine and went well for a RDA surgery. (Don’t forget about her, I’ll be coming back to her….)

Sunday: My parents decided to come down for Easter dinner, so I had the ham all set to go in the oven at 10am when the pager went off.  It was for YET ANOTHER right DA down in Massachusetts!  Rather than the ham going in the oven, it went in the crockpot and off I went for the lovely hour drive south.  Again this cow’s surgery went well and I was able to get back home and finish making dinner before my parents arrived. Thankfully the rest of the day was quiet.

Monday:  Two herd checks.  The first herd check had complaints of all their baby calves dying within a week after birth. Almost always, calf issues come back to cleanliness of the milk and the equipment (buckets, bottles, etc) feeding the calves. All the calves are fed from one cow on this farm so we thought we better start with the source- her.  We took a sample of her milk and cultured it on growth media in our lab. Sure enough, there were “too numerous to count” (TNTC) bacteria in the sample.  After discussion with the farmer, they decided to sell the cow and start using a different cow for the calf milk. We shall see if this improves the situation. 

Tuesday:  My big herd check day.  I’m usually on this farm for 3-4 hours a week.  I was done with herd check around 11 and called into the office to see what other sick cow calls we had holding. The only call was for another possible DA cow.  This client’s farm is another good hour away from the clinic so I again headed south.  The cow was further along in lactation and did not actually have a DA. Instead, I think she ended up with a bad chunk of feed and had indigestion.  Her treatment was “pink pills” (essentially pepto bismol) and time.  She should be just fine.

At about 3pm an emergency call came in. This was for a beef cow with a prolapsed uterus.  I know I need to discuss this in more depth and promise I will at some point. I am just waiting for one where I actually remember to take a picture. Anyway, in this area, the wind was BRUTAL on Tuesday. It was about 35-40 degrees out, but with the wind, I’m not sure it felt much above 10 degrees.  Of course, this beef cow is outside and the client just happens to live on top of a mountain.  This was not a good situation. The owner had been at the state department of agriculture all morning for a meeting and the cow had prolapsed at some point while she was gone. She was not sure how long the uterus had been out, but she was willing to try for the cow.  The uterus was very friable, edematous and the tip of it was actually white from lack of blood supply. I gave a valiant effort, but too much time had passed and I advised immediate euthanasia of the cow.  And now begins my feeling of being “Dr. Death- the bearer of bad news.”

Wednesday:  Two more herd checks. On the first farm, there were a batch of calves that did not get dehorned when they were little. I’m not 100% sure of the reason they were missed, but either way, they were so now I get to take them off when they are much bigger.  I had a student riding with me that day which was a great learning experience for her.  We spent a couple hours dehorning heifers, which is a great workout to say the least.  The arteries that supply the horns are even more present in older animals, than in younger. As you remove the horn they begin spurting everywhere until you can get the cauterized.  So, needless to say, after about doing 15 animals (30 horns), I had blood spatter, all over and was feeling like I better not get pulled over or go into any Stewart’s shops or someone will arrest me thinking I just murdered someone/something.

 When I called in to the office, I learned of yet ANOTHER RDA. I’m not sure what is going on with the feed, or the sun or the moon these last two weeks, but there has been a ridiculous amount of RDAs.  I get to the farm and immediately find the cow that is sick. I can tell the abomasum has twisted and rotated on itself causing a torsion and the cow seemed to be getting bigger as I stood there. As I’ve mentioned before, RDAs are a bit more of an emergency than LDAs and as the stomach rotates around itself, it cuts off blood supply, acts like an osmotic gradient and starts to fill with fluid, rapidly dehydrating the cow. The owner still wanted me to try surgery.  It was a disaster. The stomach had been cut off from blood supply for too long, was friable and the abomasum was full of fluid. I was able to get the abomasum unturned, but was not able to correctly fix the situation. I closed her up and suggested she be euthanized as the surgery failed.  

 

He then had me look at a second cow with an LDA that I was also going to perform surgery on.  Her surgery went a little better, but still not as flawless as I would like. When cows are in-utero, the umbilicus is comprised of three vessels. One of these goes to the liver ("a" in the figure), while the other two("b" in the figure) go to the bladder.  After a calf is born, these vessels no longer function for blood circulation. The two that went to the bladder become ligaments of the bladder, while the one that goes to the liver becomes the “falciform ligament.” Many times as cows get older the falciform ligament essentially disappears.  This was a first calf heifer and her falciform ligament was still very present. This was causing issues when I was trying to correct the DA. As I try to pull the abomasum from the left side of the cow, down along the body wall and up to the right side, it kept catching on this ligament. I was able to suture only the omentum (the connective tissue of the intestines) rather than the actual abomasum itself.  It may be just fine, but when you only tack the omentum, there is still a chance that she will get another DA sooner than later, as the omentum is not as strong as the actual stomach lining.

From there I had to go look at two more sick cows. One of which had ulcers and the other appeared to be shutting down. Her manure was very yellow, her body temperature was subnormal and she looked very sick. I could not find an obvious reason for her state, and therefore had little to suggest to the farmer to help her out.  Her recommendation, again, was slaughter.

Finally, I received a call from the farmer from Saturday. His cow had the right DA.  I had been talking to him throughout the week and it seemed as though the cow would perk up, do really well, then crash again. By Wednesday, he thought he was hearing another right DA. I thought I better check her out so headed his direction. Sure enough, the first surgery had failed and I had to repeat it. Unfortunately, you can’t just open the cow up through the same incision. Instead, I had to tip her upsidedown, on her back and perform surgery on her underside, rather than performing it standing. The surgery seemed to go fine and I haven’t heard from him today, so hopefully no news is good news. 

After Tuesday and Wednesday, I felt like my only recommendation was euthanasia on more cows than I was saving; hence the “Dr. Death.”  You’d think that dealing with euthanasia and these death sentences would get easier with time.  As part of “self-preservation” you will hear many veterinarians say they have to separate themselves from it. It doesn’t mean we can’t be compassionate, and that it doesn’t affect us, it does. It is a great responsibility to recommend putting an animal out of suffering and I’m glad I can give animals that liberation, but it doesn’t make it easy and it certainly isn’t fun.  Next week is another week.