Term
| List/describe the types of Immune Mediated Non-erosive polyarthropathies |
|
Definition
-Type I Idiopathic (65%)
-Type II assoc. w/infxn (UTI,
endocarditis, other) (10%)
-Type III hepatic/GI assoc. (4%)
-Type IV distant neoplasia (2%)
-Misc. categories
-tick borne dz-exposure vs infxn;
50% positive
-SLE (systemic lupus erythematosus)
(8%)
-vaccine/drug induced (4%)
-early erosive (2%) |
|
|
Term
| What is the most common type of immune mediate polyarthropathy (IMPA)? |
|
Definition
| Type I- Idiopathic/Primary |
|
|
Term
| What is the signalment for idiopathic IMPA? |
|
Definition
| middle aged large breed dogs (1-4 yo) |
|
|
Term
| what % of dogs with idiopathic IMPA have lameness/gait abnormalities? and what amount of these involve single vs multiple limbs? |
|
Definition
60% lameness gait abnormalities
60% multiple limbs
20% single limbs
20% shifting limbs |
|
|
Term
| what region of the limbs are most commonly affected by idiopathic IMPA? |
|
Definition
|
|
Term
| what are the clinical signs commonly assoc w/ idiopathic IMPA? |
|
Definition
| lameness/gait abnormalities, inability to rise, fever, exam-joint pain and/or swelling |
|
|
Term
| what clinical sign of idiopathic IMPA is a common cause of referral |
|
Definition
|
|
Term
| T/F: you CAN distinguish idiopathic IMPA on clinical presentation alone |
|
Definition
| False: You CAN NOT distinguish idiopathic IMPA on clinical presentation alone. |
|
|
Term
| Describe the clinical presentation of patients with idiopathic IMPA |
|
Definition
primary complaint of chronic lameness w/ or w/out other systemic signs
lameness may be cyclic, monoarticular, or polyarticular
joint distension, soft tissue swelling |
|
|
Term
| what is the cause of the clinical signs in idiopathic IMPA? |
|
Definition
| immune complex deposition and hypersensitivity rxns are cause of clinical signs |
|
|
Term
| How do you diagnose idiopathic IMPA |
|
Definition
clinical signs
Minimum database (CBC, Chem, UA)
Radiographs
Histopath (not routinely performed) |
|
|
Term
| what fraction of patients would the minimum database be useful for? and unuseful for? |
|
Definition
useful for 1/3 of patients (that dont have type I IMPA)
unuseful for the 2/3 of patients with primary IMPA |
|
|
Term
What may a CBC indicate for patients with:
primary IMPA
SLE/tick-borne dz
infectious IMPA (type II) |
|
Definition
Primary IMPA: non-specific leukocytosis, mild anemia, CBC may be normal
SLE/tick-borne dz: cytopenias
Infectious: evaluate for organisms/ inclusions |
|
|
Term
| What might you see on xray in a patient with IMPA? |
|
Definition
fluid in the joint-> decreased opacity of the fat pad
fuzzy soft tissue density surrounding the joint
[if Rheumatiod arthritis -> may see bone loss] |
|
|
Term
| What tissue sample(s) would you take for histopath? and what might you see? |
|
Definition
Synovial membrane biopsy:
- inflamm. infiltrate of
lymphocytes, plasma cells,
macrophages, neutrophils
- fibrin deposits presents,
vasculitis
- infiltrate of lymphocytes, plasma
cells
Muscle biopsy: (polyarthritis/polymyositis)
- myositis-mononuclear cell and
neurophilic infiltrate & necrosis |
|
|
Term
How would you diagnose secondary IMPA
type II
misc.
Type III
Type IV |
|
Definition
PE, history, clinical signs, clinico-pathologic findings
chronic infectious dz:
- sterile arthritis with a positive
culture of infectious foci
elsewhere in the boby (eg.
urinary, resp, bacterial
endocarditis, discospondylitis)
drug induced:
-suspected if use of ANY drug,
vaccinations
Plasmacytic-lymphocytic synovitis:
-freq Dx at surgical repair for
ruptured cranial cruciate
ligament
enteric/hepatic/neoplastic:
-usu found in assoc w/ thorough
work up |
|
|
Term
| What kind of patient prep is needed for arthrocentesis? |
|
Definition
sedation
aseptic technique |
|
|
Term
T/F:
only a single joint needs to be sampled in arthrocentesis |
|
Definition
| False: sample multiple (3-6) joints |
|
|
Term
| What 2 joints are easiest to tap for arthrocentesis? |
|
Definition
|
|
Term
| which joints have a higher diagnostic yeild for arthrocetesis? |
|
Definition
tarsal/hock joints
-include at least 1 hock joint sample |
|
|
Term
| What kind of diagnostic tests can you perform with synovial fluid? |
|
Definition
direct smear
cell counts
bacterial cultures |
|
|
Term
| T/F: it is easy to see landmarks for arthrocentesis with joint effusion |
|
Definition
|
|
Term
| Does visocity of the synovial fluid increase or decrease with inflammation |
|
Definition
|
|
Term
| What diagnostic test is essential to differentiate between inflammatory and noninflammatory joint diease?* |
|
Definition
|
|
Term
| What will the synovial fluid look like in an inflammatory joint disease? |
|
Definition
-increased volume of synovial fluid
-fluid discoloration
-decreased viscosity
-fluid may clot when exposed to air due to increased fibrinogen
-bacterial and Mycoplasma cultures megative |
|
|
Term
**What is the predominant cell type seen in synovial fluid anlysis for inflammatory joint disease?
what does the cell count look like? |
|
Definition
**Nondegenerate Neutrophils**
markedly increased nucleated cells (3000-100,000) |
|
|
Term
| What is an ANA test and what is the typical outcome of this test for IMPA? |
|
Definition
ANA= anti-nuclear antibody test
usu. negative or low titer |
|
|
Term
| What is a diagnostic test for IMPA if you were concerned about a tick borne disease |
|
Definition
Serology
- positive from exposure
- acute and convalescent titers are
recommended for cases that you
suspect have tick borne dz |
|
|
Term
| How would you treat primary IMPA? |
|
Definition
Immunosuppressants
- Prednisone
- repeat arthrocentesis-minimal risk
(2-3 wk intervals to guide therapy)
- When to add ancillary therapy?
- refractory patients at 2wks
or relapsed patients
- Azothiaprine, cyclosporine,
leflunomide
-also, scree for underlying
causes |
|
|
Term
| What is the prognosis of primary/idiopathic IMPA? |
|
Definition
>55% can be tapered off immunosuppressants
20% managed with long term meds
15% refractory to initial trx
recurrence 10% |
|
|
Term
How would you trx secondary IMPA?
(immunosuppressants, ricketsial, drug/vaccine) |
|
Definition
Immunosuppressants?
-w/detection & trx of the
underlying cause these aren't
needed
Rickettsial
-A.phagocytophila & B.burgdorferi
*Doxycycline
-Short tern NSAIDs
Drug/vaccine induced
-resolve shortly after detection...
short term NSAIDs |
|
|
Term
how would you trx secondary IMPA?
(SLE, neoplasia) |
|
Definition
SLE:
- challenging to definitively Dx
- long term immunosuppression needed
- Px- guarded
Distant neoplasia
- ID & elimination if possible
- Lymphoma/osteosarcoma/hemangiosarc |
|
|
Term
| List some important "Do's" for Dx and Trx of IMPA |
|
Definition
-Attempt to detect underlying dz to determine Px and guide trx
-allow Hx & exam to guide testing
(recent drugs/vaccines, heart murmur-
bacterial endocarditis, skin/oral
lesions-SLE)
-allow your CBC/chem/UA to guide additional testing
-thrombocytopenia or anemia
(rickettsial dz, SLE)
-liver enzyme elevation/
hypoalbuminemia- Liver/GI assoc.
IMPA
-azotemia/proteinuria - Rickettsial
dz/SLE
-bacteruria- infxn assoc. IMPA
-allow response to therapy and repeat arthrocentesis guide trx
-Px: good...most dogs will respond...
-consider additional testing in those that do not respond/relapse
-repeat joint imaging/arthrocentesis
-additional screening for cancer
-look for the "red herring"
(Bartonella, RMSF, E.canis) |
|
|
Term
| List some important "DON'Ts" for IMPA Dx and Trx |
|
Definition
-do not assume that all cases of IMPA are idiopathic
-do not over-interpret ancillary tests
-SLE requires more than positive
ANA test
-RA requires more than positive RF
-Lyme/anaplasma exposure may not
be causing dz |
|
|
Term
| What is the prognosis for primary IMPA? |
|
Definition
|
|
Term
| What is the prognosis for secondary IMPA? |
|
Definition
depends on underlying cause
-rickettsial dz: excellent
-drug/vaccine related: excellent
-neoplasia: poor |
|
|
Term
| What is an example of an erosive arthropathy? |
|
Definition
|
|
Term
| What is erosive arthritis/ Rheumatoid arthritis (RA)? |
|
Definition
chronic, progressive inflammatory joint disease characterized by erosive and destructive changes within the joints
(also: feline chronic progressive polyarthritis) |
|
|
Term
| What is the etiology of RA? |
|
Definition
cause is unknown, but is classified as an immune mediated disease
cellular and hypersensitivity rxns present (types II, III, IV)
Synovitis likely due to immune complex rxns with Ag, Ab, rheumatiod factor (RF), and complement
- RFs are compsed of anti-IgG Ab
- RFs activate complement cascade->
stimulate release of PGEs-> cause
inflammation |
|
|
Term
| What is the typical clinical presentation of patients with RA? |
|
Definition
small and medium breeds
middle aged dogs (4-7yo)
Greyhounds and Shelties predisposed
initial signs parallel IMPA (joint pain, effusion, soft tissue swelling, decreased range of motion)
often episodic w/ increasing frequency and duration w/each relapse
signs of systemic illness (fever, lymphadenopathy, anorexia) |
|
|
Term
|
Definition
|
|
Term
| Which joints are most commonly affected by RA? |
|
Definition
| carpal, tarsal, interphalangeal joints |
|
|
Term
| What Dx tests would you perform for RA? and what would the results look like? |
|
Definition
PE, Hx, clinical signs, clinico-pathologic and radiographic findings
CBC/Chem/UA:
similar to nonerosive arthritis/IMPA
Synovial Fluid Analysis:
nucleated cell count moderately to
markedly increased(3000-100,000)
predominant cells are degernerate
neutrophils
cultures negative
like IMPA: increased volume of
synovial fluid, fluid discoloration
& decreased viscosity
RF serolgy:
positive in 25-70% of dogs (positive
titers found in dogs with chronic
infxns and 5% of normal dogs...not
very helpful)
ANA test
variably positive(freq non-specific)
Radiographs
-joint capsule distension,
periarticular swelling, bony
erosions or loss of trabecular bone
density in epiphyses
-may not see erosions early in dz
-Lesions are progressive, leads to
2nd degen joint dz**
Histopath
-synovitis w/synovial cell
hyperplasia, villus atrophy, fibrin
deposition, marked inflammatory
infiltrate of lymphocytes and
plasma cell macrophages
-granulation tissue can arise from
synovium |
|
|
Term
| Contrast the predominant cell types in RA and IMPA. |
|
Definition
RA: degenerate neutrophils
IMPA: nondegenerate neutrophils |
|
|
Term
| How might you diagnose RA based on the American Rheumatoid Association data? |
|
Definition
- stiffness after rest
- pain/tenderness in at least 1 joint
- swelling in at least 1 joint
- swelling of at least 1 other joint in
3 months
- symmetrical joint swelling
- SQ nodules over bony prominences or
extensor surfaces or in juxta-
articular regions
- **destructive xray changes typical
- **positive agglutination test for
serum RF
-poor mucin precip from synovial fluid
- **characteristic histopath changes in
the synovial membrane
*at least 2 **criteria should be met for RA |
|
|
Term
|
Definition
-No specific therapy
-pain management
-corticosteroids at anti-inflammatory or immunosuppressive doses (usu. become refractory)
-combo immunosuppressive therapy may slow progression ** |
|
|
Term
| what is the prognosis of RA? |
|
Definition
Poor!!
most animals euthanized due to chronic pain from degenerativ joint dz |
|
|
Term
| Which has a worse prognosis, IMPA or RA |
|
Definition
|
|
Term
| What breeds are predisposed to IMPA? |
|
Definition
| german shepherd, doberman pinscher, lab, golden retreiver, irish setter |
|
|
Term
| What are dog erythrocyte antigens? |
|
Definition
| cell membrane receptors on RBCs |
|
|
Term
| how many blood groups do dogs have? |
|
Definition
|
|
Term
| Most dogs are positive for which dog erythrocyte antigen (DEA)? |
|
Definition
|
|
Term
| do anti-DEA 4 antibodies cause hemolysis? |
|
Definition
|
|
Term
| What is a canine universal donor? |
|
Definition
Positive for DEA 4
Negative for DEA 1,2,3,5,6,7,8 (all except 4) |
|
|
Term
| How many blood types do cats have? what are they? |
|
Definition
3
type A, B, AB
(also MLK- mike the cat has his own blood type) |
|
|
Term
| What is the universal donor for cats? |
|
Definition
|
|
Term
| type B cats have HIGH levels of what kind of Ab's? |
|
Definition
anti-A Ab's
**so NEVER give type A to type B (type B students hate type A students) |
|
|
Term
| type AB cats have antibiodies against which blood types? |
|
Definition
|
|
Term
| what 2 conditoins would you see high levels of Abs against type A RBCs? |
|
Definition
severe/fatal transfusion rxn (ie-give type A blood to type B cat)
neonatal isoerythrolysis |
|
|
Term
How long will RBCs last in the following situations:
1)type A cat gets type A blood
2)type A blood given to type B cat |
|
Definition
|
|
Term
How many blood types in horses?
Universal donors for horses are negative for which Abs? |
|
Definition
|
|
Term
| Which blood groups have the greatest significance in bovine? |
|
Definition
|
|
Term
| What are the indications for a transfusion? |
|
Definition
Anemia
Coagulopathies
Hypoalbuminemia
Thrombocytopenia (ie- ITP) |
|
|
Term
| Which breed is often a good blood donor? why? |
|
Definition
Greyhounds!
can really see their veins
PCV normally runs higher |
|
|
Term
| How do you select a canine donor |
|
Definition
>25kg
normal/healthy
CBC/Chem/UA/fecal
Negative for: HW, Lyme dz, babesia,
rickettsial dz
DEA 1, 2, 7 negative |
|
|
Term
| What do you want in a feline donor? |
|
Definition
>4.5kg
indoor only
normal/healthy;males (healthier weight)
CBC/Chem/UA/fecal
blood type
negative for:FeLV/FIV,toxoplasma gondii |
|
|
Term
| what step do you add to feline blood collection steps/techniques/procedure? |
|
Definition
| Sedation (ketamine/midazolam) |
|
|
Term
| How much packed RBCs do you get from one unit of fresh whole blood (450mL)? |
|
Definition
|
|
Term
| What is the purpose of a crossmatch? |
|
Definition
detect presence of antibodies against RBCs
-incompatabilities/preventing
transfusion rxns |
|
|
Term
| For a crossmatch what blood component is the Ab vs the Ag? (serum or RBCs) |
|
Definition
|
|
Term
| What is the *Major crossmatch? |
|
Definition
-Patient serum (Ab)
-Donor RBCs (Ag)
*if problem here, do NOT give donor RBCs to the patient |
|
|
Term
| What is the Minor crossmatch? |
|
Definition
Donor serum (Ab)
Patient RBCs (Ag)
(not like real life as in a transfusion the patient is getting donor RBCs) |
|
|
Term
| what do you look for when evaluating a crossmatch result? |
|
Definition
Macroscopically:
hemolysis
agglutination/clumping
-cells should fall freely from the
pellet
-differentiate rouleaux vs agglutin.
Microscopically:
agglutination
(rouleaux will disperse with a drop
of saline)
hemolysis |
|
|
Term
| If you are in an emergency situation and unable to crossmatch (or you suspect IMHA) what should you do to choose a donor? |
|
Definition
|
|
Term
| WHat clinical signs indicate anemia and that the patient may need a transfusion |
|
Definition
| tachycardia, tachypnea, dyspnea, depression, PCV< 12-15% |
|
|
Term
| How much blood do you need? |
|
Definition
| 1mL per pound raises the PCV by 1% |
|
|
Term
| What is the max length of time for giving a transfusion? why? |
|
Definition
4-6 hrs
risk of bacterial infection |
|
|
Term
| How much type A blood can result in death in a type B cat? |
|
Definition
|
|
Term
| List some signs of transfusion complications/ reactions |
|
Definition
Immunologic
- fever, hemolysis, acute
hypersensitivity, platelet and
leukocyte sensitivity,
immunosuppression
Non-immunologic
-circulatory overload, bacterial
contamination, transmission of
infectious diseases, citrate
toxicity (hypocalcemia), pulmonary
microembolism |
|
|
Term
| when should you STOP a transfusion |
|
Definition
body temp raises one degree higher than pre-transfusion temp
tachycardia, tachypnea, vomiting develops |
|
|
Term
| when should you STOP a transfusion |
|
Definition
body temp raises one degree higher than pre-transfusion temp
tachycardia, tachypnea, vomiting develops |
|
|
Term
| how would you treat a transfusion rxn? |
|
Definition
IV catheter & crystalloids
monitor BP (colloids if low)
administer diphenhydramine
administer: dexmethasone sodium phosphate & epinephrine for anaphylactic shock; pred acetate for urticaria (wheals) |
|
|
Term
| what are the indications and contraindications for an autologous blood transfusion |
|
Definition
indications: preoperative donation
salvage procedure in cavitary bleeding
contraindications: bacterial contamination, neoplasia? |
|
|
Term
| What are some complications of autotransfusions? |
|
Definition
citrate toxicity (hypocalcemia)
-manifests as weakness, seizures
bacterial contamination
iatrogenic metastasis |
|
|
Term
| how many blood groups do avians have? |
|
Definition
|
|
Term
| what infectious disease should you screen for in an avian donor? |
|
Definition
|
|
Term
| how much blood can an avian donor give? |
|
Definition
10% blood volume (blood vol is ~10%BW)
(ie- 500g parrot can give 5mL blood) |
|
|
Term
| what two methods can be used to administer an avian transfusion? |
|
Definition
|
|
Term
| What is unique about ferret blood types? |
|
Definition
there are none
so crossmatch NOT needed |
|
|
Term
| what are the pros and cons of using oxyglobin? |
|
Definition
pros:
no crossmatch
long shelf life
no immune rxns
cons:
interferes w/lab tests
colloidal osmotic pressure increased
t1/2 in dogs = 1-2days
IMHA? |
|
|
Term
|
Definition
|
|
Term
| how do you monitor oxyglobin efficacy? |
|
Definition
monitor HgB
estimate PCV by multiplying HgB x 3 |
|
|
Term
| what are the indications for use of hetastarch |
|
Definition
hypotension
hypoproteinemia
hypoalbuminemia |
|
|
Term
| what effect will heastarch have on albumin levels? |
|
Definition
|
|
