Antoine's Story (Heart Disease/Pulmonic Stenosis)

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Josephine
Little Jo Wheek

Post   » Sun Apr 10, 2005 4:39 pm


He was found by accident during a night I will never forget, chasing PetCo employees around and wreaking havoc due to the poor conditions there. I pulled a sick baby sow from one of the aquariums and was trying to convince the employees that the hard breathing, lethargy, and crusty eyes meant something when I saw what was in the little room behind the small animals.

A cloudy, filthy aquarium housed a scruffy looking Teddy boar. He was meant to be a dark-eyed white, but he had some urine staining and a reddish streak on his back, which later manifested itself almost like some sort of reverse agouti coloring. He was thin and had many scabs. He seemed very skittish, but I was able to lift him out of the aquarium to take a closer look. His skin was terrible, flaky like a pig with mites or the Teddy scurf. I told the employee that he could (and probably did) have a contagious skin condition and they needed to clean the area and wash their own hands well once handling the pig.

I questioned the now frightened employee. "When is this pig seeing a vet? Has he seen a vet? What treatment is he getting?" All of these questions were answered with "I don't know. I don't have any proof. Our 'Animal Care Specialist' is not here. Our manager is not here." Other similar statements were made. After all the trouble I had given the employees that evening, one employee said they might sell him to me for $3-4, but they eventually just let me take him. I put him in a box and headed home. Never did I think that this pig would be one of the most social and endearing pigs that I had owned in more than 20 years of loving these little creatures.

That pig was later named Antoine. His skin cleared up a bit and the scabby areas healed with a course of ivermectin, but less than 3 months after acquiring him, I realized that he was still quite scrawny and even emaciated. He appeared to be an adult and ate fairly well without gaining weight. His attitude was very bright when stimulated, but he did seem generally somewhat depressed. There was just something not quite right. His left earmargin was beginning to turn black (necrose) and just slough off, leaving little ragged edges that looked like fighting wounds (but he was housed alone in my home). His diet was consistent with what the rest of my pigs ate: Timothy, Oat, and other grass hays always, Alfalfa hay occasionally, Oxbow Cavy Cuisine pellets (Timothy based), a fresh human-grade grain mix occasionally as a treat, fresh veggies 1-2 times daily (parsley, wheat grass, bermuda grass mix, collard greens, kale, romaine, various lettuces and other greens, dandelion greens, spinach, carrot tops, citrus fruit, etc.).

Josephine
Little Jo Wheek

Post   » Sun Apr 10, 2005 4:45 pm


My vet of many years (Dr. Kathryn McKenzie) took one quick listen to his chest. “He’s got a heart murmur. It’s pretty obvious.” And so the journey began in August of 2000.

8/00 Weight is 960 grams. Initial vet visit and diagnostics. X-rays within normals except the heart is obviously misshapen, rounded (consistent with many heart problems). Murmur is easily asculted with a stethoscope and severe enough that it is palpable through the chest. Jugular pulses are present (also a sign of severe heart problems). Gross exam of molars, premolars and incisors normal. A fecal was negative. Bloodwork consistent with a stress leukogram and liver indices ALT 90 (normal 27-29) and AST 246 (normal 40-45) are elevated. Dr. McKenzie consulted with a Dr. at UC Davis via the phone to get further ideas on treatment protocol since neither of us had dealt with such a situation before. The literature was and is definitely scarce.

The recommendations from UCD were to suspect some sort of GI disease and supplement nutritionally with force-feeding and a short course of Banamine (flunixin meglumine), a powerful GI NSAID at .01 mg/pound SID for 3 days. I also supported with vitamin C at 50-100 mg SID, SQ fluids at 30 mls SID-BID with B vitamins added. He was getting at least 15-30 mls of Oxbow Critical Care supplemented daily. His appetite and attitude improves briefly on the Banamine, but then recedes again.

10/00 Antoine continues to do poorly. He loses about 150 grams in one month (weighs 630 grams). He continually seems weaker and more depressed except is very bright at feedings (which he seems to enjoy). Dr. McKenzie recommends doing more diagnostics (namely a cardiac ultrasound) at UC Davis. Neoplasia (cancer) is suspected as one of the possible problems in addition to the heart issues.

A few days later, we were seen at the UCD VMTH Avian/Exotic department. His murmur is rated as a grade 4/6 systolic left basilar murmur. Jugular pulses still present. He had a cardiac ultrasound (ECHO/echocardiogram) which diagnoses his murmur as pulmonic stenosis, a malfunction of the pulmonic valve in the heart. It is a congenital (present from birth) heart murmur. Usually the treatment is surgical in other animals and no medical treatment is available. No one known does heart surgery in guinea pigs that UCD could refer us to. His poor, emaciated state makes him a poor surgical candidate.

They also did an informal ultrasound of his abdomen, namely his liver. His hepatic veins are distended, which is consistent in severe heart issues. He has no pulmonary edema norascites (fluid in the lungs or abdomen) which are further signs of congestive heart failure. Another set of x-rays were taken and are consistent with the earlier findings. We also did another blood panel which shows more of a stress response and further elevated WBC count (35,000). He was anesthetized with isoflurane gas for the jugular blood draw. His liver enzymes are elevated consistent with the earlier blood work.

In short, there is no sign yet of cardiac decompensation (heart failure), but the liver is enlarged and is now suspected as potentially being the primary problem. Antoine’s case is discussed later at patient rounds, where many students and DVMs listen to cases and give feedback on treatment and diagnostics to recommend (especially with unusual cases). I get a call the next day on further recommendations. The UCD resident DVM tells me that the heart problem does not explain the weight loss or poor condition of Antoine. He suspects there is likely a mass in the abdomen, probably near the liver or in the liver. He recommends doing an abdominal ultrasound of the entire abdomen, a liver biopsy, a bone marrow biopsy (since there may be a higher number of young RBCs in the circulating bloodstream), AND an abdominal exploratory surgery. The prognosis is extremely poor and the resident pretty much advises me Antoine is going to die fairly soon. He would be able to run these diagnostics to help find some answers. I am concerned my pig will not survive running the diagnostics (esp. the exploratory, which seems to interest the resident and is mentioned multiple times). All I hear is the poor prognosis ringing in my ears.

Josephine
Little Jo Wheek

Post   » Sun Apr 10, 2005 4:50 pm


I am now very emotionally attached to this sweet pig and cry often. I decide not to return to UCD for further diagnostics recommended.

Dr. McKenzie and I discuss doing some research to see what I can find on possible treatments on similar cases. I continue supportive care and start to post and search on cavy forums about his case.

Less than two weeks after the UCD visit, I get in touch with a Dr. Nye at Midwest Bird and Exotic Animal Hospital in IL. I believe it was a lead from someone (maybe pinta?) who gave me this clinic as Dr. Susan Brown’s place of practice (Dr. Brown is well-published in exotic mammal medicine). Dr. Nye informs me Dr. Brown is no longer there, but suggests starting a heart medication, enalapril (ACE inhibitor), at a ferret dose (1/8-1/4 mg/kg EOD-SID) and some prednisone at 1/4 mg SID to support Antoine, since he is obviously dying. We have nothing to lose. He also recommends trying some silymarin (milk thistle) extract to help support liver function. Antoine has gained 30 grams in these past two weeks with my aggressive supportive care. Dr. McKenzie prescribes the enalapril and prednisone as recommended by Dr. Nye. We start with enalapril at 1/8 mg SID.

11/00 Antoine seems a bit perkier a week after starting meds. We do another blood panel to recheck things. His WBC is now within normal limits (18-20,000). His liver enzymes (ALT and AST) are still high, if not a bit worse (102 and 273 respectively).

1/01 Antoine continues to improve. He’s gained 80 more grams since November (weighs 850 grams). He’s been weaned off of the prednisone and the enalapril is decreased to 1/8 mg EOD. Discontinue SQ fluids, but continue supplementing with Critical Care in a bowl (which he devours).

Josephine
Little Jo Wheek

Post   » Sun Apr 10, 2005 4:52 pm


3/01 Doing very well on enalapril and still gaining weight. Up 100 grams in past 2 months (weighs 950 grams).

2/02 We’ve made it more than a year on maintenance enalapril. I’ve discontinued the Critical Care months ago. Except for the heart meds, he gets no other special reatment diet or management wise. He now weighs 1260 grams. His labwork shows his liver values are nearly normal. His ALT is 37 (normal range 27-29) and his AST is 55 (normal range 40-45). He’s one bright and happy little pig and now lives with two sedate Silkie boars. He loves to rumblestrut and chase them around. We try to taper off enalapril over the next few months, but he starts to get graying ear margins and slows down a bit. We keep him at 1/8 mg EOD for many years. I discontinue the milk thistle extract.

07/03 Weight is now 1020 grams. He seems bright and fairly well. Labwork is consistent with last year (mild ALT/AST elevations, non-clinical). Due to the weight loss over the past few months, we do a full body ultrasound (with a radiologist) and jaw x-rays. All are within normal limits, except for the heart issues and a possible blocked ureter. A urinalysis is run and within normal limits. His x-rays are non-remarkable. Dr. Legendre consults via email saying his teeth below the jawline look healthy. Since nothing can be done surgically for the possibly blocked ureter, we maintain current treatment.

11/03 Antoine’s two cage mates have died, so I try pairing him with other boars. One match doesn’t work out and he ends up with a bite wound abscess that takes 3 months to heal with two antibiotics (Baytril and TMS) and two separate surgeries (local anesthesia only).

08/04 Antoine is successfully paired with a younger Silkie boar named Ciel. They are very cute together. Ciel is a 4 year old orphaned and hand-raised baby that screams a lot, but he eventually starts to bond to Antoine and they groom each other.

Josephine
Little Jo Wheek

Post   » Sun Apr 10, 2005 4:58 pm


09/04 Weight 980 grams. Labwork is starting to show a bit of liver elevations again. ALT 43, AST 81.

03/21/05 I’m suspicious Antoine is having some problems since he looks a bit different. I increase his enalapril to 1/8 mg SID. His skin is starting to be scurfy, so I start ketoconazole shampoos.

03/31/05 I wake up and Antoine is very edematous and lethargic. I take him to see Dr. McKenzie. X-rays show very little heart detail, but the changes are consistent with heart enlargement, pulmonary edema, and ascites. He’s in congestive heart failure. More bloodwork is taken (fairly normal, ALT is now subnormal at 23, and AST is 66). I decide to give it all we can and start diruetic therapy. We start Lasix at 1 mg q6h and enalapril at 1/8 mg BID. He weighs 1000g at the vet’s.

04/01/05-04/04/05 I increase his Lasix since his labwork looks normal (we were concerned about kidneys). His enalapril eventually gets increased to 2.5 mg BID. He's getting anywhere from 3-4 mg Lasix every 6-8 hours with not much effect. His edema is starting to subside on the 3rd, but by that point I know we're in a losing battle. I'm weighing him every 6 hours and taking heart and respiration rates, which remain fairly static. He continues to eat his veggies and I try not to limit his veggies much even though I'm concerned about monitoring fluid intake and output.

04/04/05 P.M. He's very weak, but sweet to the end. I give him some veggies as he tries to stand. I know I have to end his suffering. He purrs as I give him the injection and he quickly loses consciousness.

Josephine
Little Jo Wheek

Post   » Sun Apr 10, 2005 5:03 pm


Post-mortem:

No unusual/unexpected findings. His heart is enlarged (probably more than 2-3 times the size of a normal cavy heart), as is his liver (no masses are seen, but if he had a liver mass he would have been dead years ago). His kidneys look fairly normal (have no idea what that hydronephrotic kidney/blocked ureter was a couple of years ago). No urinary tract stones. Ascites, pulmonary edema. Congestive heart failure. My poor boy. He was one strong pig to have made it 4.5 years on treatment.

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melcvt00

Post   » Tue Apr 12, 2005 10:23 am


Wow.

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