Weird Case Files with Dr. Denise: Mollie
Weird Case Files is a clinical column where we examine weird, inscrutable and illuminating cases our doctors have encountered. Today, we investigate Molly, a 6-year-old Cavalier King Charles with an unexpected hidden condition.
As a veterinary nerd, the only thing more exciting than new continuing education is the opportunity to immediately apply what I’ve learned or reviewed. Imagine my delight at seeing a dog with a history of keratoconjunctivitis sicca appear on my schedule, after listening to an IndeVets podcast on the subject during that morning’s commute. (Check out episode 34, “Casey, Yes!“)
Smug with my extraordinary preparedness, I reviewed the provided history.
Meet Mollie, a dog with KCS
Mollie is a 6-year-old female Cavalier King Charles Spaniel who had previously been diagnosed with KCS and prescribed Optimmune Ointment. The owners had recently run out, noticed an increase in ocular discharge, and were interested in restarting medical management. Simple enough.
On presentation, Mollie decided to be slightly more complicated.
While I performed a full exam, Mollie’s owners shared that she had a history of heart murmur, episodic anorexia with diarrhea, ear infections, as well as a neurologic issue that caused headaches.
They mentioned that it seemed a little strange that she was going into heat again so soon after her last cycle, then requested that we add vaccines and anal sac expression to our to-do list for the day.
- T: 101.0F, P: 120, R: 30
- MM: moist, adequately hydrated, CRT<2sec
- BCS: 3/5 MCS: Normal
- Pain score: 2/5 (see ophtho & abd)
- Oral: Moderate to heavy calculus, retained deciduous incisor (suspected to be 501 or 601).
- Otic: Mild tan ceruminous debris in vertical canal AS; tympanum intact AU.
- Ophtho: OU – mild blepharospasm, mild green mucoid discharge; the surface of both corneas appeared smooth and clear with no appreciable defect or neovascularization. Pupils are equal and reactive to light, with globes symmetric in appearance.
- Abd: Tense, moderately distended with moderate mid-abdominal discomfort on palpation – during handling of this area pt repeatedly vocalized. Cardio/pulm: Grade III/VI left systolic ejection murmur, normal rate and rhythm, all lung fields auscultated clear.
- Integ: The haircoat and skin are normal.
- Musculo: The muscles are in good condition. The skeleton is observed to be normal with no lameness noted.
- Neuro: The nervous system is normal. There are no observable defects in the nerves, spinal cord, or brain function.
- Uro/gen: Moderate swelling of vulva and mammary chains – no discharge appreciated.
- LN: The external lymph nodes (mandibular, prescapular, popliteal) all palpate normally.
- AG: Both sacs full of thick material and easy to express.
On further probing, the clients shared that her last heat had ended 3 to 4 weeks ago. They suspected her to be going into heat again based on the swelling of her vulva.
Mollie had seemed to be urinating more and though she had always been a thirsty girl, she had recently been emptying the cat’s water bowl in addition to her own. Her appetite was normal, with no vomiting, diarrhea, coughing, or sneezing. We removed vaccines from the to-do list, adding bloodwork and radiographs.
Dealing with the unexpected
When appointments take a hard right turn, I find it easier to achieve owner buy-in if we do not completely abandon what motivated them to make the appointment in the first place.
It took minimal time and effort to perform a Schirmer tear test, fluorescein stain, and tonometry while waiting for her complete blood count and serum biochemistry results. It may seem like a small consolation to confirm a low STT with otherwise normal ophthalmic testing when the next items on the itinerary carry the threat of emergency surgery, but accomplishing initial goals can bring a sense of normalcy and control in a situation otherwise lacking both.
Radiographs demonstrated large tubular soft tissue opacities within the abdomen, extending cranially from the pelvis. These were differentiated from the colon, which was mildly gas dilated with a small amount of heterogeneous material consistent with feces.
Mollie had a vertebral heart score of 11.5 and normal lung fields. While this VHS suggests enlargement, its deviation from breed-specific scoring is relatively conservative. The proposed normal ranges for Cavalier King Charles Spaniels span from 10.1 to 11.1 and 10.3 to 11.3, versus the general formula with an upper limit of 10.6.1,2
Her bloodwork was remarkably normal; changes consisted of an increased platelet count and mild elevation in cholesterol.
This posed somewhat of a challenge. With modest clinical signs at home and no vaginal discharge to speak of, mucometra or hydrometra remained possible. Who wouldn’t want to avoid surgery if medical management was a viable option?
Those differentials were all the more appealing in a patient with a history of heart murmur and unclear neurologic concerns. We discussed this dilemma at length, weighing referral options and the merits of relatively early surgical intervention at a time when Mollie was an acceptable surgical candidate.
Despite her heart murmur, she was reported to have normal activity at home with no evidence of significant cardiopulmonary compromise. Her neurologic status was appropriate on presentation and though her ‘headache’ episodes were poorly characterized, she had not had a significant episode within recent memory.
Still, an undocumented prior recommendation to avoid spaying at all costs made moving forward difficult for the family. Discussing the medical management of KCS was a welcome reprieve from the heaviness of our big decision-making.
(If you are interested in a quick review of the subject, I highly recommend Episode 34 of The IndeVets Happy Hour Podcast, “Casey, Yes!“)
Abdominal distension and pyometra
During this portion of our consultation, Mollie did her part by laying on the exam room floor in a manner highlighting the abdominal distension that had gone unnoticed at home. She made a very compelling argument.
By the time we circled back to the topic of her belly, Mollie’s owners were ready to talk surgery.
Local service shortages restricted our referral options, but we were able to arrange for a transfer to a sister clinic for same-day access.
Mollie underwent surgery for what was confirmed to be a closed pyometra. She did well under anesthesia with an uneventful recovery. Needless to say, my convenient KCS appointment exceeded all expectations.
Mollie gave us a powerful reminder of the importance of a complete physical examination with comprehensive history taking. You never know when your EENT recheck will come with a side of pyometra.
Dr. Denise Johnson is an Associate IndeVet practicing in Ohio.
More from IndeVets:
- Lamb CR, Wikeley H, Boswood A and Pfeiffer DU (2001). Use of breed-specific ranges for the vertebral heart scale as an aid to the radiographic diagnosis of cardiac disease in dogs. Vet. Rec. 148: 707-711.
- Lord PF, Hansson K, Carnabuci C, Kvart C, and Haggstrom J (2011). Radiographic heart size and its rate of increase as tests for onset of congestive heart failure in Cavalier King Charles Spaniels with mitral valve regurgitation. J. Vet. Int. Med. 25 (6): 1312-1319.