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The Family Pet by Dr. Michael Trapani

It's A Fluke

Jul 30, 2017
by Dr. Michael Trapani

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We have a theory of the disease and a treatment that appears to work. Does that mean the diagnosis is correct?

His name is Dandy-Lion. He’s a little Maltipoo from the South Bay. Dandy had turned a miserable shade of orange with severe jaundice. He ate little and vomited when he did eat. He had intermittent fever, was depressed and losing weight. His regular veterinarian performed blood tests that showed his bilirubin and liver enzyme levels were literally sky-high. Dandy was sent to a specialist, and then another specialist. Everyone repeated Dandy’s blood tests and got the same results. Dandy was placed on antibiotic and nutritional support for his very sick liver, which didn’t really help. Finally, it was recommended that Dandy undergo an endoscopic liver biopsy procedure with a price tag of $6,500. Simply. Not. Possible.

The next thing you know, Dandy is in Bodega Bay. When we read through his lab reports, it was clear that his liver cells (the hepatocellular part of the organ) were sick and leaking enzyme like crazy. Dandy’s blood levels, normally in the 60s, were over 2,000 – with enzymes that are cleared from the blood every 24 hours. His hepatobiliary tissue (the part of the liver that makes and excretes bile) was equally sick. Dandy was also anemic. Worst of all, Dandy’s liver function, as measured by his ability to clear bile pigments and maintain blood albumen levels, was iffy: Dandy was on the edge of liver failure.

And yet... When the specialists looked inside Dandy’s liver using ultrasound, it didn’t look that bad. It wasn’t the happiest liver, and showed signs of cellular infiltration from inflammation, but the structure was intact and there were no gall stones or obstruction of his bile ducts. Ultrasound offered no explanation for Dandy’s severe liver disease, hence the biopsy recommendation.

I know! Right now you’re thinking, “It’s Salmon Poisoning. Dandy has been fed poorly cooked salmon and become infected with the liver fluke Nanophyetus salmincola. This flatworm carries a bacteria, Neorickettsia helminthoeca, that infects the dog’s liver and can cause all of the things Dandy is experiencing.”

And that’s what I thought, but the owner was certain that Dandy had never eaten under-cooked salmon (although perhaps the neighbor...). We searched Dandy’s stool anyway, looking for even a single fluke egg, enough to prove the diagnosis. No such luck.

We had to do something. Dandy was started on the specific antibiotic required to eliminate Neorickettsia and arrangements were made to perform liver biopsy, the test for defining liver disease. The problem with biopsy wasn’t risk or the owner’s reluctance, but cost. We found an alternative method (for 80% less than the previously quoted price) and obtained samples.

A week passes. Dandy is feeling better on antibiotic: He’s eating better and not vomiting. His biopsy report comes in... and his liver doesn’t look that bad. He does not have cancer or copper storage disease or any of the other diseases that might push him towards liver failure, but the pathologist cannot offer a diagnosis.

Then the follow-up blood results arrive: Dandy’s hepatocellular disease is much better. His enzyme levels have dropped 75%, from sky-high to really high... but his hepatobiliary parameters (where flukes live) are worse! The best news is that Dandy is no longer skirting liver failure. His anemia is improved and he’s gained a little weight. We’re getting somewhere, just not far enough.

But it still sounds and acts like Salmon Poisoning so, once again, we search through Dandy’s poop looking for even one lousy fluke egg – but no. However, progress is progress and this approach has yielded more progress than anything previously done, so we extend the treatment two weeks and take another look at Dandy’s blood picture.

Same pattern. Check the poop, still no fluke eggs. Dandy’s progress has stalled. It’s time to apply Trapani’s Principle, which states: “You must never allow your principles to prevent you from doing the right thing.”We can’t prove Dandy has liver flukes, and we hate to treat without a proven diagnosis. However, treating flukes is only a matter of giving a big dose of tapeworm medication. The drug isn’t cheap, but it is safe. What’s expensive are all the rechecks and blood panels.

Just do it. If Dandy has liver flukes, he will feel a little worse for about three days after treatment, and then he will get much better – which is exactly what he does. At his next follow up check Dandy’s hepatobiliary enzymes are way down and his bilirubin levels are approaching normal. He’s gained weight, feels better, and is more active and playful. His enzyme levels may take months to completely settle down, but his active disease is disappearing.

Dandy has responded like a patient with liver flukes, but no proof was ever discovered. Past cases of Nanophyetus have provided necessary proof. Why not Dandy? In hindsight, I wonder if Dandy did not actually suffer from Metorchis, a different liver fluke that is carried by garden snails and found to infected foxes, and rarely, dogs and cats. We might find Metorchis if Dandy died and we took his liver apart. Even then... Sometimes you never really know!

Copyright © 2012 by Dr. Michael Trapani

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