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The Martha's Vineyard Times is a weekly publication.
May 26 - June 1, 2005 Edition
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Visiting Vet The Martha's Vineyard Times Good girl, Elsa May 26, 2005 By Michelle Gerhard Jasny, VMD Elsa, the longtime and well-loved pet of Vicki and Will Pfluger, always wanted to get the very biggest stick. Photo courtesy of Vicki Pfluger The first few years of practice, I kept a small boarding kennel at my home. There was a raft of pups who visited frequently. Dexter. Fastjack. Peaches. Elsa. I was single, childfree, and had a lot of time to devote to my tail-wagging wards. Elsa, a four-month-old chocolate lab puppy, was particularly needy. She played well with friends but when nighttime came, and everyone snuggled down in their crates, Elsa would fuss, whine, and bark. One night she would not stop. I went down and opened her crate. Before I could say “Good Girl,” she bounded up the stairs and exuberantly leapt into my bed. It wasn’t exactly what I had planned, but, oh well, it was better than the barking. Elsa and I spent several cozy nights together. Over the years she outgrew her fear and slept happily in her crate. When she was middle-aged, Elsa developed a recurrent nasal discharge. The stuff coming out her nose ranged from runny clear, to thick white, to yucky greenish yellow. We reviewed the possibilities of viral, bacterial, or fungal infection, of nose mites, or allergies. We tried a multitude of empirical treatments from antihistamines to antibiotics. Over the years, her stuffy nose would come and go. It seemed to respond best to antibiotics but we were never able to make the problem go away and stay away. We discussed consulting a specialist who could look up her nose with a special fiberoptic scope and make a definitive diagnosis with skull X-rays, rhinoscopy, biopsies, and cultures from deep in the nasal passages. ( Culturing the stuff she was sneezing out was not a useful option because, frankly, snot is invariably full of environmental contaminants.) Elsa’s owners kept the idea of more extensive work-up in mind for the future but opted to stick with antibiotics as needed. “We’ve got a problem” This routine worked well for years but as Elsa aged, her owners decided to see the specialist. They arranged an appointment off-Island but, as fate would have it, right before their scheduled visit Elsa became dramatically worse. Besides her usual nasal discharge, she was lethargic, and not eating well. She was breathing harder and faster, and coughing and gagging more than usual. I suggested I take a peek at her right away. On physical exam, Elsa was clearly frailer. Her heart and lungs sounded okay and her temperature was normal. Maybe her mother was overreacting…but Elsa had this little moist cough that I didn’t like. “Let’s just snap a quick chest X-ray” I suggested. When my assistant brought me the film, I sighed. “We’ve got a problem,” I told her mom. I hadn’t seen a picture like this in a long time. Elsa’s lungs were full of fine granular densities — classic for one of two problems: metastatic cancer or fungal pneumonia. Fungal pneumonia is caused by mycotic organisms invading and colonizing the lungs. Although it is extremely uncommon in this part of the country, in Elsa’s case, her runny nose increased our index of suspicion. Why? Because chronic nasal discharge like hers can sometimes be caused by a fungal infection, usually involving an organism called Aspergillus. Most common in farm dogs, aspergillosis is ordinarily confined to the nose, but in some cases can spread systemically. If Elsa had been harboring a fungal infection all these years, maybe it had finally spread to her lungs. Where do these fungi come from? Most are simply present in the environment — in soil, dust, straw, grass clippings, hay, decaying vegetation. Why one animal becomes infected and another doesn’t is somewhat of a mystery. Depending on what part of the country the dog is in, other organisms to consider in cases of fungal pneumonia include blastomycosis, histoplasmosis, coccidioidomycosis, and cryptococcosis. Here on the Vineyard, we see aspergillosis sporadically, and rarely other types, but we always have to be on our toes as many dogs here travel all over the country. Elsa, however, had not been out of state. Tricky diagnosis Making a definitive diagnosis can be tricky. For nasal infections, the most accurate test is a deep nasal biopsy. For pneumonia, isolating organisms from the lungs via fine needle aspirate or bronchoalveolar lavage is the gold standard. These tests are invasive and generally require anesthesia. Another option is fungal serology, i.e., testing the blood for antibodies to the various fungi. Unfortunately, false-negatives and false-positives do occur. Elsa’s owners were concerned about whether she could handle a trip off-Island, let alone anesthesia and invasive procedures. We decided to start with the blood tests. Fungal pneumonia can be treated with oral antifungal drugs such as itraconazole. Unfortunately these medications are very expensive and may need to be given for extended periods of time, often two to three months. For a typical Island Labrador, cost may exceed one thousand dollars per month. The drugs also have a moderately high risk of side effects. Five to ten percent of treated dogs develop liver toxicity and need to discontinue or reduce the dose of the medication. Finally, cure rates are only about 50 to 70 percent, and relapses are not uncommon. For Aspergillus infections confined to the nasal passages, an alternative is topical treatment. The affected dog is anesthetized and the nasal passages and sinuses are filled with an antifungal solution. The position of the head is rotated every 15 minutes. At the end of an hour, the medication is drained out and the dog allowed to wake up. Success rates are reported as high as 86 per cent, although some dogs may require multiple treatments. Elsa’s family was willing to try the oral antifungal medications, if she could tolerate them…but then we got the test results. Negative for all the different fungal infections. We knew there was a small chance we were dealing with a “false negative,” but it could also mean that the radiographs were showing metastatic cancer, not fungal pneumonia. The prognosis was poor in either case and the next diagnostic steps weren’t simple. Should they go to the specialist? Or should we take a hospice approach? We put her on bronchodilators to help her breathe easier, and anti-anxiety medications to relax her, but the very next night she developed severe respiratory distress and was euthanized. I try never to use the euphemism “put to sleep.” It can confuse children (whose parents want to “put them to sleep”) and I prefer to face death a bit more head on. But for Elsa, I’d like to think of her curled up somewhere with her head on a pillow, snoozing peacefully, looking just as she did when she slept in my bed as a puppy. Good Girl.

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