Travis, a 3-year old MN Dalmatian, presented to BVNS Richmond in April of 2017. A month before coming to us, he was seen at his primary care veterinarian as well as an internist for vomiting, lethargy, and inappetence.

Presenting Complaint

Ataxia and falling over when walking. Suspected spinal disease.

Diagnostics Prior to Presenting to BVNS:

GI biopsies: lymphoplasmacytic gastroenteritis NH3+: 18 (normal)

EXAM FINDINGS

Mentation: Subdued to dull

Posture of Head and Body: Limbs occasionally found in abnormal positions (ie. abducted, splayed, crossed)

Gait: tetraparesis with general proprioceptive ataxia noted in all 4 limbs. Occasionally, the patient displayed subtle signs of vestibular ataxia

Postural Reactions: Normal to slightly delayed paw replacement in the forelimbs and very delayed in both rear limbs

Thoracic Limb Reflexes: Normal withdrawal reflexes bilaterally

Pelvic Limb Reflexes: Normal patellar and withdrawal reflexes bilaterally

Cutaneous Trunci: Present bilaterally at L5 (normal)

Perineal Reflex: Normal

Muscle Tone: Normal tone

Cranial Nerve Function: Normal cranial nerve function

Retinal Exam: Normal fundic exam OU

Hyperesthesia: No pain elicited on spinal palpation or cervical manipulation

Other Findings: Patient resisted lateral recumbency and dorsal recumbency. After examination, patient altered between dull and stupor in the exam room. Stumbling and not appropriately responsive to auditory or visual stimuli

Q & A

Based on Travis' history and clinical signs, where would you localize?

Localization:

Multi-focal localization. There were aspects of the exam that suggested intracranial disease (i.e. alternating mental status, reduced response to auditory and visual stimuli), and other aspects that suggested spinal cord disease (tetraparesis).

What diagnostic plan should be considered?

Diagnostic Plan:

(i) Brain MRI: bilaterally symmetrical lesions within the brain most suggestive of metabolic, toxic, or degenerative disease. Given the hospital hepatopathy, the lesions are consistent with Wilson disease

(ii) Abbreviated Cervical MRI: normal

(iii) Cerebrospinal Fluid Analysis: normal

What is was the tentative diagnosis for Travis' case?

Tentative Diagnosis:

Brain disease consistent with neurotoxicity (endogenous > exogenous) or inborn error of cellular metabolism

DEFINITIVE DIAGNOSIS AND TREATMENT

What were the follow-up diagnostics?

Bile acid profile:

pre: 149.5 umol/L, (normal:0 – 6.9 umol/L)

post: 280.6 umol/L, (normal: 0 – 14.9 umol/L)

Liver biopsy: descriptive for copper storage disease

Based on the results, what was the definitive diagnosis? What treatments should be initiated?

Definitive Diagnosis: Copper-storage disease with secondary brain pathology consistent with Wilson disease in humans

Treatment: Penicillamine, Prednisone, Denosyl, and Phosphatidylcholine

FOLLOW-UP DIAGNOSTICS (ABOUT 7 MONTHS LATER):

Brain MRI: mild, bilaterally symmetrical lesions noted in the body of the thalamic hemispheres, the rostral thalamic nuclei, and the body of the caudate nuclei. The previously noted midbrain and lentiform lesions were no longer present.

DISCUSSION

We are often presented with patients with signs consistent with “routine” spinal disease. Travis’ medical history prior to coming to BVNS was extremely important in explaining his clinical signs. His exam changed and took on different qualities during his initial consultation at BVNS. While he was sent to us for problems walking, it became clear that he had intracranial abnormalities as well. The brain MRI showed symmetrical abnormalities that are typical of toxic or metabolic derangements. Given his age, breed, lab work abnormalities, and some additional ancillary tests, an accurate diagnosis was reached. Copper-associated liver disease is common in Dalmatians and can also result in brain pathology.

TAKE HOME POINTS FROM DR. HIGGINBOTHAM

1. A patient's past medical history is extremely important.

2. A patient's condition can change abruptly during an exam.

3. Bilaterally symmetrical brain disease is often associated with toxic or metabolic disease.

4. Diseases such as Travis' are treatable and potentially reversible.

Thank you Cooke Veterinary Medical Center of Chesapeake, VA for referring this case.

What you should expect from BVNS when you refer a case:

• Faxed Referral Letter (with call to confirm receipt).

• Desire to discuss any case, whether it is a referred case or a consultation.

• Dedication to provide superior service to you and your clients.

For more information on services offered, please visit us at www.bvns.net

Selected References

1. Brewer G. Wilson disease and canine copper toxicosis. Am J Clin Nutr 1998; 67(suppl):1087S-1090S

2. Webb CB, Twedt DC, Meyer DJ. Copper-associated liver disease in Dalmatians: a review of 10 dogs(1998-2001). J Vet Intern Med 2002; 16:665-668