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Severe chemosis caused by nephrotic syndrome in a goat: A case report
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The Veterinary Journal The Veterinary Journal 175 (2008) 141–143 www.elsevier.com/locate/tvjl
Short Communication
Severe chemosis caused by nephrotic syndrome in a goat: A case report P. Stummer
a,*
, A. Fuchs-Baumgartinger b, S. Franz c, B. Nell
a
a
c
Department of Small Animals and Horses, University of Veterinary Medicine, Vienna, Austria b Department of Pathobiology, University of Veterinary Medicine, Vienna, Austria Department of Farm Animals and Herd Management, University of Veterinary Medicine, Vienna, Austria Accepted 22 December 2006
Abstract A 3-year old female goat with nephrotic syndrome was presented because of severe bilateral chemosis. The diagnosis was based on clinical findings, decreased packed cell volume, increased serum urea and creatinine, decreased serum protein and protein loss via the urinary tract. At post mortem examination, a chronic glomerulonephritis and interstitial nephritis were found. In addition to severe conjunctival oedema, ascites and subcutaneous oedema in the region of the larynx were noted. Immunohistochemistry for the detection of chlamydial antigen in the conjunctiva was negative. This is the first report of severe chemosis caused by nephrotic syndrome in a goat. 2007 Elsevier Ltd. All rights reserved. Keywords: Goat; Chemosis; Conjunctiva; Renal failure; Nephrotic syndrome
A 3-year old female white goat with no history of prior illness was referred to the Clinic of Surgery and Ophthalmology at the University of Veterinary Medicine, Vienna, with a 1-day history of severe bilateral conjunctival swelling. The goat was kept with 30 others, none of which showed similar clinical signs. Physical examination revealed poor body condition, pale mucous membranes (including the conjunctiva), delayed capillary filling time and a poorly filled femoral artery. Eating, drinking, defecation and urination were normal. Ophthalmological examination revealed bilateral third eyelid protrusion and severe chemosis (Figs. 1 and 2) such that the goat was unable to close both eyes completely, causing dryness and erosions of the conjunctiva and cornea. Fluorescein staining (Haag-Streit International Fluoreszein Papier) of the cornea was bilaterally positive. The direct and indirect pupillary light reflexes were normal. Initial differential diagnoses of the chemosis included infectious (mycoplasma, chlamydia) and neoplastic (lymphosarcoma) disease. Due to the anemia and the poor body
*
Corresponding author. Tel.: +43 1 25077 6190; fax: +43 1 25077 5390. E-mail address: [email protected] (P. Stummer).
1090-0233/$ - see front matter 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.tvjl.2006.12.011
condition, blood was drawn for a complete blood cell count (CBC) and serum chemistry profile. Urinanalysis, faecal examination and ultrasonography of the abdomen were also performed. CBC showed a packed cell volume (PCV) of 9.8% (normal range 20–38%), haemoglobin of 3.6 g/dL (normal range 9–13 g/dL) and an erythrocyte count of 5.5 · 106/ lL (normal range 8–16 · 106/lL). Serum chemistry revealed a total protein of 4.61 g/dL (normal range 6– 7.8 g/dL), albumin 1.92 g/dL (normal range 2–3.2 g/dL), urea 458.4 mg/dL (normal range 15–39 mg/dL), creatinine 8.1 mg/dL (normal range 6–7.8 mg/dL), alkaline phosphatase 499 U/L (normal <50 U/L), aspartate aminotransferase 242 U/L (normal <65 U/L), glutamatedehydrogenase 9.13 U/L (normal <5 U/L), gamma glutamyl transferase 69 U/L (normal <30 U/L), calcium 1.73 mmol/L (normal range 2.20–2.80 mmol/L), phosphorous 1.56 mmol/L (normal range 1.30–2.80 mmol/L), potassium 4.6 mmol/L (normal range 4.9–6.1 mmol/L) and magnesium 1.67 mmol/L (normal range 0.78–1.07 mmol/L). Parasitological examination of the faeces proved negative. The specific gravity of the urine was 1015, pH 7, and a severe proteinuria was determined by means of a test strip for urinanalysis (Combur Test, Roche Diagnostics).
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P. Stummer et al. / The Veterinary Journal 175 (2008) 141–143
Fig. 1. Severe chemosis of the right eye.
Fig. 3. Pale kidney.
glomeruli showed hyalinisation and a thickening of the Bowman’s capsule, moderate cellular proliferation and periglomerular fibrosis (Fig. 6). Glomerular amyloidosis could be excluded using Congo red stain. Tubular proteinuria and nephrocalcinosis were additional findings. A reduced erythropoiesis in the bone marrow and slight
Fig. 2. Severe chemosis of the left eye.
Ultrasonography of the abdomen showed a dilated caudal vena cava, ascites and hypoechoic areas in the renal parenchyma although the kidneys were of normal size. Based on these findings, a presumptive diagnosis of nephrotic syndrome caused by chronic renal failure could be made. Due to a guarded prognosis the goat was euthanased, and a necropsy as well as a histopathological examination was performed. At post mortem examination, the animal showed severe oedema of the conjunctiva, the retrobulbar tissue and the subcutaneous tissue in the ventral region of the head, as well as severe ascites. Grossly, the kidneys were pale and contained numerous 1–5-mm cysts (Figs. 3 and 4), located in the renal cortex. No gross abnormalities were found in other organs. Histologically, the conjunctiva showed a secondary erosive keratitis and necrotising conjunctivitis due to chemosis. The necrotic superficial rim was infiltrated by a thick wall of neutrophil granulocytes (Fig. 5). Severe generalised chronic interstitial nephritis and chronic membranoproliferative glomerulonephritis were found in both kidneys. The nephritis was characterised by marked interstitial fibrosis with slight mononuclear cell infiltration, tubular atrophy and tubular compression causing large cysts. The
Fig. 4. Numerous 1–5 mm cysts in the renal cortex.
Fig. 5. Severe edema of the conjunctiva and superficial necrotizing conjunctivitis. H&E, bar = 250 lm.
P. Stummer et al. / The Veterinary Journal 175 (2008) 141–143
Fig. 6. Chronic interstitial nephritis. H&E, bar = 250 lm.
extramedullary erythropoiesis in the liver were noted. The immunohistological examination of the conjunctiva and the kidney for chlamydial lipopolysaccharide by using a genus specific monoclonal antibody (Clone ACI, Progen) and the ABC technique (Vectastain ABC Kit, Vector Laboratories) proved negative. Mycoplasma DNA could not be detected in the conjunctiva using polymerase chain reaction (PCR). The pathohistological diagnosis was consistent with nephrotic syndrome caused by renal failure. Differential diagnoses for chemosis in a goat included infectious keratoconjunctivitis and lymphoma (Whittaker et al., 1999). Mycoplasma conjunctivae and chlamydial infections are the most important primary causes of infectious keratoconjunctivitis in sheep and goats (Hopkins et al., 1973; Hosie, 2000; Matthews, 1999; Smith and Sherman, 1994; Wilsmore et al., 1990). Histologically, conjunctivitis is characterised by conjunctival oedema and massive lymphofollicular hyperplasia (Hopkins et al., 1973; Hosie, 2000; Wilsmore et al., 1990). In this case, a severe necrotizing and purulent conjunctivitis accompanied by marked oedema of the propria conjunctivae were found while lymphofollicular hyperplasia was not evident. The necrotising conjunctivitis and erosive keratitis were caused by the chemosis and not by an infectious agent, which was confirmed by PCR and immunohistochemical examination. Lymphoma can also be associated with severe chemosis. Lymph node enlargement as described in a heifer by Joyce (1973) was not present in our case. The histopathological examination showed no autonomic growth so lymphoma could be excluded. Nephrotic syndrome has been described in ruminants (Murray and Rushton, 1972; Wiseman et al., 1980). The causes of a nephrotic syndrome were chronic glomerulone-
143
phritis (Wiseman et al., 1980; Maxie, 1993) and amyloidosis (Maxie, 1993; Murray and Rushton, 1972). Nephrotic syndrome is characterised by proteinuria, hypoproteinaemia (hypoalbuminaemia), formation of oedema, as was the case with this goat, and hypercholesterinaemia (Grauer, 1998). Lipid and cholesterol values were not determined in the present case. In ruminants with renal failure, intermandibular, brisket, sternal and udder oedema were noted (Murray and Rushton, 1972; Wiseman et al., 1980). To the authors’ knowledge, there are no reports of chemosis related to nephrotic syndrome in ruminants, although the condition has been described in humans (Meyer-Lehnert and Vetter, 1990; Spallek et al., 1997). This case shows that chemosis, in addition to other subcutaneous oedema, can be a clinical sign of renal failure.
References Grauer, G.F., 1998. Urinary Tract Disorders. In: Nelson, R.W., Couto, C.G. (Eds.), Small Animal Internal Medicine, second ed. Mosby, Missouri, pp. 571–669. Hopkins, J.B., Stephenson, E.H., Storz, J., 1973. Conjunctivitis associated with chlamydial polyarthritis in lambs. Journal of American Veterinary Medicine Association 163, 1157–1160. Hosie, B.D., 2000. Ocular disease. In: Martin, W.B., Aitken, I.D., (Eds.), Disease of Sheep, third ed. pp. 301–305. Joyce, R., 1973. Chemosis associated with malignant lymphoma in a heifer. Veterinary Medicine Small Animal Practice 170, 333. Matthews, J., 1999. Eye Disease. In: Matthews, J. (Ed.), Diseases of the Goat, second ed. Blackwell Science, Oxford, pp. 280–284. Maxie, M.G., 1993. The Urinary System. In: Jubb, K.V.F., Kennedy, P.C., Palmer, N. (Eds.), Pathology of Domestic Animals, fourth ed. Academic Press, California, pp. 475–476. Meyer-Lehnert, H., Vetter, H., 1990. Eyelid and ankle edema. Schweizer Rundschau fu¨r Medizinische Praxis 79, 296–300. Murray, M., Rushton, A., 1972. Bovine renal amyloidosis: a clinicopathological study. Veterinary Record 90, 210–216. Smith, M.C., Sherman, D.M., 1994. Urinary System. In: Smith, MC., Sherman, DM. (Eds.), Goat Medicine, first ed. Lea & Febiger, Pennsylvania, pp. 387–409. Spallek, G., Buttgereit, F., Audring, H., Hiepe, F., 1997. Persistent facial swelling of unclear etiology. Differential diagnostic possibilities. Hautarzt 48, 828–833. Whittaker, C., Gelatt, KN., Wilkie, DA., 1999. Food Animal Ophthalmology. In: Gelatt, KN. (Ed.), Veterinary Ophthalmology, third ed. Lippikott Wiliams and Wilkins, Philadelphia, pp. 1117–1176. Wilsmore, A.J., Dagnall, JR., Woodland, RM., 1990. Experimental conjunctival infection of lambs with strain of Chlamydia psittaci isolated from the eyes of a sheep naturally affected with keratoconjunctivitis. Veterinary Record 127, 229–231. Wiseman, A., Spencer, A., Petrie, L., 1980. The nephritic syndrome in a heifer due to glomerulonephritis. Research in Veterinary Science 28, 325–329.
The Veterinary Journal The Veterinary Journal 175 (2008) 141–143 www.elsevier.com/locate/tvjl
Short Communication
Severe chemosis caused by nephrotic syndrome in a goat: A case report P. Stummer
a,*
, A. Fuchs-Baumgartinger b, S. Franz c, B. Nell
a
a
c
Department of Small Animals and Horses, University of Veterinary Medicine, Vienna, Austria b Department of Pathobiology, University of Veterinary Medicine, Vienna, Austria Department of Farm Animals and Herd Management, University of Veterinary Medicine, Vienna, Austria Accepted 22 December 2006
Abstract A 3-year old female goat with nephrotic syndrome was presented because of severe bilateral chemosis. The diagnosis was based on clinical findings, decreased packed cell volume, increased serum urea and creatinine, decreased serum protein and protein loss via the urinary tract. At post mortem examination, a chronic glomerulonephritis and interstitial nephritis were found. In addition to severe conjunctival oedema, ascites and subcutaneous oedema in the region of the larynx were noted. Immunohistochemistry for the detection of chlamydial antigen in the conjunctiva was negative. This is the first report of severe chemosis caused by nephrotic syndrome in a goat. 2007 Elsevier Ltd. All rights reserved. Keywords: Goat; Chemosis; Conjunctiva; Renal failure; Nephrotic syndrome
A 3-year old female white goat with no history of prior illness was referred to the Clinic of Surgery and Ophthalmology at the University of Veterinary Medicine, Vienna, with a 1-day history of severe bilateral conjunctival swelling. The goat was kept with 30 others, none of which showed similar clinical signs. Physical examination revealed poor body condition, pale mucous membranes (including the conjunctiva), delayed capillary filling time and a poorly filled femoral artery. Eating, drinking, defecation and urination were normal. Ophthalmological examination revealed bilateral third eyelid protrusion and severe chemosis (Figs. 1 and 2) such that the goat was unable to close both eyes completely, causing dryness and erosions of the conjunctiva and cornea. Fluorescein staining (Haag-Streit International Fluoreszein Papier) of the cornea was bilaterally positive. The direct and indirect pupillary light reflexes were normal. Initial differential diagnoses of the chemosis included infectious (mycoplasma, chlamydia) and neoplastic (lymphosarcoma) disease. Due to the anemia and the poor body
*
Corresponding author. Tel.: +43 1 25077 6190; fax: +43 1 25077 5390. E-mail address: [email protected] (P. Stummer).
1090-0233/$ - see front matter 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.tvjl.2006.12.011
condition, blood was drawn for a complete blood cell count (CBC) and serum chemistry profile. Urinanalysis, faecal examination and ultrasonography of the abdomen were also performed. CBC showed a packed cell volume (PCV) of 9.8% (normal range 20–38%), haemoglobin of 3.6 g/dL (normal range 9–13 g/dL) and an erythrocyte count of 5.5 · 106/ lL (normal range 8–16 · 106/lL). Serum chemistry revealed a total protein of 4.61 g/dL (normal range 6– 7.8 g/dL), albumin 1.92 g/dL (normal range 2–3.2 g/dL), urea 458.4 mg/dL (normal range 15–39 mg/dL), creatinine 8.1 mg/dL (normal range 6–7.8 mg/dL), alkaline phosphatase 499 U/L (normal <50 U/L), aspartate aminotransferase 242 U/L (normal <65 U/L), glutamatedehydrogenase 9.13 U/L (normal <5 U/L), gamma glutamyl transferase 69 U/L (normal <30 U/L), calcium 1.73 mmol/L (normal range 2.20–2.80 mmol/L), phosphorous 1.56 mmol/L (normal range 1.30–2.80 mmol/L), potassium 4.6 mmol/L (normal range 4.9–6.1 mmol/L) and magnesium 1.67 mmol/L (normal range 0.78–1.07 mmol/L). Parasitological examination of the faeces proved negative. The specific gravity of the urine was 1015, pH 7, and a severe proteinuria was determined by means of a test strip for urinanalysis (Combur Test, Roche Diagnostics).
142
P. Stummer et al. / The Veterinary Journal 175 (2008) 141–143
Fig. 1. Severe chemosis of the right eye.
Fig. 3. Pale kidney.
glomeruli showed hyalinisation and a thickening of the Bowman’s capsule, moderate cellular proliferation and periglomerular fibrosis (Fig. 6). Glomerular amyloidosis could be excluded using Congo red stain. Tubular proteinuria and nephrocalcinosis were additional findings. A reduced erythropoiesis in the bone marrow and slight
Fig. 2. Severe chemosis of the left eye.
Ultrasonography of the abdomen showed a dilated caudal vena cava, ascites and hypoechoic areas in the renal parenchyma although the kidneys were of normal size. Based on these findings, a presumptive diagnosis of nephrotic syndrome caused by chronic renal failure could be made. Due to a guarded prognosis the goat was euthanased, and a necropsy as well as a histopathological examination was performed. At post mortem examination, the animal showed severe oedema of the conjunctiva, the retrobulbar tissue and the subcutaneous tissue in the ventral region of the head, as well as severe ascites. Grossly, the kidneys were pale and contained numerous 1–5-mm cysts (Figs. 3 and 4), located in the renal cortex. No gross abnormalities were found in other organs. Histologically, the conjunctiva showed a secondary erosive keratitis and necrotising conjunctivitis due to chemosis. The necrotic superficial rim was infiltrated by a thick wall of neutrophil granulocytes (Fig. 5). Severe generalised chronic interstitial nephritis and chronic membranoproliferative glomerulonephritis were found in both kidneys. The nephritis was characterised by marked interstitial fibrosis with slight mononuclear cell infiltration, tubular atrophy and tubular compression causing large cysts. The
Fig. 4. Numerous 1–5 mm cysts in the renal cortex.
Fig. 5. Severe edema of the conjunctiva and superficial necrotizing conjunctivitis. H&E, bar = 250 lm.
P. Stummer et al. / The Veterinary Journal 175 (2008) 141–143
Fig. 6. Chronic interstitial nephritis. H&E, bar = 250 lm.
extramedullary erythropoiesis in the liver were noted. The immunohistological examination of the conjunctiva and the kidney for chlamydial lipopolysaccharide by using a genus specific monoclonal antibody (Clone ACI, Progen) and the ABC technique (Vectastain ABC Kit, Vector Laboratories) proved negative. Mycoplasma DNA could not be detected in the conjunctiva using polymerase chain reaction (PCR). The pathohistological diagnosis was consistent with nephrotic syndrome caused by renal failure. Differential diagnoses for chemosis in a goat included infectious keratoconjunctivitis and lymphoma (Whittaker et al., 1999). Mycoplasma conjunctivae and chlamydial infections are the most important primary causes of infectious keratoconjunctivitis in sheep and goats (Hopkins et al., 1973; Hosie, 2000; Matthews, 1999; Smith and Sherman, 1994; Wilsmore et al., 1990). Histologically, conjunctivitis is characterised by conjunctival oedema and massive lymphofollicular hyperplasia (Hopkins et al., 1973; Hosie, 2000; Wilsmore et al., 1990). In this case, a severe necrotizing and purulent conjunctivitis accompanied by marked oedema of the propria conjunctivae were found while lymphofollicular hyperplasia was not evident. The necrotising conjunctivitis and erosive keratitis were caused by the chemosis and not by an infectious agent, which was confirmed by PCR and immunohistochemical examination. Lymphoma can also be associated with severe chemosis. Lymph node enlargement as described in a heifer by Joyce (1973) was not present in our case. The histopathological examination showed no autonomic growth so lymphoma could be excluded. Nephrotic syndrome has been described in ruminants (Murray and Rushton, 1972; Wiseman et al., 1980). The causes of a nephrotic syndrome were chronic glomerulone-
143
phritis (Wiseman et al., 1980; Maxie, 1993) and amyloidosis (Maxie, 1993; Murray and Rushton, 1972). Nephrotic syndrome is characterised by proteinuria, hypoproteinaemia (hypoalbuminaemia), formation of oedema, as was the case with this goat, and hypercholesterinaemia (Grauer, 1998). Lipid and cholesterol values were not determined in the present case. In ruminants with renal failure, intermandibular, brisket, sternal and udder oedema were noted (Murray and Rushton, 1972; Wiseman et al., 1980). To the authors’ knowledge, there are no reports of chemosis related to nephrotic syndrome in ruminants, although the condition has been described in humans (Meyer-Lehnert and Vetter, 1990; Spallek et al., 1997). This case shows that chemosis, in addition to other subcutaneous oedema, can be a clinical sign of renal failure.
References Grauer, G.F., 1998. Urinary Tract Disorders. In: Nelson, R.W., Couto, C.G. (Eds.), Small Animal Internal Medicine, second ed. Mosby, Missouri, pp. 571–669. Hopkins, J.B., Stephenson, E.H., Storz, J., 1973. Conjunctivitis associated with chlamydial polyarthritis in lambs. Journal of American Veterinary Medicine Association 163, 1157–1160. Hosie, B.D., 2000. Ocular disease. In: Martin, W.B., Aitken, I.D., (Eds.), Disease of Sheep, third ed. pp. 301–305. Joyce, R., 1973. Chemosis associated with malignant lymphoma in a heifer. Veterinary Medicine Small Animal Practice 170, 333. Matthews, J., 1999. Eye Disease. In: Matthews, J. (Ed.), Diseases of the Goat, second ed. Blackwell Science, Oxford, pp. 280–284. Maxie, M.G., 1993. The Urinary System. In: Jubb, K.V.F., Kennedy, P.C., Palmer, N. (Eds.), Pathology of Domestic Animals, fourth ed. Academic Press, California, pp. 475–476. Meyer-Lehnert, H., Vetter, H., 1990. Eyelid and ankle edema. Schweizer Rundschau fu¨r Medizinische Praxis 79, 296–300. Murray, M., Rushton, A., 1972. Bovine renal amyloidosis: a clinicopathological study. Veterinary Record 90, 210–216. Smith, M.C., Sherman, D.M., 1994. Urinary System. In: Smith, MC., Sherman, DM. (Eds.), Goat Medicine, first ed. Lea & Febiger, Pennsylvania, pp. 387–409. Spallek, G., Buttgereit, F., Audring, H., Hiepe, F., 1997. Persistent facial swelling of unclear etiology. Differential diagnostic possibilities. Hautarzt 48, 828–833. Whittaker, C., Gelatt, KN., Wilkie, DA., 1999. Food Animal Ophthalmology. In: Gelatt, KN. (Ed.), Veterinary Ophthalmology, third ed. Lippikott Wiliams and Wilkins, Philadelphia, pp. 1117–1176. Wilsmore, A.J., Dagnall, JR., Woodland, RM., 1990. Experimental conjunctival infection of lambs with strain of Chlamydia psittaci isolated from the eyes of a sheep naturally affected with keratoconjunctivitis. Veterinary Record 127, 229–231. Wiseman, A., Spencer, A., Petrie, L., 1980. The nephritic syndrome in a heifer due to glomerulonephritis. Research in Veterinary Science 28, 325–329.