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By S. Hogar. Northwest Missouri State University. 2018.

There also may be an association with a malformation syndrome with dysmorphic features specific to the syndrome generic losartan 25 mg without prescription, such as short stature and webbed neck seen in Noonan s syndrome buy losartan 25mg. Diagnostic Testing Any suspicion of cardiomyopathy should prompt a consult to the pediatric cardiologist generic losartan 50 mg overnight delivery. Echocardiogram is the most widely used and most informative noninvasive test for diagnosing cardiomyopathy (Fig. With echocardio- gram, the practitioner cannot only specify the type of cardiomyopathy but also determine the degree of dysfunction of the heart muscle. Measurements of the pressures in the ventricles and the great vessels like the pulmonary artery may also be performed. In addition a chest X-ray, electrocardiogram and a 24 72 h Holter monitor are necessary for evaluation. In some cases there may be need for more invasive tests like radionuclide ventriculogram or cardiac catheterization. This helps in evaluating for possible infections of the heart and certain metabolic diseases. Certain biochemical, genetic and enzyme deficiency tests are needed before starting the most appropriate medical therapy. It is especially important to get a metabolic screening in children with cardiomyopathy under 4 years of age. This may require additional blood, urine and tissue testing in consultation with special- ists such as geneticists or neurologists. Improving the contractility by using dopamine and dobutamine in critically ill patients and digoxin orally as maintenance therapy. Control of symptoms related to obstruction with calcium channel blockers or beta blockers like verapamil and propranolol. Prevention of arrhythmias and sudden death with antiarrhythmics like amio- darone or disopyramide. Patients with associated metabolic disorders may need careful dietary monitoring of fats, avoidance of fasting and possible daily carnitine orally. Dual chamber pacing has been shown to decrease outflow obstruction in hypertro- phic cardiomyopathy. An automatic internal cardioverter defibrillator is recom- mended in cases of severe life threatening arrhythmias, syncope, or history of resuscitation from a cardiac arrest. Myectomy is the surgical removal of part of the thickened septal muscle that blocks the blood flow in hypertrophic cardiomyopathy. Even though it may control symptoms of heart failure secondary to obstruction, studies have not shown that this procedure prevents sudden death from arrhythmias or stops progression of the disease. Heart transplantation is the last resort when patients reach the end stage of the disease. About 20% of symptomatic infants with cardiomyopathy require a cardiac transplant within the first year of life. In addition, children greater than 50 kg are eligible for support by a device called Left Ventricular Assist System for about 3 12 months. Those with a family history of cardiomyopathy and no symptoms may continue screening every 5 years thereafter. If a specific genetic diagnosis is made all siblings should be genetically tested to assess their risk. Torchen Prognosis The overall prognosis depends on the type of cardiomyopathy and the age at first diagnosis. Up to 40% of children with a diagnosis of cardiomyopathy fail medical treatment within first year of diagnosis. Mortality and heart transplant rates are much higher in children with cardiomyopathy as compared to adults. For those children who acquire cardiomyopathy secondary to a viral infection 33% recover, 33% stabi- lize and 33% experience progression of their disease. Current 5-year survival for children diagnosed with hypertrophic cardiomyopathy is 85 95%, while it is 40 50% with dilated cardiomyopathy. Sudden cardiac deaths accounts for 50% of deaths in hypertrophic cardiomyopathy and 28% in restrictive cardiomyopathy. Case Scenarios Case 1 History: A 6-month-old girl is suspected of having reactive airway disease. For the past 2 months she has had several visits to the primary care physician for manage- ment of shortness of breath and wheezing. Inhaled bronchodilators were prescribed in the past with no significant improvement. Mother brought her because of con- cern of increasing effort to breathe and poor feeding. Physical examination: The infant appeared pale and in mild to moderate respira- tory distress with visible intercostal and subcostal retractions. Peripheral pulses were equally diminished with pro- longed capillary refill (3 s). Diagnosis: Chest X-ray showed significant cardiomegaly with prominent pulmo- nary vasculature markings suggestive of pulmonary edema. An echocardio- gram was performed which revealed dilated and poorly contracting ventricles with severe mitral regurgitation due to a dilated mitral valve ring. Laboratory studies for viral titers were obtained to investigate the possibility of viral myocarditis. Diuretics and intrave- nous milrinone were used with improved evidence of cardiac output. Viral myocarditis was ruled out in view of negative inflammatory markers and negative viral titers. Endomyocardial biopsy was performed revealing nonspecific myocardial fibrosis with no evidence of inflammation. The child s oral intake improved after few days and the child was discharged home. At the time of discharge the ventricu- lar function was slightly improved, but continued to be depressed. Case 2 History: A 2 year old was seen by the primary care physician at 5 years of age because of concern by mother that the child appeared to pass out for few seconds that same morning. Mother states that the child s father died suddenly last year but did not know why since they were separated. The precordium was hyper- active with a prominent and slightly laterally displaced apical impulse. A harsh 3/6 systolic ejection murmur was heard over the midsternum, no diastolic murmurs were detected. Diagnosis: In view of the heart murmur, which was not previously appreciated, the child was referred for further evaluation to a pediatric cardiologist. The primary care physician was also concerned to hear of the sudden and unexplained death of the father. Chest X-ray revealed cardiomegaly and electrocardiography showed normal sinus rhythm with evidence of left ventricular hypertrophy.

Hyperpnea implies an to be associated with closure of the atrioventricular increased depth of respiration purchase losartan 25mg mastercard. Classically inspiratory dyspnea tends split rst heart sound that results in a gallop rhythm 10 Part I Examination and Assessment (e order 25 mg losartan with amex. This split rst Following auscultation of the heart losartan 50 mg overnight delivery, auscultation of heart sound is attributed to asynchronous closure of the left lung eld should begin. The entire lung eld the atrioventricular valves or asynchronous onset of should be ausculted and subsequently the trachea aus- contracture of the ventricles and should be considered culted to rule out referred sounds from the upper airway. The caudal border of the lung eld extends approxi- Heart murmurs, or bruits, are abnormal and should mately from the sixth costochondral junction ventrally be assessed as to valvular site of maximal intensity, rela- to the eleventh intercostal space dorsally. A comparison of sounds between both sides and murmurs to be objective about the intensity of the mur- different locations on the chest should be emphasized. Cattle receiving a rapid cow s mouth and nose shut for 15 to 45 seconds to force infusion of high volume intravenous uid may have a the cow to take a deep breath. In sick adult cattle, heart sounds adventitious lung sounds, other signs of lower airway also may radiate through an extremely dry rumen, be- disease may include a rapid intolerance of the procedure coming audible in the left paralumbar fossa. This has and development of dyspnea, or the initiation of spon- been classically described in cattle with primary ketosis, taneous and frequent coughing during the rebreathing but the phenomenon is not limited to this disease. Calves can be backed into a corner, and the ex- Splashing sounds associated with the heart beat usu- aminer can hold the nose and mouth shut to auscultate ally suggest a pericardial effusion, most commonly asso- the lungs without additional help. Thoracic During auscultation of the heart and lungs in the left or lung abscesses located adjacent but external to the hemithorax, the examiner may also palpate the jugular pericardium also occasionally may give rise to splashing and mammary (supercial abdominal) veins for rela- sounds should liquid pus in the abscess have been set in tive degrees of tension, pulsation, or thrombosis. Atrial brillation is the most common cardiac arrhyth- Assessment of the Rumen and Abdomen mia in dairy cattle and is associated with hypochloremic, The examination proceeds to the left abdomen and be- hypokalemic metabolic alkalosis. Palpation and aus- be contributory, but hypokalemia seems to be the most cultation of the rumen should be performed. A rapid (88 to 140 beats/min) erratic bar fossa may aid this evaluation and is a better means heart rate of varying intensity and a pulse decit character- of determining the relative consistency of rumen con- ize the physical ndings in atrial brillation. Healthy cattle have one or two primary rumen brillation is suspected, simultaneous auscultation of the contractions per minute. Hypomotility suggests stasis heart and palpation of the facial artery or median artery caused by endotoxemia, peritonitis, hypocalcemia, or are indicated to determine a pulse decit. Hypermotility may suggest vagal indiges- mias other than atrial brillation are rare in adult dairy tion. Calves affected with white muscle disease and calves cial inguinal lymph node should be palpated, and the that are hyperkalemic may have cardiac arrhythmias. We prefer the examiner to be positioned cultation and percussion of the left abdomen to detect in a kneeling position near the right fore udder attach- resonant areas (pings) indicative of gaseous or gas/uid ment. A closed st is rested on the examiner s left knee, distention of viscera in the left abdomen. In descending and gentle but deep pressure is applied intermittently to order of frequency of occurrence, these would include left specic areas to the left and right of midline as the exam- displacement of the abomasum, rumen gas cap, pneumo- iner moves forward until the xiphoid area is reached. When sions of each area to allow her to relax before pressure is pings are identied, simultaneous ballottement and aus- applied to the next area. An average of 8 to 10 deep pres- cultation should be performed to determine the relative sure applications is used while the examiner observes the amount of uid present. When a painful area is identied, the cow usually will lift her abdomen off the examiner s st, then tighten her Right Side neck musculature and show an anxious expression. The examiner does not need to watch the abdo- Auscultation of the right heart and lung elds is similar men because one will feel the cow s abdomen lift away. In general, the heart Subtle or chronic peritonitis cases may demonstrate only sounds on the right side are slightly less audible than tightening of the neck musculature or show facial expres- those on the left side because the majority of the sions indicative of pain. Auscultation of the violent reactions, and the patient may either move away right heart requires the examiner to force the head of from the examiner or kick especially if the patient is a the stethoscope as far as possible cranially under the nervous cow. Murmurs originating from the technique, in which rm pressure is applied to the with- right atrioventricular valve are best heard on the right ers area with one or both hands by grasping the withers side around the third intercostal space at the level of the and pinching. A cow with peritonitis may be reluc- clinical basal border of the lung remains clinically iden- tant to lower her withers and thereby push against the tical to that found on the left side. This technique requires more auscultation of the right hemithorax, the examiner subjective analysis because many nervous cows are reluc- should assess the ipsilateral jugular vein, mammary tant to respond to the withers pinch. Suspicious Mammary Gland areas discovered during auscultation of the right hemi- Evaluation of the mammary gland is then conducted by thorax may be evaluated further by percussion. The conformation and suspensory weak- Assessment of the Abdomen nesses may be evaluated but have been noted, usually Evaluation of the right abdomen begins with simulta- during the general examination, by observation. Dry neous percussion and auscultation of the entire ab- cows are assessed rst by palpation, and secretion is dominal area. Milking taneous ballottement and auscultation will allow a cows routinely require a strip plate evaluation of the relative assessment of the quantity of uid present in a secretion in each quarter. The black plate to highlight abnormalities, and a normal ngertips should be used for determination of local- secretion from one quarter is left as a pool on the strip ized abdominal pain in the right abdomen. Deep pres- plate so that potential abnormal secretions can be sure is exerted in the intercostal regions, paralumbar milked into it. Caudal abdominal or pelvic head leads to the most patient apprehension, this part adhesions and rectal tears also may be conrmed by pal- of the examination is left to next to last and followed pation examination. Following the rectal or vaginal examination, cat- frontal and maxillary sinuses should be evaluated by tle with pelvic pain should be observed for persistent te- percussion. If previ- nesmus, and if present epidural administration may be ous physical ndings suggest the possible diagnosis of required. The age of the cow and vulva using the at of one s hand, straw, or hay to may be estimated by examination of the teeth. Urine obtained in this manner The palate and oral mucous membranes should be should be tested with multiple-reagent test strips or examined with the aid of a focal light for erosions or tablets for urinary ketones and other abnormal constit- ulceration. The odor of the breath and oral cavity should uents that might suggest further evaluation via a cathe- be noted. If lameness or musculoskeletal abnormalities are sus- The muzzle should be examined for the degree and sym- pected, specic examination of the limbs, feet, or addi- metry of moisture present because Horner s syndrome tional observation of the cow may be indicated. Although most dairy cattle At the completion of the physical examination, the ex- have been dehorned, those with horns should have the aminer may have arrived at a specic diagnosis or may horns palpated to detect horn fractures or fractures of have formulated a differential diagnosis requiring ancil- the skull at the cornual base of the horn. Some ancillary procedures are available im- mediately, whereas others require laboratory evaluation Rectal Examination or special equipment that may require economic deci- Before completing the physical examination, a rectal ex- sions before undertaking. The rectal examina- useful ancillary test that will provide immediate informa- tion may conrm many causes of abdominal distention tion in many sick cattle. With time, on-site ultrasound examination of sick cattle will likely become a more Aspiration may be required to diagnose uid-lled common occurrence. In most instances, aspiration will differentiate abscesses, he- matomas, and seromas. The procedure is contraindi- Abdominal Paracentesis cated should physical examination make hematoma Abdominal paracentesis is indicated when peritonitis is (proximity to a major vessel or anemia) the most likely suspected or exfoliative cytology may be helpful to diag- diagnosis. The procedure is performed best in the ventral used to differentiate seromas that do not require drain- abdomen to the right of midline but medial to the right age from abscesses that subsequently require surgical mammary vein. If the right ventral information about cause and treatment of respiratory abdomen fails to produce uid, paracentesis may be at- diseases.

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Their pre- Treatment for ketosis is aimed at restoring energy me- disposition to sepsis with mild to moderate metritis may tabolism to normal for milk production cheap 25mg losartan with visa. These treatments may be com- usually occurs with multiple fetuses and is triggered by bined to suit the needs of the case and the abilities of some other illness or external event that restricts access the herdsman purchase losartan 50 mg amex. Cows do not become blind as do sheep allow time for the cow to maintain normoglycemia quality losartan 50mg. Niacin (12 g orally daily) will also inhibit lipoly- sis and is frequently administered daily to cows with chronic ketosis. The most important treatment of cows with chronic fat mobilization and hepatic lipidosis is twice-daily forced feeding. If these treat- ments do not appear to be effective after 3 to 5 days, then it may be necessary to reduce the cows milk pro- duction by milking for 1 minute twice daily until the negative energy balance cycle is broken. There was no obvious smell from the rear required for 4 to 7 days before the ketosis is permanently of the cow, and the metritis did not appear to be severe resolved. We have performed this on many cows with enough to make most cows systemically ill. The severe chronic fat mobilization, and it, along with previously hepatic lipidosis most likely predisposed the cow to the mentioned treatments, has been successful in all but one fatal toxemia from a relatively moderate metritis. Additionally, owners have reported the milk pro- duction for the remainder of the lactation was very good. Although cows with chronic fat mobilization have de- help in restoring the cow s appetite. Cows with nervous layed time of estrus and their production is diminished ketosis can be treated with chloral hydrate (40 g orally during the rst 6 weeks of lactation, their prognosis for daily), which serves as both a sedative and as a substrate complete recovery is excellent. The most frequent complication associated with intervention to prevent irreversible hepatic lipidosis and treatment of these cows is thrombophlebitis caused by multiorgan failure. Intensive support Treatment of periparturient overweight cows with ke- of the cow with dextrose and force feeding is necessary. Cows with chronic as described above and have only limited milk removed fat mobilization and ketosis/hepatic lipidosis are often (if there is mastitis in a quarter, it should be stripped and the best cow in the herd and produce a high milk vol- intramammary antibiotics administered). These cows do not get better overnight with any apy can be used as described previously for cows with treatment and in fact may have already been treated with chronic fat mobilization. Reduced neutrophil and he- the above listed traditional therapy for ketosis for 1 to patic macrophage function in these cows may allow 3 weeks before veterinary attention is sought. Treatment septic conditions such as even mild metritis or mastitis should include continual 5% glucose administration in to overwhelm the patient. Although lipotropic medica- declines by up to 20% in late gestation to the day before tions such as choline and methionine are used by some calving. If lipotropic companied by an increasing rate of lipid mobilization medications are used, rumen-protected choline is pre- from body fat stores. Most herd owners random cows can be used to determine whether energy would agree that 20% of fresh cows with ketosis repre- balance in the late dry period may be responsible for a sent a herd problem. Prob- component testing has also been used to monitor en- ably all cows with clinical ketosis have greater than ergy consumption in lactating cows. Attempts to ommended practices of nutrition and feed bunk manage- decrease milk fat production in early lactation could ment. In many herds with a high incidence of ketosis, the have benecial effects in preventing ketosis as long as problems originate with nutritional mistakes during the milk production were not further increased. Obesity or other diseases that restrict feed intake are a simultaneous increase in hormone-sensitive lipase both potential causes. The process is initiated by prolactin and pre- rumen stula of the difference between intake at 3 weeks cedes the onset of lactation. Insulin secretion declines prepartum and voluntary intake until calving reduced in preparation for lactation. The mammary gland of the the increase in liver triglyceride accumulation from 23% dairy cow does not require insulin for glucose uptake, to 16%. Further restriction of intake in the late dry period persist until about 8 weeks into lactation, when lipid when a decline normally occurs can be a herd problem. Mismanagement of this minimum requirement for metabolizable protein for group has occurred, leading to outbreaks of postpartum close up cows and heifers is 900 g/day. Guard describes a herd with a ketosis prob- this increases to at least 1100 g/day. The area cess dietary protein in any form, but particularly non- in front of the bunk was a deep mudhole. In addition, protein nitrogen or readily soluble protein, may lead to there was an electric fence surrounding the bunk and herd problems with ketosis. Several outbreaks of ketosis strung across the top to prevent cows from stepping into affecting animals in many stages of lactation have oc- the feed. Creating a new 20-m feed bunk away from curred following the on-farm experimental addition of mud and electricity appeared to solve the ketosis prob- urea to the diet. Although unlikely under modern management ing from incomplete digestion of the corn grain in corn practices, Dr. Guard also describes simple starvation re- silage to just trying something because cows were not sulting in death from hepatic failure of about half of the milking as expected. In all known cases of urea feeding periparturient cows during a 4-week period in a 300-cow ketosis outbreaks, recovery was spontaneous when the herd. The late dry action included conning the cows to the barn period is not a time to try to get cows to lose weight! In this model, hepatic lipido- In one study niacin was supplemented at 6 g/day to sis preceded clinical ketosis. This is not surprising be- cows beginning 2 weeks prepartum and continued at cause fatty inltration of the liver impairs gluconeogenic 12 g/day postpartum for 12 weeks. Cows receiving 6 or 12 g/day Long dry periods per se appear to put cows at in- had slightly higher milk production and blood glucose creased risk for clinical ketosis whether obesity develops than those receiving 0 or 3 g/day. Many individual cows with severe ketosis that tions, the feeding of niacin to prevent ketosis has not may be refractory to routine treatments have been dis- been widely used. Cost and the inconvenience of pro- covered to have preceding dry periods of 3 or more viding a feed ingredient only to early lactation cows months. I have particularly noticed this to be common have both contributed to the lack of adoption. The pathophysiology effective periparturient use of niacin may be in herds of this phenomenon has not been described, but many with a high incidence of ketosis (clinical or subclinical) practitioners have made the same observation. The action of these antibiotics is to re- particular during the last 3 weeks before calving, has duce acetate production and enhance propionate produc- been shown experimentally to predispose cows to keto- tion by rumen bacteria. The treatment group in this study was supplemented to glucose by the liver, an increase in its supply would with animal source protein to increase the bypass frac- diminish the likelihood of hypoglycemia and excessive tion and total crude protein intake. In situations where monensin is fed within a ration poses to both milk fever and subclinical hypocalcemia if dry matter intake decreases, the concentration of mo- principally because it interferes with skeletal calcium re- nensin may be too low to have the needed effect on the sorption and intestinal absorption by conformationally rumen microorganisms.

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Because the maxillary sinus has less of a labyrinth-like anatomy than does the frontal si- nus 25mg losartan with amex, one hole may be drilled using a 1 purchase losartan 25mg mastercard. Culture of the purulent material in the si- nus is essential for selection of appropriate systemic anti- biotic therapy 50mg losartan mastercard. Analgesics may relieve some of the pain associated with eating and thus improve appetite. Pregnant cattle with conrmed lym- phosarcoma masses seldom live through more than 2 to 3 months of gestation. Embryo transfer attempts in cows with conrmed lymphosarcoma frequently are unsuccessful because of the cow s catabolic state. Squamous cell carcinoma may occur in an orbital lo- cation but usually is preceded by lid, conjunctival, or corneal squamous cell carcinoma. Orbital squamous cell carcinomas are locally invasive, tend to metastasize, and have a grave prognosis. Carcinomas of respiratory epithe- lial origin also have been observed in older dairy cattle (more than 8 years of age). Although prognosis is poor, affected cattle may be productive for 1 to 3 years with these slow-growing tumors. Neurologic Diseases Diagnosis depends on nding other evidence of lym- phosarcoma in the patient. Unlike cases with an orbital abscess, serum mous cell carcinoma, carcinoma, and adenocarcinoma) globulins and inammatory markers are often normal in that invade the orbit causing upper respiratory dyspnea cattle with lymphosarcoma. Aspirates from the retrobul- and decreased air ow from one or both nostrils, as well bar region may be helpful in some affected cattle. Tumors have a hopeless The lymphoid tumors can be palpated along the perior- prognosis. Cattle with conrmed orbital lym- thalmos, absence of all ocular tissue, is seldom an ap- phosarcoma usually die within 3 to 6 months as a result propriate term because histologic section of orbital tis- of diffuse lymphosarcoma. Physi- cal, toxic, and infectious causes have been suggested but seldom are conrmed to explain all sporadic microph- thalmia. In Guernsey and Holstein calves, the de- fect has been linked with cardiac and tail anomalies. Most commonly these calves have a ventricular septal defect and wry tail, as well as unilateral or bilateral mi- crophthalmia. Tail defects other than wry tail have been observed in some Guernsey and Holstein calves with microphthalmia and/or ventricular septal defect. In Guernseys, these malformations are thought to be caused by a recessive trait, but in Holsteins, the exact mode of inheritance is unknown. Congenital megaglobus results from anterior cleav- age abnormalities or multiple congenital anomalies producing glaucoma in utero. The resulting absence of an anterior chamber causes congenital glaucoma and buphthalmos. Convergent strabismus with or without associated relative exophthalmos has been described as an inher- ited trait in Jersey and Shorthorn cattle. Bilateral relative exophthal- mos ( bug-eyed cows ) is a condition that has been observed in several dairy breeds and probably is a ge- netic trait. Exophthalmos in these cows does not pro- gress to a pathologic state or exposure keratitis because the eyelids still cover the cornea adequately. The calf also had Congenital nystagmus has been observed in several congenital absence of the tail and a ventricular septal breeds and is common in Holsteins. It persists throughout the animal s life and does not seem to interfere signicantly with vision. The temporal bulbar conjunctiva has become pigmented as a result of chronic exposure. Enucleation has been successful in these cases, and the relatively rare incidence rules against inheritance. Microphthalmic globes usually are not treated, but if no other anomalies exist, the owner may elect to raise a calf with unilateral microphthalmos. Chronic conjunctivitis occurs in some microphthalmic patients and, if persistent and severe, may dictate enucleation to stop chronic discharge and y irritation, thereby aiding patient comfort. Acquired Diseases Acquired megaglobus may follow severe intraocular in- ammation of exogenous or endogenous cause. Endophthalmitis and pan- ophthalmitis secondary to septic uveitis or ocular perfo- ration may also cause megaglobus. If megaglobus is se- vere enough to cause exposure keratitis, the affected globe should be enucleated to prevent eventual perfora- tion or panophthalmitis. Neurologic Diseases Unilateral facial nerve palsy causing ptosis and exposure keratitis is common in calves affected with otitis media/ interna and adults affected with listeriosis. Trauma may cause facial nerve injuries resulting in neuroparalytic keratitis in bovine patients of any age. The most com- mon cause of bilateral eyelid paralysis in cattle is stan- chion trauma wherein a cow pulls back against a stan- chion until her head is trapped along the temporal ridge between the ears and orbit. Signs of neuroparalytic keratitis include lacrimation, ptosis, absence of palpebral response, and progressive corneal exposure damage. Treatment requires therapy for primary diseases and protection of the cornea with frequent application of antibiotic ointments or tarsor- rhaphy. Cattle with facial nerve paralysis appear to be much less likely to develop corneal ulcers than in many other species. Treatment of stanchion paralysis requires warm compresses, systemic antiinammatories, and pro- tection of the cornea with ocular lubricants or broad- spectrum antibiotic ointment if indicated. Tetany of the retractor oculi muscles pulls the improvement in appetite and production as a result of resolution of pain and irritation caused by the enlarged globe caudally in the orbit, allowing passive prolapse of globe. Inammatory Diseases Less frequently, megaglobus follows intraocular neo- plasia or granulomatous infections of the uveal tract. The eyelids can perforations, chronic uveal inammation, and severe be severely swollen as a result of hemorrhage or inam- pinkeye complications such as corneal perforation and mation because cattle have abundant eyelid skin with a iris prolapse. However, if chronic conjunctivitis, surgeon a great deal of tissue to work with if surgical or facial dermatitis from discharges, and y irritation affect plastic repair is necessary. Cellulitis of the eyelids and secondary orbital cellulitis are possi- ble in neglected or dirty wounds. Less common causes of lid inammation include Congenital Diseases actinobacillosis granulomas appearing at the site of pre- Ancillary or supernumerary nasolacrimal duct open- vious eyelid injury and demodectic mite infestation. Lacerations of the eyelid may be closed using a two-layer technique with absorbable sutures (2-0) in the lid stroma and nonab- sorbable sutures (2-0 or 3-0) in the skin. Atypical large bropapilloma growing from the upper Actinobacillosis granulomas should be debulked, eyelid of a Holstein heifer. This tu- mor requires aggressive early therapy to prevent pro- gression, or the cow will be lost. In tion of early tumor formation when the mass is less most instances, the tumors are raised, rm masses with than 2. These large tumors also are are mostly white or have nonpigmented lid margins or more likely to invade adjacent adnexal tissue, orbital nictitans are at risk.

Signs of colic usually are associated with renal or ureteral inammation and pain discount losartan 50 mg amex, infection cheap 50 mg losartan with visa. Acute pyelonephritis should be considered as a but urinary obstruction caused by blood clots blocking differential for acute colic in postparturient cattle discount losartan 50 mg visa. Further agita- should be mandatory components of the physical exami- tion, such as swishing of the tail, may be observed if the nation of any sick cow with signs of colic. Cattle with less obvious uri- Latent or subclinical pyelonephritis may exist in cattle nary abnormalities will have positive blood and pro- with multiple medical problems, especially during the tein reactions on reagent test strips, and urinalysis will rst few months of lactation. Routine use of multiple test reagent strips to had dystocia may develop pyelonephritis that is masked screen urine during the routine physical examination is by more obvious signs in other systems. Only through an excellent means to detect pyelonephritis and other screening urine and subsequent urinalysis will the con- urinary tract diseases. Therefore antibiotics should be discontinued Diagnosis for 24 to 48 hours before culture of the urine. Colony counts acute pyelonephritis but may be absent in chronic pyelo- ( 103/ml on a catheterized sample or 104/ml on a nephritis. Postrenal obstruction remains an essential aid to diagnosis because it allows usually is obvious following the physical examination detection of unilateral or bilateral ureteral enlargement and rectal examination. Pre- kidney in unilateral left kidney infection or bilateral renal azotemia also should respond to rehydration infections. Most cattle with pyelonephritis the kidney may feel mushy ; and there may be a pro- that also are azotemic have bilateral disease and renal nounced arterial pulsation. These usually are chronic infec- ful to diagnosis in right kidney infections unless the tions and also have elevated globulin levels, hypoalbu- infection is very chronic with massive enlargement of minemia, inability to concentrate urine, and may have the right kidney. Ultrasonography is another helpful electrolyte abnormalities such as hypochloremia, hypo- ancillary aid to diagnosis and may reveal valuable prog- natremia, hypokalemia, and hypocalcemia. Proteinuria from blood loss alone in acute cases or more commonly appears to be very signicant in pyelonephritis and oc- by blood loss from the urinary tract coupled with re- curs in most cases. Serum globulin values may be higher duced erythropoiesis subsequent to renal parenchymal ( 5. After the organism is iden- acute cases in which brin, blood clots, and pus are tied and antimicrobial susceptibility determined, an apparent in voided urine. Some cows with acute pyelo- antimicrobial agent should be selected that maintains nephritis will suffer severe renal hemorrhage that may high concentrations in urine, is not nephrotoxic, and is obstruct the ureter or urethra, thus leading to inter- approved for use in cattle. Cows af- fected with chronic pyelonephritis also have a greater risk of developing a bilateral infection, leading to azote- mia and renal failure. Chronically affected cattle also have increased incidence of renal stone formation. The abnormal kidney usually is palpable per rectum, even if the right kidney is involved. The kidney simply feels like a mass the size of a football or basketball and has suffered chronic pyelonephritis, abscessation, and hydronephrosis. Penicillin, because of its urinary route of excre- tion, has an exponential concentration in urine versus plasma that may make the drug effective in vivo against some E. If no improvement has occurred during the initial 72 to 96 hours of penicillin therapy in E. Recommended therapy for bovine pyelonephritis, as with any urinary tract infection, is long term at least 3 weeks. The prognosis for cows with acute pyelonephritis and treated with long-term antimicrobial therapy is good un- less functional or mechanical urogenital abnormalities persist. The red uid is urine The prognosis for chronic pyelonephritis is guarded and blood and debris collected from the retroperitoneal because abscesses of the kidney or total loss of the space. Etiology Glomerulonephritis is thought to develop either as a result of antigen-antibody complexes deposited in the glomeruli or specic antibodies produced by the affected animal that attack glomerular basement membranes. In either event, damage to the glomeruli interferes with normal ltration such that protein loss from the kidney occurs and renal failure follows. The calf had marked hypoproteinemia infections, such as abscesses that continue to promote and hypertension. This familial problem was most likely a Weight loss, decreased appetite and production, poor genetic disorder with an antibasement membrane anti- hair coat, and ventral edema are typical signs in cattle af- body responsible for the glomerular lesions. Some patients have diar- nately, only one of the three animals was presented for rhea. We have also con- or chronic infections may be present in these patients, rmed renal failure caused by glomerulonephritis in a the possibility of renal disease may be overlooked. The heifers had a Rectal palpation of an enlarged left kidney may be the rather acute onset of diarrhea and edema caused by only specic physical abnormality detected. Diagnosis Because the clinical signs are similar for glomerulone- phritis and amyloidosis, renal biopsy is essential to conrm the diagnosis. Laboratory data as regards serum teinemia and hypoalbuminemia in a 2-year-old Holstein urea nitrogen, and creatinine and electrolyte levels may having glomerulonephritis of possible genetic origin. Diarrhea, although more typical of amyloidosis, may be present in some glomerulonephritis patients if hypoprotein- emia is so severe as to lead to edema of the gut wall. Unfortunately cattle with glomerulonephritis usually have progressed to renal failure by the time an accurate diagnosis is reached. Treatment Early or acute cases may be treated by supportive care for renal failure and specic therapy directed against any infections (e. Because the kidney appears to be a major site of deposition in the cow, pro- C teinuria and a nephrotic syndrome develop in bovine amyloidosis patients. Approximately half of the reported cases in two B, Glomerular loops are expanded by eosinophilic ma- case series had evidence of chronic infection that could terial and increased mesangial cells and (C) marked be interpreted as contributory to the development of diffuse thickening of glomerular basement membrane. Terminally, cattle with amy- Signs loidosis are azotemic, proteinuric, and isosthenuric. Weight loss, reduced production, diarrhea, and ventral Hypocalcemia is typical and associated with hypoal- edema characterize the early signs of amyloidosis in buminemia and calcium-binding principles. Ap- be stained with special stains to highlight amyloid de- petite may be fair to normal early in the course but tends positions. Rectal palpation may allow detection of an The iodine stains amyloid-inltrated renal tissue ma- enlarged, rm left kidney, and test reagent strips conrm hogany brown, and further staining with sulfuric acid marked proteinuria. Diar- loid for light microscopy, whereas electron microscopy rhea is thought to originate from amyloid deposition identies a characteristic brillar appearance. Diarrhea probably Treatment worsens the hypoalbuminemia because of protein loss No practical treatments exist, and the disease is fatal to from the intestine. Diagnosis The diagnosis of amyloidosis requires renal biopsy or necropsy to differentiate the disease from glomerulone- phritis. The kid- An 8-year-old Red and White Holstein with amyloidosis neys were enlarged, tan colored, and rm. The kidneys were three or four times dots can be seen in the glomeruli because of the Lugol s the normal size because of the amyloid deposition. Renal Tumors Although primary renal adenomas, adenocarcinomas, and nephroblastomas are reported in cattle, these tu- mors are too rare to merit discussion. The kidney is one of many organs involved in multicentric lympho- sarcoma in cattle. Lymphoma invasion of the left kid- ney may cause the kidney to develop an unusual shape when palpated per rectum.