ADR (Ain’t Doin’ Right) Shar-Pei- or
What to do when blood work is normal in a sick dog.
Pardon me while I preface this discussion with the following disclaimer.
I often get inquiries about sick Shar-Pei and "the blood work is normal".
I will be talking about what I do in such cases. The material contained
herein is based on my experience, what I've read in the veterinary literature,
opinions and observations. Any comments, criticism or questions should be
directed to me. I also look at this as a work in progress and fully expect
to add to it as experience, new information and discussions with colleagues
further enlightens me. I present this material now to provide some insight
into what to do with the difficult Shar-Pei case.
I look at the diagnostic workup in any sick animal in terms of levels.
These levels may be thought of as the floors of a building and divide out based
on the availability of tests, costs of tests, ease of obtaining the test samples,
the equipment needed to run the diagnostic tests and the experience and comfort
level of the veterinarian in interpreting the test results. The higher you go
up in the building the more specific, more specialized and more expensive the
The first level of diagnostics consists of the history and physical
examination. This level is extremely important and requires the owner's
accurate information and observations. Many times a tentative diagnosis
is reached at this level but if not, the information collected here often
determines whether to proceed with the rest of the work up or consider a
The second level of diagnostic testing is the basic workup consisting
of a complete blood count (CBC), a blood chemistry screen, a urinalysis, a
stool sample check and usually a chest and abdominal radiograph or
radiographs. The purpose of the basic workup is to provide a sense of
direction for additional testing, if needed. Many times the basic workup
provides enough information for a diagnosis. The fact that the basic workup
doesn't provide a diagnosis should not be interpreted to mean that the dog
is normal or that there is nothing wrong. Normal results more often mean
additional testing needs to be done. Another possibility is that the workup
was done too early in the course of the disease process before significant
changes have occurred. This workup doesn't adequately evaluate the
gastrointestinal system, the endocrine system, the neurological system, the
cardiopulmonary system or the musculoskeletal system. It often does not
help when evaluating for infectious diseases or immune-mediated disease.
Once the basic workup is complete and has not provided a definitive diagnosis,
the third level of diagnostics come into play. In my scheme of things,
this is the level in which the options for diagnostic testing increase
dramatically. Hopefully, the information gathered at the first and second
levels provides enough information to narrow down the testing choices in
this third level. In this category I place serologic testing for
leptospirosis, testing for systemic mycoses such as blastomycosis and
histoplasmosis, testing for tick-borne diseases such as Lyme's disease,
ehrlichiosis, and others. Other blood tests in this category would include
testing for immune-mediated diseases such as autoimmune hemolytic anemia,
systemic lupus erythematosus, immune-mediated thrombocytopenia, myasthenia
gravis, masticatory myositis, etc. Bacterial culture and sensitivity
testing would be included here as would uncommon tests such as urine protein:
creatinine ratios and urine cortisol: creatinine ratios. Additional testing
could also include tests of the endocrine system such as the ACTH stimulation
test and dexamethasone suppression tests for Cushing's disease, thyroid
function tests, insulin levels, etc. Testing of pancreatic digestive
function utilizing the TLI (trypsin-like immunoreactivity test) may also
fit in this level. Tests of the gastrointestinal system like a B12/Folate
blood test or the newer fecal a1- proteinase inhibitor test fit in this
level as well. There are quite a few blood tests at this level but bear
in mind that the information obtained from the first two levels will provide
a direction for the testing here. Other testing here would include contrast
radiographic studies, which utilize iodine-containing solutions or barium to
highlight the gastrointestinal tract, the urinary bladder, the kidneys, the
spinal canal, etc. Electrocardiography and blood pressure measurement might
also be used at this level.
A definitive diagnosis may still be elusive and fourth level diagnostics
may be required. Diagnostic tests here include ultrasonography, contrast
radiography, MRI, CT scans, laparoscopy and fiberoptic endoscopy. Various
biopsy techniques including the exploratory laparotomy are placed at this level.
Please remember this classification is my own way of explaining diagnostic
testing. The levels are not written in granite and vary with the availability
of equipment and laboratory services. For example, a veterinarian with
ultrasound experience and equipment may do an ultrasonographic examination
very early in the workup. Likewise a veterinary internist may proceed
directly to specialized testing that a general practitioner may not have
access to or not do very often.
With the "ain't doin' right" Shar-Pei the following disease categories need to be considered specifically:
- Inflammatory Bowel Disease
Gastrointestinal disease often is not demonstrated in the general workup, but I do pay
particular attention to the albumin and total protein levels. These are often slightly
low due to loss of protein in the GI tract which occurs with IBD. Additional tests
which may help to further define the problem include a direct fecal smear to rule out
Giardia, a fecal floatation to rule out intestinal parasitism, a trypsin-like
immunoreactivity test (TLI) to rule out exocrine pancreatic insufficiency or lack of
digestive enzymes, a B12/Folate blood test to rule in protein-losing enteropathy and a
relatively new test called a fecal alpha-1 protease inhibitor test which also helps to
diagnose protein-losing enteropathy. These tests can be done at many local
veterinary labs or more information can be obtained from the Gastrointestinal
Function Test Laboratory, College of Veterinary Medicine, TAMU 4474, College
Station, TX 77843-4474, phone (979) 862-2861. They also have a web site at
www.cvm.tamu.edu/gilab. Ultimately, IBD is a diagnosis based on intestinal
biopsies via exploratory abdominal surgery or fiberoptic endoscopy.
- Familial Shar-Pei Fever
A multitude of abnormalities can show up in the blood work in cases
of FSF depending on when during the episode blood tests are taken.
Usually a moderate to severe stress leukogram is present characterized
by a neutrophilia or increase in the neutrophil count. Often there is
an increase in the liver function test results due to the release of
acute phase reactant proteins. Other changes can include increases
in kidney function tests due to dehydration and electrolyte abnormalities
due to vomiting and diarrhea. The diagnosis is based on the characteristic
fever and fairly quick response to therapy. Complications of FSF need to
be considered such as DIC (disseminated intravascular coagulation),
STSS (streptococcal toxic shock syndrome), splenic torsion or
thrombosis, thromboembolism in general, SIRS (systemic inflammatory
response syndrome) and MODS (multiple organ dysfunction syndrome).
- Cancer, in general, can result in clinical signs of weight loss,
changes in behavior, decreased appetite, lethargy, depression, etc.
Primary cancer types to think about in Shar-Pei include lymphoma and
mast cell cancer. Radiographs often are helpful as are additional
diagnostics such as ultrasound, CT scans, MRI and exploratory surgery
with biopsy. As an aside, gastrointestinal lymphoma can present with
clinical signs similar to IBD.
- Endocrine diseases are a fourth category in which vague and nonspecific
clinical signs often predominate. Hypothyroidism, Cushing's disease
(hyperadrenocorticism), Addison's disease (hypoadrenocorticism) are
diseases, which may not easily show up on routine blood testing and
require additional tests to diagnose them.
- Infectious diseases including tick-borne diseases can also have vague
signs and require additional blood testing beyond the routine workup.
These diseases include Lyme's disease, ehrlichiosis, babesiosis,
leptospirosis, and others. Systemic mycoses (fungal infections)
such as blastomycosis, histoplasmosis and, in some parts of the
country, cocciodiodomycosis would be included in this category as
well. Chronic bacterial disease such as brucellosis should be
considered in appropriate circumstances. Further pursuit of these
diseases involves the use of serologic blood testing.
- Immune-mediated disease including immune-mediated hemolytic anemia,
immune-mediated thrombocytopenia, immune-mediate skin disease such as
pemphigus variants, hepatitis, glomerulonephritis, and various
neuromuscular disorders such as myasthenia gravis and masticatory
myositis fit in this category. Specialized tests are necessary
such as various immune panels, acetylcholine receptor antibody levels,
2M muscle antibody levels, etc.
- The cardiopulmonary system can be further evaluated with the use of
an electrocardiogram, cardiac ultrasound. I have seen primary and
metastatic (cancer spread from another area to the lungs) neoplasia
to the lungs, heart-based tumors and primary heart disease in Shar-Pei.
Early in the course of these diseases coughing and breathing problems
may not be part of the clinical picture and only decreased activity,
weight loss, loss of appetite may be noted.
- The neurologic system is notorious for being difficult to evaluate.
Additional testing involves CSF (cerebrospinal fluid) tap, myelograms,
CAT scans and MRI studies. Diseases to rule out include various types
for cancer including lymphoma, and discrete tumors involving the brain
and spinal cord. Inflammatory disease such as granulomatous
meningoencephalomyelitis (GME) and otitis media or middle ear
infection need to be considered. Another condition to be considered
here in the Shar-Pei is glaucoma or an increase in intraocular pressure.
In some Shar-Pei I've seen an early intermittent glaucoma characterized
by temporary blindness and pain which may last for only a few hours and
then return to normal. Checking intraocular pressure during an episode
would be the means of diagnosis. Another aspect of this subject involves
Cognitive Dysfunction Syndrome (CDS) also called canine Alzheimer's
disease. Many vague symptoms can fit this syndrome in the older patient.
Lastly, emotional and behavioral upsets can often reflect as vague and
non-specific signs such as loss of appetite, weight loss, lethargy, etc.
- The musculoskeletal system is also not evaluated very well in the routine
workup. Pain related to degenerative joint disease (arthritis) and/or
muscle/ligament strains and sprains can be reflected in vague signs such
as decreased activity, decreased appetite, lethargy and changes in behavior.
Often diagnosis is based on additional radiographs and, more importantly,
response to therapy with pain-relieving medications. Anterior cruciate
ligament rupture and luxating patella involve the stifle, hip dysplasia
and elbow dysplasia are orthopedic problems seen in Shar-Pei.
- Lastly, in intact animals, the reproductive system can be a source of vague
symptoms. In males, I worry about prostate disease whether it be
prostatitis, benign prostatic hypertrophy, prostatic abscesses or
cysts, testicular torsion or prostatic cancer. In females we need to
consider ovarian disease such as ovarian cysts or ovarian cancer and
uterine diseases such as endometritis, pyometritis, uterine cancer, etc.
One of the major points in the workup is to do it within a reasonable period of time. Too often therapeutic trials are tried as the pet continues to deteriorate and by the time additional testing and/or biopsies are recommended it's too late. The Shar-Pei owner must decide early in the course of the workup how far to go in terms of finances, time, commitment to the pet, etc. Often the delays in the progression of the workup are due to wavering on the owner's part.
My intent has been to illustrate the complexities of the workup and the range of diagnostic tests and procedures, which are available to the pet owner and the veterinarian. There are other testing procedures I may have missed and others, which will be available in the future. One thing is always certain - cutting edge technology will never stand still.