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Acute hepatic encephalopathy due to mushroom toxicity in a 14-month-old Miniature Australian Shepherd dog: Our January 2016 Case Of the Month

Patient Information

Age
1 Year
Gender
Male, Intact
Species
Canine

Images

Gallbladder cholangitis pattern. Note the hypoechoic parenchyma with inflammatory pattern (arrow) and double layered gallbladder wall.
Fluid-filled stomach
Minor heterogenous changes in the right pancreatic base and hyperechoic periserosal inflammatory pattern (arrows) indicative of pancreatitis.
Mildly increased cortical thickening indicative of mild interstitial nephrosis pattern. Note the free fluid surrounding the caudal aspect of the kidney in the near field.
Normal left adrenal gland just cranial to the left renal artery.
Normal right adrenal gland superimposed over the vena cava.
Thickened, edematous gall bladder wall. Normal common bile duct positioned above normal portal vein. Note fluid-filled stomach upper right.

Everyone loves a great mushroom... unless it's the poisonous kind of Amanita of course. Ever wonder how mushroom toxicity presents clinically and sonographically? Well, Animal Sounds Northwest's (Eugene, Oregon http://www.animalsoundsnw.com/ ) rock star sonographer Amanda Lacey imaged this young Aussie that presented for fulminant liver failure. See what the probe and needle showed on this transcontinental community effort to save this dog, and what happened between Amanda's probe at Dr. Eric Glaze's & Dr. Ken Fletcher's Albany Animal Hospital in Oregon, Lindquist's diagnosis and direction from Sparta, NJ in real-time, Oregon State's tempestive same day medical intervention in Corvallis, Oregon, and the will of this young Aussie dog to overcome those mushrooms that he never should have eaten. This round mushroom was overcome by our "flat world" of technology and effort. (https://en.wikipedia.org/wiki/The_World_Is_Flat)

History

The patient is a 14 month old M Miniature Australian Shepherd dog who presented with an acute case of vomiting, lethargy and ataxia.  The owner was unaware of any exposure to toxins or ingestion of obstructive material. Physical exam: 10% dehydrated; mm pink but tacky; abdomen tender on palpation; weight wnl. CBC/Chem: WBC 21,120, decreased cholesterol and protein; elevated CK, ALKP, ALT, BUN and ammonia. Lepto negative.

Image Interpretation

The spleen was volume contracted. The liver was swollen and hypoechoic with a double layered gallbladder. The stomach presented fluid accumulation. The small intestine was unremarkable. There was no evidence of a foreign body. The pancreas was largely uniform with minor, heterogenous changes noted in the right limb. This is consistent with pancreatitis. Surrounding free fluid was noted in the abdomen. Rapid view of the heart revealed volume contraction and shocky contractility.

Sonographic Differential Diagnosis

Acute hepatitis/cholangitis pattern. Free fluid, potentially owing to neoplasia or portal hypertension. Based on the ultrasound results, treatment for gastritis, cholangiohepatitis and pancreatitis would be recommended in this patient. Leptospirosis or toxin exposure is possible. Plasma expander +/- plasma transfusion would be ideal. No complication to FNA was noted. Volume contracted heart with shocky contractility. Very guarded prognosis depending upon underlying cause.

Sampling

Ultrasound-guided FNA of the liver was performed without complication. Cytology results: Mild vacuolar degeneration with suggested regeneration Comment: The mild vacuolar change noted could be associated with a toxic event as suggested. No evidence of underlying disease was detected and overt inflammation was not observed.

DX

Acute hepatitis/cholangitis pattern. Free fluid, potentially owing to neoplasia or portal hypertension.

Outcome

On subsequent referral to Oregon State University, it was determined that the patient did indeed suffer from mushroom toxicity (specifically, one of the genus Amanita, which were found in the patient's backyard and appeared to be partially eaten). Treatment consisted of supportive care and reducing neurotoxins produced in the GI tract. The patient's treatment plan included Denamarin, Lactulose, Cerenia and Omeprazole and a diet of Hill's L/D. Repeated chemistry panel on 10/29/15 and again on 11/23/15 showed progressive decreases in the levels of BUN, GGT and ALKP until normals were attained.

Videos

Left liver view with double layered edematous gall bladder wall, normal common bile duct and normal portal vein. Minor free fluid.
Free fluid surrounding a swollen, hypoechoic liver with edematous gall bladder.
Fluid filled stomach indicative of gastric ileus and trace free fluid upper left.
Swollen liver, free fluid and increased portal markings. Normal pylorus.
Portal hilus view showing normal portal vein, vena cava and aorta. Note enlarged and rounded hepatic lymph node above portal vein. (arrow)
Portal hilus view showing normal to subnormal vena cava volume and normal aorta. Passive congestion owing to thoracic disease can be ruled out with this view as a potential cause of ascites since the vena cava is normal to small in this case as opposed to enlarged in the case of passive congestion form thoracic disease. (Right heart failure, obstructive masses, thrombus...)
Volume contracted heart with shock-type contractility. Normal heart structure from this obliqued short axis view.