S2 E1: Urine Luck!

Welcome to Tails from the Lab, where an ever optimistic veterinarian and slightly salty technician entertain listeners with true stories and tall tales revolving around laboratory diagnostics.

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Welcome to today’s episode. You’re in luck.

How could I forget? I’m Jessica.

And I’m Holly.

Welcome to Tales from the Lab. We’re so excited to have you all here.

It is a busy time of year for everybody, or at least for us. It’s a busy time of year. I think you just keep adding more and more things to my calendar.

There’s a lot to do, a lot of education.

There is a lot of education going on.

We had a wonderful time at London Vet Show. We got to meet our first fan. That was super exciting. Yeah. So this is my shout out to Deirdre in Ireland.

She’s a Clinpath resident. That was pretty awesome to meet her and get to actually hear from someone that’s been listening and was really excited. Although she did say, I didn’t realize it was the two of you until the picture came up at the end of our talk.

Oh, so she didn’t actually show up for our talk because. So she wasn’t following us. She hadn’t come to see us live specifically.

She came for the Clinpath stuff and then was like, oh, it’s you two.

That’s pretty fun still.

Yeah, it is really fun.

Bella. She’s an 11 year old female spayed labradoodle and she’s been a patient at our hospital for years.

She was diagnosed with idiopathic epilepsy years previously and she has been on fenobarb and it’s been uneventful, her management of her seizures.

She comes in regularly for her annual exams and actually biannual exams and prescription refills to stay on the fenobarb.

And everything had been going fine at home.

She had had two seizures at home. So out of the blue, that was new, a change for her. And I wasn’t part of this follow up on those seizures, but I believe that they called in, they had talked about the increased seizure activity, or the.

The breakthrough seizure activity, if you call it that. And they increased her phenobarb dose, told them, yes, you can increase your phenobarb dose. And they made an appointment For a recheck sound.

Right.

That sounds absolutely right.

That’s what we think. She comes in for her recheck. Right. Owners believed they were there for a check in.

Right.

And a prescription refill. Yep.

The technician that was in this room did a really great job because in talking to them,

she discovered that Bella was actually urinating more frequently.

And she also had some weight gain and some hair thinning over her dorsum. So just some changes. The increased urination, you definitely could explain that by the increase in the phenobarbital.

But how many times have we thought, oh, it’s going to be because of this? And it was something else.

We need objective data.

That’s right.

That’s exactly right. To try and interpret those behavioral changes to know if they’re actually pathophysiologic.

Yeah. And again, the weight gain could certainly be in response to phenobarbital. You know, eating more, you know, we’re urinating more. So.

But great job to the technician because she told the owners, I really think that we probably should do a urinalysis just in case it’s not.

I don’t think the owners knew the weight gain or had appreciated the hair thinning over the dorsum. Right. I think that because we get objective data like weighing the patient, it was brought to their attention.

Right. Because you don’t know it when you’re the owner and sometimes you actually don’t even realize it can be fairly insidious, the increased drinking or increased urination if it’s slower in onset.

Right. And when they were asked further pointed questions, as you bring up, I think they had indeed said, oh, we remembered her doing this when we loaded her on her phenobarb.

So they were not concerned.

Right.

But together with weight gain and in speaking to the veterinarian, also to the physical exam and about that hair loss pattern. Right. That again, had been a little insidious in onset.

I think they decided we really should probably get some lab work going because it’s a good time to get another baseline in case there have been changes.

Yes. And so in addition to a phenobarbital level, we’re going to want to do that full minimum database. We’re going to want a cbc, chemistry, electrolytes and that all important urine that I think that we,

at least at our hospital sometimes forget we need to get it.

I think it is safe to say it’s not just at our hospital.

I was trying to be nice.

I think it is a problem across our profession and it is so important in its own right. Right. And I think we’ve talked about this for. Maybe we haven’t done a urine focus one.

Of course, it’s important in its own right to evaluate the urinary tract specifically.

But of course, to properly interpret your CBC and of course, your biochemical changes, that we need to pair that data together. And we are so lucky. In Bella’s case,

we have her historical data. Right. That we do lab work in periods of wellness and for her prescription refills.

Right.

So we had been keeping an eye on things and trending some of her data. And actually, one thing that the owners and the clinician had been aware of is that she had had a rise of in her liver enzymes and her alkyne phosphatase.

Right. In her alt. Right. So both of those had been increasing since she had been on the phenobarb,

or at least over the past several years that they had attributed to the phenobarb and hadn’t worked up further given the absence of other clinical disease clinical signs.

Well, as they were talking further about the case right there at ultrasound, as the technicians are holding the dog and the doctor’s doing the ultrasound to grab the cystocentesis,

he struggled for a while, right. In trying to find the bladder. And he’s one of our more seasoned doctors. Right. After looking for a while and being pretty frustrated,

he said, well, well, you know, she must have urinated on the way in. Right. And I guess just take her back to the room as we wait for her blood work results.

Um,

and I couldn’t resist, of course, as a clinopathologist, to be like, oh, man, we really do need that urine, though.

Right.

I overheard the technician just explaining that she was peeing more. Right. And it might be her fenobar, but it may not. And as we’re evaluating her chemistry that we are also looking at, we really want that, that paired urine.

And I said,

do you think that maybe they took her outside on a walk? They could get a free catch sample even if she just marked, even some marking behavior might give us a few drops to even get a urine specific gravity.

I get tasked with going outside to collect urine, which I fully understand the reason why we need to get it.

We typically do cystocentesis, like we were saying, but a free catch is also a great option.

So out I go with my urine collection stick and another technician,

and we actually get quite a lot of urine in our little collection bowl.

And it is,

I mean, dark red pigmented urine. And I am now I’m Intrigued and excited because he couldn’t find the bladder.

It obviously was rather large because we got,

you know, 200, 300 mls of urine.

And now I’m like, what the. What is going on?

It’s so clearly pathologic too. Right.

I remember his expression, the doctor’s expression as he came into lab and you were like, this is Bella’s urine. And he said, what? He said, go grab me a ladder of radiograph.

What’s going on? Right. So like, he couldn’t. How could I not have seen it if she has that much urine in her?

Correct. So we take her down to radiology and we snap a quick lateral radiograph and you can see the bladder. It just looks a little different than what we would normally see.

Right. So you can definitely see the outline of the bladder and there’s still urine in there. Right.

And sorry to interrupt you. I will post the. Not only the image of the urine, but also the. The image of the lateral radiograph up on our Instagram so that you guys can all take a gander at what.

We were seeing,

because it’s remarkable. Right. It was the first time we had seen a bladder look like this. And so I’m gonna do my best to describe it. The bladder wall itself has a mixed radio density to it.

Right. So a dark outline to the bladder. That’s irregular, I would say. And then it seems like the bladder’s filled with more radio opaque, more radiopaque. Right. With like that typical soft tissue appearance.

Although in this case, I’d say it looks modeled. It turns out this is Emphysematis cystitis. The reason it looks like this. Right. Is that there’s gas producing bacteria. I think the gas producing bacteria in the bladder wall, which I appreciate here.

Right.

It changed the echogenicity in the ultrasound and superimposed on the other soft tissues around there. So he couldn’t delineate the bladder, you know, from the surrounding tissues.

Right.

But it was the first time we had seen that at our hospital.

Yeah.

So the next thing we have for Bella is to look at her urinalysis. Right. So we have this pathologic urine that we were pretty excited to get, especially because we almost missed it.

Correct. Yeah.

So we have this pigmenturia and we know from Sally that we don’t want to over call it as hematuria. We don’t want to just make that assumption. We need to look at it microscopically before we can make that determination and kind of go down the different pathways.

And likely in hers, given the clots.

Right. I mean, she literally had large clots,

which is wild.

That they didn’t appreciate that at home. Obviously only urinates outside.

And maybe she spends a lot of time outside by herself. That even if she had a dysuria. And maybe she does, maybe she doesn’t, but they didn’t appreciate frequent squatting or any uncomfortable.

Yeah, I feel like we have more hematuria in the winter in Pennsylvania because people see it in the snow.

Yeah, 100%. Yeah.

Okay. So she had on her urine sediment.

Innumerable red blood cells.

White blood cells significantly increased. Not just that were blood associated. Right.

And reported bacteria.

Right.

So we do have.

What we like to do in the face of suspected bacteria. Right. And they’re in sediment. Is to turn that urine sediment into a cytologic preparation. Right. Where we’re used to looking and confirming bacteria is when it’ on a dry slide and stained routinely.

Right. So maybe you speak to making a urine.

Well, what I would like to say is that what this would be a great thing for is a little tech talk on urine.

So we could go through how to prepare your urine and also this Lyme prep.

I love it.

That way we can, you know, keep moving through the case.

I think it sounds perfect.

Okay, tech talk coming on your list. On my list. Thank you. More things.

You said it. Your words, not mine. Okay, so we do confirm that she has a bacterial infection. Right. Looks like rod shaped bacteria.

And again, thank goodness we got that sample. It is.

It’s very upsetting to think that if without the owner’s concern,

there was a chance that we could have refilled her prescription and sent her back home with this infection.

Correct.

And I told you, I looked back in her record when they were talking about the case and seeing that we had seen her about four or six months ago, and we do have a urine from that day, and she actually had a urinary tract infection, then it was not cultured.

It was treated empirically with antibiotics, and we did not do any follow up.

So it’s interesting to note that we actually don’t know whether she’s had a persistent chronic infection. Right. Or a recurrent one. But it definitely made us look a little more critically,

I think, at the rest of her lab work to wonder, is there a reason that she would have a recurrent infection? So we look at her chemistry profile.

When I had mentioned before that she had had an elevation in her ALT and her alkaline phosphatase, and they did continue to rise with a much more significant jump in her alkaline phosphatase at this visit than it was six months previously.

And wondering if she may have a reason for immunosuppression or an altered immune response that made her predispose to recurrent or persistent infections.

Is that now the doctor is looking at this more critically to wonder, you know, do you think she could have underlying Cushing’s, is that now contributing to this elevation of her liver enzymes?

And really markedly so on the alkaline phosphatase is really her increase here with only a mild elevation in her alt.

And additionally,

just we’ll also mention on her chemistry profile, there was another change since her last visit as well, and that was that her cholesterol was now increased.

Increased cholesterol in a mature dog. Common reason actually is going to be underlying hypothyroidism.

So another endocrinopathy.

One endocrine disease is complicated.

Yes. One endocrine disease is complicated.

Comorbidities are complicated.

Do not hesitate to reach out to Antech’s Consultation Services.

They are a fantastic group of board certified specialists and a variety of specialties and they love what they do.

Yeah. And I think they do a really good job supporting and really helping doctors with these difficult diagnoses and interpretations of lab work.

We speak from experience.

Yeah.

Because we’ve reached out to them for their clinical expertise. Right. It’s more than just the test, but it’s how the test applies to that patient at that time. And I think Bella’s a perfect example.

Right. Where the clinician’s concerned about underlying hyperdrenocorticism, maybe, maybe underlying hypothyroidism.

And yet we’re in the face of this emphysematous cystitis. And what does that workup look like and how we’re going to interpret the results.

And in Bella’s case,

the recommendation is to not confuse the workup for hyperrenocorticism or hypothyroidism with her current clinical presentation of emphysematous cystitis. Right. And so to work on treating first this known infection and then when we revisit, she’s still polyurethic.

Polydipsic underlying concerns for hypodrenal cortisone, if they persist,

then your workup with your low dose dexamethasone suppression test, or however you want to test that adrenal excess, you’ll have more confidence in the interpretation because it’s not confounded by this comorbidity.

And I think that’s a really nice point. It’s Nice to have the guidance from the consultation service to be like, okay,

take one thing kind of at a time in this case and we’ll start with clearing up that bacterial infection. And indeed, we cultured our urine,

came back with E. Coli. Luckily it was responsive to the antibiotics, so we had that nice list of antibiotics and whether it was sensitive or resistant. So we were able to treat that bacterial infection first and foremost.

Also in the consideration for possible underlying hypothyroidism right now, not that,

you know, her hyper adrenocorticism could contribute to the high cholesterol as well, if that’s what’s going on, given the jump in her alkaline phosphatase. But with hypothyroidism, you know, being on the phenobarbital,

that’s going to mess with the measurement of total T4, even free T4. Right. So I think that would be a. It’s a challenging workup in the face of phenobarbital treatment medication.

And so again, tabling that for now so we’re not wasting the owner’s money looking at values that don’t apply to this patient at this time.

So our take homes, what are our big points for this case? I think first and foremost is don’t forget to get urine.

As we know, if you’re going to run chemistry and cbc, we need the urinalysis to properly interpret that.

But in addition,

when she’s polyurechic and polydipsic, it would have been a real miss to not have that urine sample.

And now they know what emphysematous cystitis looks like. Maybe not by my description,

but when they go on Instagram, yeah, they can.

See what it looks like on the radiograph and also they can see what that bacteria looked like when we did the Lyme prep for her urine sample. Because sometimes that can also be tricky when you are looking either under the microscope or on your AI analyzer.

If there is bacteria, especially if we have a lot of red blood cells or sometime that amorphous debris, it can be difficult to see. So putting it in the form of a cytological prep can make it easier for us.

Perfect. And to not hesitate to reach out to Intech’s consultation service that they are a wealth of knowledge.

Again, really enjoy what they do and make the practitioner’s job a whole lot easier to have them to lean on.

Thank you for listening.

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