Kara, a 6.5 year old female intact Alaskan Malamute, was presented to Hickory Veterinary hospital on June 4, 2010. Kara had vomited once prior to presentation, and the owners relayed that Kara appeared "bloated." It was their intention to breed Kara, though they were unable to verify the onset of her most recent estrus cycle.
In addition to the abdominal distension appreciated by the owners, the admitting veterinarian also noted serous to mucopurulent vulvar discharge. Radiographs demonstrated a large discreet soft tissue opacity in the mid-to-caudal abdomen, and a FAST scan was also consistent with multiple fluid-dilated loops. In spite of these findings, initial blood work was generally unremarkable. The admitting veterinarian strongly recommended hospitalization and an exploratory laparotomy given her suspicion for a pyometra; however, the owners declined and elected to pursue medical therapies in lieu of surgery. Intravenous fluids, ampicillin and enrofloxacin were initiated, and intravaginal misoprostil was administered (25mcg BID, placed at the level of the cervix).
Within 24 hours Kara's leukocyte count plummeted, and the attending surgeon again recommended surgery based on the probability of septicemia secondary to closed pyometritis. The owners agreed an exploratory laparotomy revealed a diffusely thickened fluid-filled uterus as well as approximately 300mLs of abdominal effusion. The bladder was also profoundly distended, thin-walled and presumptively necrotic at the level of the apex. The dorsal aspect of the trigone also appeared altered as the mucosa was discolored "purple." Thromboses were noted at both locations. Twenty-five hundred milliliters of hemorrhagic urine was evacuated from the urinary bladder prior to uterine resection, and an in-dwelling urinary catheter was placed. Urinalysis and urine culture subsequently revealed isosthenuria, proteinuria, pyuria, hematuria, bacteruria, and an enrofloxacin-resistant E. coli.
Bethanecol was initiated post-operatively for Kara's profound bladder atony as well as cefoxitin and later, Timentin, which was shown to be an appropriate choice based on the susceptibility pattern on the urine MIC. Clinically, Kara was recumbent and painful on abdominal palpation within the first 48 hours post-operatively. Her urine collection system yielded large quantities of hemorrhagic urine (>3mL/kg/hr). An abdominal ultrasound performed at the time was consistent with a distended urinary bladder containing echogenic debris as well as a diffusely hyperechoic peritoneum consistent with the peritonitis documented during surgery.
Serial complete blood counts and chemistry screens obtained post-operatively demonstrated a marked neutrophilia initially approaching 50K/mcL as well as a moderate azotemia and hyperphosphatemia. Despite Kara's profound inflammatory leukogram, coagulation parameters assessed post-operatively were within normal limits with the exception of a moderate and later, marked thrombocytopenia. Two days post-operatively, Kara was also noted to be anemic and hypoalbuminemic. She developed peripheral edema shortly thereafter, and synthetic colloid as well as intermittent plasma therapy were initiated.