Not Gout - Anyone See This Before - Pic Heavy

[bayoupig5]

Hello All,

I am attaching the link to my previous post about Akasha for mor info and reference: Gout, what to do from here? Pics Attached | Health | Bearded Dragon .org

Akasha has been in brumtion and semi brumation since her diagnosis. She has been treated as having gout since early fall. She has had one short course of antibiotics, Baytril 10 days and Ceftazadime for three weeks, but her foot remains swollen; although slightly less so. I have followed Vet # 1's advice and have been feeding with Repashy Beardie Buffet, have totally laid off the live feeders. I have also dehydrated my own greens/veg and made them into powders for reconstituted slurries as an additional supplement. I have been giving Akasha water mixed with calcium and/or multi vit throughout brumation as well. When Akasha is even slightly awake, fresh veg is provided to her, but as always never gets eaten , I have recently offered a live feeder or two, but she is not interested.

I took her to another Vet, Vet #2 this past Thursday, as since she is up more has produced bowel movements. Bowels are very soft, watery, but so is the urate. Urate started out as pink, but after 3 movements was red (see attached pic). She had not eaten anything red. Vet #2, did an examination and found her to look relatively healthy, no dehydration, no swollen abdomen, kidneys feel good, weight is up (?hydration). He decided to do some very reasonably priced x-rays (thanks goodness), which showed abnormality in her foot. I have attached copies. He did not feel that FNA and cytology would be beneficial and was he worried that this could make things worse. I have sent in a fecal sample for ova and parasites (waiting on results).

So Vet #1 diagnosed MBD, with Gout. Akasha's ratios were way out for sure at that time, but she did not show any sign of kidney disease. Also once I read the cytology report, the cytology did not say for sure that uric crystals were found, but that they were suspected.

Vet#2 diagnosed bone cancer, or osteomyelitis, and although her ratios were out back in September did not see evidence of MBD or Gout on x-ray. A repeat panel has not been done at this time. Vet did not feel new results would change the course of treatment at this time.

So....totally different diagnoses!

Akasha, did have another bowel movement after the pic. This time urate was white, semi formed, poop was soft and formed, but again lots of water coming through. I gather cancer, or infection can cause metabolical issues. Akasha is on long term antibiotics - 6 weeks of Baytril, in the hopes that this is an infection and not cancer. I have dealt with septic arthritis before in another lizard 3 years ago, and this does not look like that at all (BTW, that lizard recovered and will be turning 10 in March).

Just looking for any ideas, opinions, as I know this community is a plethora of knowledge. Thanks in advance.

 

[beardie]

@AHBD @Drache613
Either of you have any thoughts?

 

[hdochow]

on the x-rays, are you talking about something in the foot itself, or more the bones of the ankle? if it is the ankle, that looks a lot like my daughter's humerus when she had osteomyelitis as a kid. the doctors described the bone as looking "moth eaten" and i've yet to come up with a better description. i'm not sure how the bones of dragons and humans compare though.

 

[bayoupig5]

I do see that the ankle looks a bit odd as well, which does look more like a septic arthritis, osteomyelitis situation, but on the bad foot x-ray you can also see that the largest toe bone has what looks to be a growth of some kind in and around it. Also the joint that connects that bone to the other smaller bones of the foot is slightly eroded. I know this may be a difficult case. Just wanted to see if anyone else had ever seen this before....maybe this is a bone cancer

 

[hdochow]

oh i see that now you mention it, and it does look suspicious. i bet my brain just saw where you said osteomyelitis and was immediately "that bone right there" looks familiar.

 

[AHBD]

I see what resembles a feathery outgrowth of some material on the long toe [ for lack of a better description ] , is that what the vet is concerned about ? I'm not sure what would cause that, does she have trouble walking ? Sorry if I missed that, I did go back over your other thread as well but can't remember all the details. And you say that she's maintained her weight ? How often does she take the slurries while she's been brumating ?
Although this is probably not related, I would suggest putting a nice thick branch that spans from the left side platform to the second floor of the right side platform. That would give her more chances for uvb exposure at different areas .

 

[Drache613]

Hello,

Poor girl, she has had some trouble for sure!
The bone looks a little off to me, maybe some thinning or deterioration. Do you have a copy of the blood tests you could post,
too?
I didn't see any swelling on other parts of her body such as fingers, toes, etc that would be caused by gout. If she did have gout,
antibiotics are not the way to go as they just make it worse. So, two different diagnosis' does bring in confusion.
They don't think it could be septic arthritis at all? Did you ever treat your other dragon's septic case with AZT?

Tracie

 

[bayoupig5]

@AHBD @Drache613

AHBD
Yes the feathery outgrowth is what the vet is most concerned with. She does not seem to have too much trouble walking, although I have not witnessed much. She is usually where she wants to be by the time I get back home from work. I put her on her basking area in the morning and she is clear across her viv in her cave by the time I get home. Her weight is not only maintained, but she is a little more. At last weigh in she was 708 grams. So she is about 15 grams larger than August of 2021. I do not give her slurries in full brumation, I was only providing water mixed with vitamins. I have recently started slurry again since she is on Baytril, in which I make her bask for at least a couple hours. I had thought of finding a branch or something for her, the last viv had that (these vivs are pretty new). I should really try to find something, that is if her foot gets better.

Drache613
There is some deterioration of the ankle joint and the distal end of that toe bone with the feathering. There is no other swelling anywhere else on this lizard at all. Uric crystals on the last blood test showed at zero. Vet #2 suspected osteomyelitis, not sure if this could be lumped in the same category as septic arthritis. I do not know what AZT is, so no, Littlefoot was not treated with this. Littlefoot was on long term Ceftazidime (I believe about 6 months). Her issue cleared up and so far she has had no relapse.

I have typed out the last bloodwork numbers. This was in August 2021, and the most concerning numbers are the calcium/phosphorous ratios which were horribly wrong. Granted Akasha was not eating vegetables on her own, only ate bugs, and the vegetable she was getting was administered by slurry. I probably did not give her enough...so that was my fault for sure. However, calcium was given at least 4 times per week regardless, multi 1-2 times per week. Calcium bugs looked like powdered doughnuts after dusting. She was given live feeders 3 times per week, veg slurry 2-3 times per week which also had a large pinch of calcium in the mix. Fresh veg was offered daily at first until it all just dried out, never being touched. During the summer she also got plenty of natural UVB outside, so I really cannot fathom the vast imbalance (felt horrible).

Blood Work - August 2021
Total Protein 71 Range 33-73 g/L
Albumin 32 Range 15-37 g/L
Globulin 39 Range 13-39 g/L
Albumin/Globulin Ratio 0.82
AST (SGOT) 38 Range 12-107 U/L
BUN 0.4 Range 0.4 - 1.4 mmol/L
Phosphorous (scary) 13.95 Range 0.84 - 3.03 mmol/L
Glucose <0.6 Range 7.1-16.3 mmol/L
The low glucose can be best verified by submitting a fresh sample in a completely spun and separated SST, or a RTT with the serum removed and placed in separate tube. (so this result may not be accurate, I am guessing)
Calcium (scary) 0.02 Range 1.7 - 5.68 mmol/L
Sodium 174 Range 143-173 mmol/L
Potassium 3.8 Range 2.6 - 6.1 mmol/L
Chloride 140 Range 103-145 mmol/L
CPK 1216 Range 17-3421
Uric Acid 0 Range 71-500 umol/L
WCB Estimate 19.5 Range 2.8 14.6
Hematocrit 36 Range 23-39
RBC Morphology Normal
Het/Poly 60
Absolute Het/Poly 11.7 Range 1.15-6.24
Lymphocytes 23
Absolute Lymphocytes 4.48 Range 0.36-8.17
Monocytes 5
Absolute Monocytes 0.97 Range 0.01-1.08
Eosinophils 2
Absolute Eosinophils 0.39 Range 0-0.36
Basophils 8
Absolute Basophils 1.5 Range 0.01-0.82
Azurophilic Monocytes 2
Absolute Azurophilic Monocytes 0.39 Range 0.01-1.54
Thrombocyte Estimate Adequate
Addendum: Severe abnormalities in Cal/Phos ratio 0:1000 (I cannot for the life of me understand how this happened)
Moderate leukocytosis, no concern for liver or kidney disease a this time, results consistent with MBD.

If this is septic arthritis again, I really would like to know why this would have happened to not one but two of my lizards. Seems crazy, but strange tings tend to happen I guess.

 

[Drache613]

Hello,

So sorry, how is Akasha doing today?
Those values don't look too bad on most things but I am not sure I have ever seen a calcium reading quite that low, or not in a
long time!
Maybe the Parathyroid gland could have a cyst or growth on it, or be malfunctioning. The uric acid levels & AST levels look good.
Have they aspirated fluids from the affected foot at all, or just done blood work? Sorry if they have & I somehow missed that.
Since you do use calcium powder regularly & have a good UVB light, I wouldn't think that would be the issue, either.
Is her beard regular color all of the time?

Tracie

 

[bayoupig5]

Kasha, is still doing well, so far. Her beard is always of normal color, so she doe not seem to be distress. I am feeding her vegetable slurries, her appetite is still low. Brumation or side effect of Baytril? She has pooped with white urates, and formed soft poo. Still some water puddles with this. Fecal came back with normal gut flora, a little high, but no parasites or anything. Sorry, it took so long to post these FNA results. Not sure they are going to be super helpful. This was done in November. The vet she saw recently, did not do another FNA of this fluid at the last visit.

Sample Description: fluid like crystals on unstained side - suspect uric acid crystals.
Microscopic Findings: stained with Diff Quick, RBCs, scant heterophils, one chain of large rods seen, suspect keratin material
Comment: gram stain on another side, could not see any more of the chains of rods, suspect gout +/- abscessation

Hope this helps, no C & S was done.

 

[Drache613]

Hello,

How is she doing today? That's great her beard is normal then, bless her.
The Baytril is harsh so that could definitely affect appetite or behavior. This time of year, brumation is always a big possibility.
As long as her weight holds stable & she seems healthy then partial brumation is fine. This is a strange case since gout is an
option but the levels are not very high.
Remind me again did they ever try the AZT treatment on her previously?

Tracie

 

[bayoupig5]

Well, this is a sad post, as Kasha had to be put down yesterday. Despite giving calcium at every feeding she did not get better.

The antibiotics had seemed to halt the foot and ankle erosion and swelling, but 6 weeks later I noticed the teeth on her right side had detached from her jaw. Further inspection noted a 5 ml by 4 ml lump in the middle of her jaw bone.

The vet was unsure if this was a continuing calcium deprivation issue or a cancer. Never the less if this was still a calcium issue it would point to some metabolic disease that could not be fixed. I was very diligently, and purposefully administering way more calcium than usual for her. I was giving her the same doses as my gravid female, so she should not be deficient in any way.

She had also developed a head tremor when walking. This is what the vet was most concerned about. He was worried of a possible neurological issue.

Kasha also lost about 50 grams in 2 months, despite frequent syringe feeding of Repashy diet mixed with homemade dehydrated veggies. She never was interested in eating her own food after her antibiotic treatment and had not eaten on her own since Oct/Nov of 2021.

So with heavy heart, I reluctantly let her go, and it was not easy. I think the worst part is not having any idea what this was. No answers is hard, I feel like I am missing something, she was only 7 and it feels like she should have had more time.

Thanks to all who tried to figure this out, even the vets were stumped.

 

[Drache613]

Hello,

Oh no, I am so so sorry that you lost Kasha, that is so heart breaking. You did absolutely everything
you could do but I realize the worst part is not having enough answers. Terrible luck, I am sorry.
The only other issues I can think of at the moment would be a parathyroid gland or hormonal type of
disorder. I'm glad she had you, when she needed you so she wasn't alone.

Tracie

 

[AHBD]

I'm so sorry about Kasha, you certainly did everything humanly possible to try and find the problem but even the vets didn't know. You are a very caring beardie parent and have been diligent in all of their health issues. I know it doesn't take away the sadness + the yearning to know what it was + why this happened. All I can offer is my heartfelt condolences.

 

[bayoupig5]

It has been a hard couple of weeks riddled with guilt and sadness. Although, I know I did all I could do, it does not ease that pain. I just wanted to thank AHBD and Tracie for their support, knowledge, and advice. You guys have always been great. You sincerely have my appreciation and respect. Your kind words do not go unnoticed. Keep up the great work, this community is lucky to have you.