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FIG 1: Dorsal plane reconstruction of both shoulders (A) and oblique transverse plane reconstruction of the right shoulder (B) showing the
moth-eaten lysis (black arrows) along the proximal humeral physis interspaced with areas of hyperattenuating bone. The left side was slightly
more affected than the left. High-frequency reconstruction algorithm, 0.7 mm slice reconstruction thickness
was diagnosed, with additional mild swelling/effusion surround- development of nausea. A 36-hour washout period was started
ing the affected sites. prior to prednisolone therapy, and omeprazole 1 mg/kg every
Following CT examination, arthrocentesis of the effused 24 hours was initiated. Over this period, the nausea resolved.
carpal joints was performed. Cytological evaluation of the fluid Prednisolone at 2 mg/kg was given for 10 days before reducing
showed a low to mildly increased cellularity with 43 per cent the dose to 1 mg/kg. Over this period, the analgesia was further
non-degenerate population of neutrophils, 32 per cent mono- phased down; methadone was replaced with 3.3 mg/kg tramadol
cytes, 20 per cent macrophages and 5 per cent lymphocytes. No orally every eight hours and 10 mg/kg paracetamol intraven-
microorganisms were visible, and bacterial culture was negative. ously every 24 hours.
The dog markedly improved and was discharged 10 days after
DIFFERENTIAL DIAGNOSIS initial hospitalisation (day 5 of prednisolone therapy) on a taper-
This patient was being evaluated for pyrexia of unknown origin ing course of prednisolone: 50 per cent reduction after the
with primary differential diagnoses being HOD and immune- initial 10 days (1 mg/kg), and then to 1.67 mg every other day
mediated polyarthritis. (based on approximately 1.5 mg/kg every other day) for
14 days, followed by a 25 per cent reduction in dose every
14 days thereafter.
TREATMENT
The dog was started on a course of oral meloxicam at 0.2 mg/kg
on day 1, followed by 0.1 mg/kg on two subsequent days, and a OUTCOME AND FOLLOW-UP
ketamine constant rate infusion (CRI) at 0.4 mg/kg/hour, and At re-examination one week after discharge, the dog was ambu-
methadone every four hours at 0.1–0.3 mg/kg to effect. After latory and had a normal physical examination. Orthopaedic
three days, the dog had made no significant improvement and examination demonstrated pain only on manipulation of the left
hence it was decided to switch to an immunosuppressive course shoulder, with manipulation of the right shoulder and both
of prednisolone. The ketamine CRI was stopped due to the carpal joints being well tolerated. Re-examination at one month
FIG 2: Dorsal (A) and transverse (B) plane reconstruction showing the lytic changes (black arrows) in the distal radial physes consistent with
hypertrophic osteopathy. Note that the moth-eaten pattern is best seen in the transverse plane reconstruction. Additional soft tissue swelling
can be seen primarily surrounding the right perilesional region (white arrows). High-frequency reconstruction algorithm, 0.7 mm slice reconstruction
thickness
after discharge found the dog to have a normal general physical deformity or even pathological fracture secondary to disease
and orthopaedic examination and unremarkable serum bio- (Demko and McLaughlin 2005).
chemical and haematological values. In the case reported here, the joint effusion was similar in
nature to those seen in immune-mediated polyarthritis, which is
DISCUSSION consistent with the two previous case reports. However, in the
HOD, although uncommon, typically affects young growing first of these cases, chloramphenicol was administered prior to
large and giant breed dogs (LaFond and others 2002). The treatment (Woodard 1982), and in the second case, pathological
disease is also known as canine metaphyseal osteopathy and has fractures were identified, which is an atypical finding for the
an unknown pathogenesis, which is likely to be multifactorial disease process (Arnott and others 2008). Arthrocentesis may,
(Schulz and others 1991, Munjar and others 1998, Harrus and therefore, be indicated as an additional diagnostic tool, and
others 2002). Many underlying aetiologies have been suggested, further reports of the character of the synovial fluid may allow
including vaccine associations, nutritional deficiencies, microor- further critical analysis of the natural history of the disease.
ganisms and genetic predispositions (Munjar and others 1998, Diagnosis of HOD is frequently made on conventional radio-
LaFond and others 2002). graphs; this patient underwent diagnostic imaging using CT as
HOD has been identified in 40 breeds of dog (Munjar and immune-mediated polyarthropathy was considered a differential
others 1998), with most breeds represented sporadically within diagnosis. Therefore, CT examination would allow ruling out
the veterinary literature. The disease has affected entire litters of further underlying causes and determine the extent of disease.
Weimaraner puppies (Abeles and others 1999) with clinical Investigation of cases where polyarthritis is a differential diagno-
signs typically developing at three to four months of age, sis includes the differentiation of erosive and non-erosive forms
though they have been observed as early as two months of age of polyarthritis (Bennett 1987a,b,c,d), as well as determining
and as late as the time of physeal closure (Muhlbauer and whether the disease processes are primary or secondary.
Kneller 2013). Male dogs are at 2.3 times greater risk of develop- Secondary diseases are considered to be graded I to IV (Bennett
ing the condition than female dogs, and the Great Dane is over- and Kelly 1987), and bicavity imaging is recommended in order
represented in the reported population (Munjar and others 1998). to accurately categorise the condition. The cross-sectional exam-
The most common presenting complaints include gait abnor- ination in this case elegantly demonstrated the metaphyseal
malities, pyrexia and pain on joint manipulation (Abeles and changes in the affected bones also enabled the demonstration of
others 1999, Joiner and Montgomery 2011, Safra and others the associated changes, including joint effusion, perilesional soft
2013). In addition, anorexia, vomiting, diarrhoea, weight loss, tissue swelling and regional lymphadenopathy. Disease primarily
respiratory signs and nasal discharge have been reported (Abeles affecting the physes or joints or any thoracic or abdominal
and others 1999, Safra and others 2013). disease was effectively ruled out using CT.
Serum biochemical and haematological abnormalities previ- To our knowledge, CT findings of HOD have not been previ-
ously reported include serum changes consistent with juvenile ously reported in dogs. Musculoskeletal CT examinations cur-
life stage; hyperphosphataemia and elevated alkaline phosphat- rently find most application for orthopaedic diseases in
ase activity, and other non-specific changes including reduced veterinary patients. CT examination of the long bones has been
urea and creatinine levels, have been reported. Non-specific primarily used in diagnosing neoplastic bone disease (Davis and
haematological abnormalities including mild non-regenerative others 2002, Vanel and others 2002, Karnik and others 2012)
anaemia, leucocytosis, thrombocytosis and thrombocytopaenia and allows for very specific determination of tumour margins
have also been reported (Abeles and others 1999, Harrus and based on its cross-sectional nature. There has been limited use
others 2002, Safra and others 2013). of this modality for diagnosis of musculoskeletal diseases in the
Joint fluid analysis has been reported in two other case growing canine patient, but the cross-sectional nature and high
reports (Woodard 1982, Arnott and others 2008); in both cases, resolution of bony structures lend itself favourably to the careful
a sterile polymorphonuclear neutrophilic infiltrate was evaluation of the epiphyseal, physeal and metaphyseal struc-
identified. tures, and 3D modelling allows further understanding of pos-
Radiographic appearance of lesions is typically of a periosteal sible present limb deformities (Dismukes and others 2008,
hyperplasia and calcification (Carbery and Thompson 1976), Meola and others 2008). Additionally, CT examination of the
creating a ‘moth-eaten’ appearance. Lesions are usually symmet- appendicular skeleton can be conducted concurrently with
ric and may occur on any long bone metaphysis; however, other bicavity imaging, facilitating a more streamlined diagnostic plan.
locations have been reported, including the mandible, cranium This report suggests that this is a useful modality that may offer
and ribs. A line of reduced opacity adjacent to the physis can be the potential for early diagnosis of this condition as it may
seen as the predominant finding; this has been described as a allow for identification of more subtle bony changes than stand-
double physeal sign. The physis itself appears normal, and mild ard radiography. Ideally CT could also be used to follow up on
metaphyseal flaring may be present. Swelling of the soft tissues bone healing but was not applied in this case as no complica-
is not uncommon. Later in the disease boney cuffs may develop tions were encountered. However, conventional radiographs
along the metaphysis and periosteal reaction can be seen will remain an inherent component of the work of these cases
(Olsson 1972, Muhlbauer and Kneller 2013). in most first opinion practices.
Treatment is non-specific and is aimed at managing the Clearly it would be ill advised to embark upon a treatment
pyrexia and the bone pain using either non-steroidal medication protocol that included both steroids and non-steroidal anti-
or steroids with adjunctive analgesia as necessary (Abeles and inflammatories (Whitely and Day 2011). It would therefore be
others 1999, Miller 2001, Safra and others 2013). useful to the clinician to have additional tools that might allow
Relapses of the disease are possible and should be treated differentiation between those patients who are likely to respond
using the regimen that was most effective for the preceding to non-steroidal anti-inflammatory medication and those who
event (Abeles and others 1999, Safra and others 2013). Relapses may not. Arthrocentesis may be of utility in this regard;
may occur up until the closure of the growth plates has com- however, further data are required to establish the diagnostic
pleted, and dogs with severe disease may develop angular limb evaluation of this disease.
Contributors All authors contributed to the production of the manuscript. MH was HARRUS S., WANER T., AIZENBERG I., SAFRA N., MOSENCO A., RADOSHITSKY M.,
the primary author with CJS, BA and RD contributing equally. Images were prepared BARK H. (2002) Development of hypertrophic osteodystrophy and antibody response in
by RD. a litter of vaccinated Weimaraner puppies. Journal of Small Animal Practice 43, 27–31
JOINER K. S., MONTGOMERY R. D. (2011) Pathology in Practice: Veterinary Medicine
Competing interests None.
today. Journal of the American Veterinary Medical Association 238, 1413–1415
Provenance and peer review Not commissioned; externally peer reviewed. KARNIK K. S., SAMII V. F., WEISBRODE S. E., LONDON C. A., GREEN E. M. (2012)
Accuracy of computed tomography in determining lesion size in canine appendicular
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