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It Takes a Team

By: John Donges Date: Nov 10, 2016

At only eight months of age, Max was fighting for his life. When he was surrendered to Adopt A Boxer Rescue (AABR) in late May, he could not walk, was in extreme pain, and had a high fever. Max rests in an oxygen cage in ICU

Jamie Meadow, LVT, Sandy Trehy, and Dawn Karam founded AABR in 2004. The all-volunteer charitable organization rescues, rehabilitates, and re-homes unwanted and abandoned Boxer dogs. Their network extends from Massachusetts to Northern Virginia.

AABR volunteers took Max to Anne Arundel Veterinary Emergency Clinic (AAVEC) in Annapolis, MD, where Meadow’s husband, Dr. Mark Meadow works. Max had a high fever and was having difficulty breathing.

A chest x-ray revealed pleural effusion, a build-up of fluid around the lungs. In addition, Max’s platelet and red blood cell counts were very low. Suspecting an infectious disease, the AAVEC team started Max on IV fluids and administered a diuretic, antibiotics, and a painkiller.

The following day, Max still could not walk and continued to have labored breathing and pleural effusion. The decision was made to transfer him to Penn Vet for further diagnostics. Max’s foster parent, Tammy Martin, an AABR volunteer, made the three-hour drive to Philadelphia with the ailing Boxer.

Critical Care

Max already had the support of AABR’s dedicated volunteers and supporters, as well as the staff at AAVEC behind him. When he arrived at Penn Vet’s Ryan Hospital, Max would soon add a large number of clinicians, veterinary technicians, and students to his team of caretakers.

During Max’s two-week stay at Ryan Hospital, eight different services played a role in his diagnosis and treatment, working together to figure out the cause of his life-threatening illness. 

Dr. Anthony Gonzalez, Resident in Emergency and Critical Care, received Max in the Emergency Service. On presentation, Max was in shock from a combination of low blood and oxygen supply. Gonzalez administered packed red blood cells and broad-spectrum antibiotics, pain medications, gastroprotectants, and anti-emetics. Max was also placed in an oxygen cage.

“When dealing with a difficult case like Max's, my initial priorities are to make sure the owner understands how critical their pet’s condition is and make certain they are committed to the potentially long, uphill battle—both emotionally and financially,” said Gonzalez. “The pet's current quality of life and projected quality of life is just as important—if not more. Max was always in good spirits, so that made it much easier for us to continue his diagnostics and hospitalization.”

The next day, Max was transferred to the ICU. He would remain there for the rest of his lengthy stay, receiving round-the-clock care from a team of dedicated veterinary technicians and students. Dr. Deborah Silverstein, Associate Professor of Critical Care, oversaw his treatments and coordinated consultations with the other services.

“Max was critically ill and in an advanced stage of disease that made it difficult to pinpoint one cause for all of his problems,” she said. “At Ryan Hospital, it’s beneficial to have the expertise of multiple specialties as we pursue our diagnostic and therapeutic treatment plans.”

Teamwork

Specialty consultations began with Dr. Alexander Tun, Neurology Resident. Given the history of fever and Max's young age, he suspected an infectious or inflammatory issue. The front and hind limb lameness was particularly suspicious for multifocal discospondylitis, an inflammation of the vertebrae and intervertebral discs.

“Max was a complicated case. He was fortunate to have arrived at Ryan Hospital, where so many experts from different specialties could work together to help address all of his issues,” said Tun.  

Dr. Mark Oyama, Professor of Cardiology, performed an echocardiogram on Max to look for an infection in the heart, specifically endocarditis. Unfortunately, nothing about the evaluation helped to determine Max’s primary disease.

This CT scan of Max's pelvis shows osteomyelitis of the bone at left. The dark region at right is an abscess.Over the next week, Max spent a lot of time in Radiology, undergoing a number of imaging scans, which revealed just how sick he was. Ultrasounds showed abscesses in his lower back, right hind limb, and pelvic canal. A CT scan also showed several abscesses in his muscles and bones. Concurrent gastritis and inflammation surrounded his pancreas. His bladder also appeared thickened.

Lumbosacral radiographs revealed that Max did indeed have discospondylitis in his vertebrae. And chest radiographs indicated there was still significant pleural effusion in his chest.

Simply put, Max was extremely ill.

Diagnosis and Treatment

The Penn Vet team hypothesized that Max most likely had an overwhelming infection in his blood that had spread throughout his body.

Max in ICU on day 10Experts in Ryan Hospital’s Microbiology lab tested numerous samples to help determine the exact cause of the illness. They tested Max’s blood and urine, cultured his lumbosacral and thoracic abscesses, and looked at the cytology. 

The culture of the lumbosacral abscess showed that Max was growing a species of bacteria called beta-hemolytic Streptococcus, which caused the spread of abscesses throughout his body. This, in turn, affected his muscles, joints, disc spaces, spinal cord, lungs, ribs, and lumbosacral bones.

“We commonly see this bacteria in dogs, but it can occasionally turn into an invasive infection,” explained Dr. Stephen Cole, Postdoctoral Fellow in Clinical and Molecular Microbiology. “The infection can spread through the blood and cause abscesses or necrotizing infections in a variety of locations. We see it cause joint infections, UTIs, and single abscesses; a severe, disseminated presentation like Max’s is rare.”

Following the diagnosis, the ICU team continued to administer IV fluids, antibiotics, oxygen, and painkillers to Max.

After a week, his edema and joint swelling improved. He progressed from being unable to stand to taking short walks. His gait, which initially was slow and stiff, improved markedly. Dr. Anthony Gonzalez with Max the day he left Ryan HospitalAlthough Max maintained a healthy appetite, he lost a significant amount of weight due to the severity of the infection. After a nutrition consultation, his diet was adjusted and he steadily gained weight.

“Although Max had stabilized, his road to recovery was only beginning,” cautioned Silverstein. “Long-term therapy would require a dedicated and conscientious foster to monitor him closely and give him his medications for several months. Without this diligent care, it would not be possible for Max to have a successful outcome.”

Thankfully, Max was in excellent hands. Martin had fostered 70 dogs before bringing Max into her home, where she converted the dining room into a recovery unit. Martin monitored Max’s progress regularly, checking his weight and temperature daily.

“It was challenging taking care of Max, but I gave it my all,” recalled Martin. “Every day was better than the previous one. And it was wonderful when I had to adjust his collar because he was gaining weight! He was the best foster boy I’ve ever had.”

Milestones

Max celebrated his first birthday on September 13. The following day marked another milestone—his three-month checkup at Ryan Hospital.

Max recuperating at Tammy's home“Max had doubled in size and looked fantastic. He was so happy to see people; he was literally bouncing off the floor,” recalled Amanda Arrowood, a veterinary technician in the ICU who became particularly attached to Max during his hospital stay. Arrowood adopted a Boxer through AABR eight years ago, and the breed has always held a special place in her heart. “Seeing Max act like a normal, healthy dog was extremely satisfying.”

Consultations with experts in Orthopedics, Radiology, and Surgery followed. CT scans showed that the abscesses had disappeared. And most of the previously detected bone and soft-tissue abnormalities had drastically improved.  

“Even though Tammy and I had kept in touch over the months since Max’s discharge, I was shocked when I saw how incredible he looked at his recheck,” remarked Silverstein. “If it weren’t for Tammy’s dedicated efforts, Max never would have survived.”

A Forever Home

A month after his follow-up visit, Max was adopted by the Garner family of Wappingers Falls, NY. The Garners have two other Boxers, Zephyr and Mavis.

“Max was the first and only dog I inquired about due to the fact he was good with other dogs and kids,” said Greg Garner. His wife works in the animal health pharmaceutical industry, so Max’s health concerns were something they were willing to take on.

According to the Garners, Max is eating “like a king” and playing and napping well with the other two dogs.

“It has been our pleasure to adopt Max,” said Garner. “He’s a wonderful addition to our family.”

Martin is elated with the outcome. “Max found himself a wonderful family,” she said.

For the clinicians at Ryan Hospital, Max’s story is not one to be easily forgotten.

“Max remains my most memorable case at Ryan Hospital,” said Gonzalez. “It was remarkable taking on his complex and unique case and watching him improve throughout his extended stay. It was a huge team effort among many services in the hospital to create the best treatment plan for him. As sick as Max was, he always had a great attitude and spirit.”

Greg Garner and his daughter pose with Max