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The Draw of Internal Medicine

By: Sacha Adorno Published: Oct 24, 2024
Dr. Joy Tomlinson
visits with Milena.
Dr. Joy Tomlinson visits with Milena.

Janet Blatchley with MilenaJanet Blatchley (right) has a tight bond with her horse, Milena. Their relationship is as close as any human connection, so Blatchley noticed subtle signs that the 12-year-old Friesian “just wasn’t herself.” Her feistiness was gone, and her appetite diminished.

“We had an appointment at New Bolton Center for a checkup,” said Blatchley. “But two days before it, Milena fainted in her stall. All bets were off—we went immediately.”

Milena arrived at New Bolton Center with slight balance issues and rapid breathing. Her clinical team, led by Joy Tomlinson, DVM, PhD, DACVIM, assistant professor of large animal medicine, conducted comprehensive diagnostics on the horse’s heart, liver, and lungs.

Tests showed Milena had likely collapsed from a cardiac arrhythmia. Immediate intervention by the cardiology team was able to correct the arrhythmia. Structural abnormalities and pulmonary hypertension were ruled out, so the team looked for a source of inflammation that might have caused the arrhythmia. Bloodwork showed the liver enzymes were abnormal, and a liver biopsy showed an accumulation of protein and severe inflammation, likely caused by an immune response triggered by inflammation elsewhere in the body. The most revealing clue to Milena’s condition lay in her lungs.

“The ultrasound and X-rays of Milena’s lungs showed some small areas of damage and nodules in both lungs,” said Tomlinson. “This and her other symptoms suggest equine multinodular pulmonary fibrosis (EMPF).”

EMPF is a rare, progressive lung disease in horses characterized by scar tissue in the lungs. It often results in respiratory issues, such as labored breathing, coughing, and exercise intolerance.

“Roughly 25 percent of horses with this condition will survive at least three months, and those that do may go into complete remission,” said Tomlinson. “We’re treating Milena with steroids at home. She’s being monitored by her regular veterinarian with intermittent recheck examinations at New Bolton Center for radiographs of the lungs and ultrasound of the liver.”

One month after diagnosis, Milena is responding well to treatment. Blatchley is cautiously optimistic, taking it day by day.

Milena represents why Tomlinson and her colleague, Daniela Luethy, DVM, MPH, DACVIM, assistant professor of large animal medicine, work in internal medicine at New Bolton Center.

“Milena’s case is a great example of how all the body systems interact,” said Tomlinson. “Disease in one system—in this case, her lungs—can lead to disease in other organs like her heart and liver. This is why comprehensive examinations and diagnostics are so important to find the correct diagnosis and institute appropriate care, and the interconnection is what interests me about internal medicine.”

Tomlinson and Luethy joined the Penn Vet faculty in the past year, attracted by the opportunity to tackle challenging conditions like EMPF with the most advanced tools available in veterinary medicine. They completed their residencies at New Bolton Center, leaving for other teaching and practice opportunities. Both then heard the call to return to Penn Vet’s people and caseload.

“New Bolton Center is a strong community; everyone here cares about our patients and the people we spend our days with,” said Luethy. “We support each other and have rigorous discussions of cases, sometimes challenging each other in constructive ways that lift the standard of care we deliver.”

For the two clinicians, New Bolton Center’s more than 6,750 in-hospital cases a year, which are mostly equine, and Field Service’s more than 23,000 animal visits annually offer a unique opportunity to care for animals they adore. Their patients include elite racehorses and beloved companion horses, rescued and agricultural cows, pigs, goats, sheep, and the occasional camelid.

Dr. Daniela Luethy and fourth-year student Austin Castellano perform a physical exam on their patient.
Dr. Daniela Luethy and fourth-year student Austin Castellano perform a physical exam on their patient.

“In internal medicine, we see many different diseases across this spectrum of animals, from gastroenterology to oncology to infectious disease,” said Luethy. “It’s this broad variety of cases that I find appealing. We see one of the highest caseloads of any academic, veterinary health care institution, which allows us to push boundaries in ways we might not otherwise.”

Tomlinson added that the caseload combined with an infrastructure that includes advanced diagnostic equipment and clinical staff and faculty in several specialties—among them neurology, ophthalmology, neonatology, cardiology, surgery, and radiology—makes New Bolton Center a special place to practice.

“It’s a tremendous advantage to have so many specialties on-site, both as separate services for clients and for consultation on our cases,” she said. “Milena’s care shows how internal medicine and specialty sections, including ultrasound and cardiology, diagnostic pathology, and radiology, work together to provide the most efficient information and the highest level of care for a patient.”

Driving medicine forward

And then there’s research. Penn Vet’s pioneering research bolsters New Bolton’s Center dynamic practice environment. As clinicians, Tomlinson and Luethy can leverage Penn Vet’s groundbreaking studies and findings in their practices and conduct their own research to answer vexing clinical questions.

“Several of Penn Vet’s clinicians have large research programs that are driving medicine forward and often include a component of clinical research,” said Tomlinson. “Our clients can participate in clinical trials, if they choose, and benefit from the latest knowledge about disease progression and treatment.”

Luethy and Tomlinson are also contributing to the science and practice of large animal medicine. “It’s exciting,” said Tomlinson. “If the scientific literature doesn’t exist or agree on the best approach, we have the infrastructure and the caseload to help answer those questions.”

Currently, Tomlinson’s research focuses on horse liver viruses, specifically parvovirus-hepatitis, equine hepacivirus, and equine hepadnavirus. She studies risk factors, transmission, and progression with the potential goal of creating a vaccine to prevent infection. Should Tomlinson pursue a vaccine, she may be bolstered by Penn Vet’s infrastructure. Last year, the School’s Institute for Infectious and Zoonotic Diseases launched an mRNA Research Initiative to fast-track the development of veterinary mRNA-based vaccines and host-directed therapies.

Luethy, too, is interested in developing novel diagnostics and treatments.

“I hope to advance small ruminant internal medicine and earlier diagnosis and treatment of cancer in large animals,” she explained. And she zooms out a bit into the wider world, looking at a significant public health concern for veterinarians: mental health. “I am interested in helping to improve the well-being of the veterinary profession. I’ve been researching the relationship between physical activity and mental health and evaluating factors that might influence a veterinarian’s career decisions.”

Holding Milena in the best of hands

All these factors come together in Milena’s case. The knowledge and community that attracts Tomlinson and Luethy to Penn Vet are also why Blatchley trusts New Bolton Center.

Although she’s aware EMPF may take Milena sooner than she wants, Blatchley hopes for the best, knowing that Milena is in the “best hands she can be between her regular veterinarian, her amazing boarders and trainer, and the special experts at Penn Vet.”

Editor’s note: At press time, we learned Milena passed away. The Bellwether team thanks her family for sharing her story with our readers.