CLINICAL CHEMISTRY CASES 2011 / HISTORIES
CLINICAL CHEMISTRY CASE 1
SUBMITTER
CONTRIBUTORS
PHONE NUMBER
Catherine Fischer, DVM
Darren Wood, DVM, DVSc, DACVP
Joanne Hewson, DVM, PhD, DACVIM
University of Guelph
Pathobiology Dept, 50 Stone Rd E
Guelph ON N1G 2W1 Canada
519-824-4120 x54654
FAX NUMBER
E-MAIL ADDRESS
519-824-5930
cfisch01@uoguelph.ca
COMPANY OR UNIVERSITY
ADDRESS
SPECIMEN: Blood (blood gas analysis, CBC, serum biochemistry), ruminal fluid (rumen
chloride)
SIGNALMENT: Two year old Holstein cow
HISTORY AND CLINICAL FINDINGS: Calved 3 weeks prior; no complications. One
week later, was treated for a uterine infection with penicillin (improved while on
penicillin). Final dose of penicillin 5 March 2011; after discontinuation, began dropping
in milk production, and became inappetant. Primary veterinarian examined on 7 March
2011, and again on 10 March 2011; noted suppurative exudate in rectum. Cow
continued to decline; anorexic 3 days, then donated to teaching hospital 11 March 2011.
Presented: Quiet but responsive, poor body condition (1.5/5), severely dehydrated,
hypothermic, hyperemic mucous membranes. Very low respiratory rate, and absent
borborygmi (ileus).
LABORATORY DATA:
Stat blood gas results, jugular venipuncture sample (Radiometer ABL800 Flex)*:
Parameter
pH
pCO₂
pO2
HCO₃ - (calculated)
Value
Unit
Reference Interval
7.47
-
7.35-7.50
77
mmHg
35-44
25.9
mmHg
30.0-37.0
55
mmol/L
21-29
Parameter
Value
Lactate (calculated)
Unit
11.4
Reference Interval
mmol/L
0.6-1.4
*Reference values determined for this machine
CBC (Advia 2120):
Parameter
Value
Unit
Reference Interval
17.0
x109/L
5.1-13.3
Neutrophils
10.37
x109/L
1.7-6.0
Bands
0.17
x109/L
0.0-0.2
Lymphocytes
3.74
x109/L
1.8-8.1
Monocytes
2.72
x109/L
0.1-0.7
Basophils
0.0
x109/L
0.0-0.2
RBC
10.7
x1012/L
4.9-7.5
Hemoglobin
181
g/L
84-120
Hematocrit
0.50
L/L
0.21-0.30
MCV
46
fl
36-50
MCH
17
pg
14-19
366
g/L
380-431
RDW
16
%
16-20
MPV
6
fL
4.6-7.4
352
x109/L
160-650
WBC
MCHC
Platelets
Serum Biochemistry (Cobas 6000 c501):
Parameter
Value
Unit
Reference Interval
Calcium
2.52
mmol/L
2.10-2.80
Phosphorus
3.25
mmol/L
1.47-2.63
Parameter
Value
Unit
Reference Interval
Ca:P Ratio
0.78
-
0.60-1.70
Magnesium
1.20
mmol/L
0.82-1.30
Sodium
121
mmol/L
132-145
Potassium
3.9
mmol/L
3.9-5.6
Chloride
43
mmol/L
90-113
CO₂
48
mmol/L
17-26
Anion Gap
34
mmol/L
10-20
Na:K Ratio
31
-
26-36
Total Protein
83
g/L
66-86
Albumin
41
g/L
30-42
Globulin
42
g/L
30-53
A:G Ratio
0.98
-
0.6-1.3
Urea
15.9
mmol/L
3.0-8.0
Creatinine
459
μmol/L
34-88
Glucose
36.9
mmol/L
2.5-4.3
Cholesterol
4.86
mmol/L
1.73-7.73
Total Bilirubin
149
μmol/L
0-3
Conjugated Bilirubin
73
μmol/L
0-2
Free Bilirubin
76
μmol/L
0-3
ALP
543
U/L
25-127
GGT
928
U/L
11-51
AST
302
U/L
44-153
CK
124
U/L
44-211
Parameter
Value
Unit
Reference Interval
GLDH
444
U/L
3-45
BHBA (βhydroxybutyrate)
NEFA
804
μmol/L
324-1296
1.2
mmol/L
0.10-0.37
Haptoglobin
1.79
g/L
0.0-0.5
Calculated
Osmolarity
285
mmol/L
276-306
ADDITIONAL DIAGNOSTIC TESTS:
Abdominal ultrasound: distended loops of small intestine and enlarged gallbladder.
Rumen chloride assay:
Parameter
Rumen Chloride
Value
Unit
96
Reference Interval
mmol/L
10-25**
**Radostits OM, Gay CC, Blood DC, Hinchcliff KW. Veterinary Medicine: A Textbook of
the Diseases of Cattle, Sheep, Pigs, Goats and Horses. 9th Ed. Harcourt Publishers Ltd;
2000:273)
QUESTIONS:
1. What are likely causes for the marked hyperglycemia?
2. What is most likely the primary lesion resulting in the biochemical changes seen?
CLINICAL CHEMISTRY CASE 2
SUBMITTER
CONTRIBUTERS
COMPANY OR UNIVERSITY
ADDRESS
PHONE NUMBER
FAX NUMBER
E-MAIL ADDRESS
Jordan Fromstein, DVM
Emmeline Tan, DVM, DVSc, DACVP
Darren Wood, DVM, DVSc, DACVP
Fiona Park, DVM
Michael Goldstein, DVM
University of Guelph
Department of Pathobiology
Ontario Veterinary College
419 Gordon Street
Guelph, Ontario
N1G 2W1
519-824-4120 x 54674
519-837-3230
jfromste@uoguelph.ca
SPECIMEN: Hematology and clinical chemistry data
SIGNALMENT: 7 ½ year old, female-spayed, Miniature Schnauzer
HISTORY AND CLINICAL FINDINGS: Dotte presented to the Ontario Veterinary College
Teaching Hospital (OVCTH) because of lethargy and a one-week history of progressive
inappetance and vomiting. Previous relevant medical history included Fanconi syndrome and
chronic kidney disease (stable for about 1 year), previous diagnosis of hyperadrenocorticism and
subsequent iatrogenic hypoadrenocorticism following mitotane treatment, and myasthenia gravis
(successfully treated and stable). On presentation she was receiving a physiologic dose of
prednisone (15 mg PO q24h), calcium carbonate (650 mg PO q12h), benazepril (2.5 mg PO q12
h), sucralfate (500 mg PO q6 h), metronidazole (125 mg PO q24h), subcutaneous fluids (every
2nd day) and desoxycorticosterone pivalate (Percorten-V, Novartis, Dorval, QC) injections every
25 days.
LABORATORY DATA:
Hematology
Test
WBC
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
Platelets
MPV
T.S. Protein
Seg Neutrophil Count
Lymphocyte Count
Monocyte Count
Eosinophil Count
Anisocytosis
Patient
10.8
4.6 L
113
0.38
82 H
25
303 L
15.5 H
418
9.6
110 H
8.75
0.86
0.65 H
0.54
1+
Normal
4.9-15.4
5.8-8.5
133-197
0.39-0.56
62-72
21-25
330-360
11-14
117-418
7-14
55-75
2.9-10.6
0.8-5.1
0.0-0.1
0.0-2.2
Units
x 109/L
x 1012/L
g/L
L/L
fL
pg
g/L
%
x 109/L
fL
g/L
x 109/L
x 109/L
x 109/L
x 109/L
Hematopathology:
Occasional platelet clumps are present. No polychromatophils noted. No visible lipemia or
hemolysis noted.
Biochemistry Profile
Test
Calcium
Phosphorus
Magnesium
Sodium
Potassium
Chloride
Carbon Dioxide
Anion Gap
Na:K Ratio
Total Protein
Albumin
Globulin
A:G Ratio
Urea
Creatinine
Glucose
Cholesterol
Result
3.67 H
5.15 H
1.2 H
156 H
3.9
125 H
8L
27 H
40 H
71
32
39
0.82
36.2 H
766 H
3.7
>28.00 H
Reference Interval
2.50-3.00
0.9-1.85
0.7-1.0
140-154
3.8-5.4
104-119
15-25
13-24
29-37
55-74
29-43
21-42
0.7-1.8
3.5-9.0
20-150
3.3-7.3
3.6-10.20
Units
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
g/L
g/L
g/L
mmol/L
μmol/L
mmol/L
mmol/L
Total Bilirubin
Conjugated Bilirubin
Free Bilirubin
Alkaline Phosphatase
Steroid-Alkaline Phosphatase
GGT
ALT
CK
Amylase
Lipase
Urinalysis - Catheter
Test
Color
Clarity
Volume Submitted
Specific Gravity
pH
SSA Protein
Glucose
Ketones
Urine Bile
Blood
Urobilinogen
Leukocytes
RBC
Epithelial Squamous
7
3
4
4749 H
2957 H
18 H
819 H
379 H
>2941 H
591 H
Result
Pale Yellow
Clear
2.0
1.011
6.0
0.3
Negative
Negative
Negative
Trace
3.2
Occ
1-3
0
μmol/L
μmol/L
μmmol/L
U/L
U/L
U/L
U/L
U/L
U/L
U/L
0-4
0-1
0-2
22-143
0-84
0-7
19-107
40-255
229-947
25-353
Units
mL
g/L
μmol/L
/400x
/400x
/400x
ANCILLARY DATA:
Abdominal ultrasound revealed mild gastric thickening, which was attributed either to normal
anatomic variation or uremic gastritis. Minimal pyelectasia was noted and was most likely
attributed to fluid therapy. A small left adrenal gland was detected.
QUESTIONS:
1. What are potential explanations for macrocytosis in the absence of significant anemia or
evidence of a regenerative response?
What are some possible explanations for the apparent discrepancy between total solids by
refractometry (110 g/L) and serum chemistry protein (71 g/L)? The plasma did not grossly
appear lipemic or hemolyzed
CLINICAL CHEMSITRY 3
Submitter: Josely Figueiredo
Contributors: Kristen Friedrichs, Julie Webb, Simon Peek, Tami Mueller
Address:
University of Wisconsin, School of Veterinary Medicine, 2015 Linden Drive, Madison, WI
53706-1102
Phone number: (608) 263-9931
Fax number:
e-mail address: figueiredo@svm.vetmed.wisc.edu
Specimen: Hematology, clinical chemistry and urinalysis
Signalment: 4 year old female, second lactation Holstein cow, 7-10 days in milk
History and clinical findings: The patient was presented to the University of Wisconsin
Veterinary Medical Teaching Hospital (UW-VMTH) in March 2011 with a three day history of
red urine and one day history of anorexia. Two days before admission the cow received Polyflex
(ampicillin), and the day prior to admission the cow was given penicillin. She had been down the
day prior to admission and was given 500 ml of a 50% dextrose and LS 50 (Lincomycin and
Spectinomycin) intravenously. The day before admission the cow gave 100 lbs of milk and
almost nothing the morning of admission. At presentation, the cow was down but bright, alert
and responsive. Vital signs revealed a normal temperature (101.8F), tachycardia (120 beats per
minute) and tachypnea (80 breaths per minute). Mucous membranes were very pale pink with a
prolonged capillary refill time. No motility was detected in her rumen. Palpation per rectum
revealed no abnormalities and the stool was normal. Urine was collected for urinalysis and blood
was collected for CBC and chemistry.
Hematology CBC – Analyzer Advia 120
Test
Result
Reference range
Plasma appearance
Moderate icterus
-
Total plasma protein
7.9 g/d
7.3 – 9.2
Fibrinogen
500 mg/dL
200 - 600
RBC*
2.65 x 106/ul
4.5 – 6.8
HGB
5.4 g/dL
7.8 – 11.4
RBC HGB
5.1 g/dL
7.9 – 11.2
HCT
15 %
20 – 30
PCV
16 %
23 – 33
MCV
55.9 fL
38 – 50
MCH
20.4 pg
15 – 20
MCHC
36.6 g/dL
37 – 41
RDW
24.6 %
16.4 – 21
Platelet
424 x 103/ul
217 – 830
MPV
8.5 fL
5.4 – 8.3
Platelet estimate
Appears WRI
*RBC morphology: Anisocytosis 2+; Macrocytosis 2+, Polychromasia 1+; Crenation 1+
Hematology WBC– Analyzer Advia 120
Test
Result
Reference range
WBC*
15.33 x 103/ul
4.7 – 11.1
SEG
9.198 x 103/ul (60%)
1.6 – 6.1
BAND
0.153 x 103/ul (1%)
0 – 0.1
LYMPH**
4.906 x 103/ul (32%)
1 – 4.9
MONO
1.073 x 103/ul (7%)
0–1
* WBC morphology: prominent fine purple granules in majority of neutrophils
** Occasional atypical lymphs: Larger than a neutrophil with high N:C ratios and dark blue
cytoplasm
CLINICAL CHEMISTRY 4
PHONE NUMBER
Melanie S. Spoor, DVM1
Linda M. Berent, DVM, PhD, DACVP1
Laura C. Cregar, DVM1
Meredith E. Thoen, DVM2
1Department of Veterinary Pathobiology
2Department of Veterinary Medicine &
Surgery
University of Missouri
College of Veterinary Medicine
900 East Campus Drive
Columbia, MO 65211
(573) 882-9386
FAX NUMBER
E-MAIL ADDRESS
(573) 882-5526
spoorm@missouri.edu
SUBMITTER
CONTRIBUTERS
COMPANY OR UNIVERSITY
ADDRESS
SPECIMEN: Blood (CBC, Chemistry, Blood gas)
SIGNALMENT: A 9-month old, intact female German shorthaired pointer
HISTORY AND CLINICAL FINDINGS: The patient was presented to the University of
Missouri Veterinary Medical Teaching Hospital (MU VMTH) after being found recumbent
outside on a cold day (outside temperature 28oF/-2 oC). On physical exam, the patient
was dehydrated, recumbent, non-responsive to stimuli and had a body condition score
(BCS) of 1 out of 9. She was found to be hypothermic (temperature < 90 oF/32 oC) and
bradycardic (45 bpm) with shallow respirations, pale mucous membranes and a CRT
greater than 2 seconds. Glucose measured via iSTAT was 20 mg/dL. A blood pressure
reading of 60 mmHg was obtained using the indirect Doppler technique. Melena mixed
with dirt was voided. The patient was resuscitated with IV crystalloid fluids, hetastarch,
dextrose, atropine and aggressive warming. A blood gas was performed during
resuscitation, and a CBC and chemistry panel were performed following resuscitation.
LABORATORY DATA:
Blood gas, CBC and chemistry data are displayed below. CBC and chemistry were
performed approximately 2.5 hours after the blood gas.
Venous blood gas:
pH
pCO2
HCO3
BEecf
iCa++
Glucose
Lactate
Patient
7.306 L
48.2 H
24.3 H
-2.3
0.73 L
20
L
1.0
Reference Interval
7.33-7.45
24-39
15-24
-2 +/- 2
1.12-1.4
81-133
0.5-2.0
Units
mmHg
mEq/L
mmol/L
mmol/L
mg/dL
mmol/L
CBC:
Patient
Plasma protein
3.8
L
WBC
5.22
RBC
3.87 L
Hgb
9.5
L
Hct
30
L
MCV
77
H
MCH
24.5
MCHC
32.0
Platelet Count
175
L
Segmented Neutrophil
0.21 L
Band Neutrophil
0.0
Lymphocyte
4.70 H
Monocyte
0.16
Eosinophil
0.16
Basophil
0
Reticulocyte count
0.2
nRBC/100 WBC
1
Morphology: Few reactive lymphocytes
Reference Interval
Units
6-8
g/dL
4.53-14.99
x103/L
5.34-8.5
x106/L
12.3-19.7
g/dL
37-57
%
59-76
fL
20.7-25.6
pg
32-36.4
g/dL
200-500
x103/L
2.27-10.14
x103/L
0-0.26
x103/L
0.76-4.23
x103/L
0.15-1.35
x103/L
0.08-1.1
x103/L
No reference interval x103/L
No reference interval %
No reference interval
Plasma character: Clear
Serum Biochemistry:
Glucose
BUN
Creatinine
Sodium
Potassium
Chloride
Total CO2
Anion Gap
Albumin
Total Protein
Reference Interval
81-133
8-28
0.6-1.6
143-152
3.4-4.9
108-117
18-26
13-22
2.9-4.0
5.2-7.4
Patient
70
L
93
H
0.4
L
143
3.9
117
20
10
L
<1.5
L
<3.0
L
Units
mg/dL
mg/dL
mg/dL
mEq/L
mEq/L
mEq/L
mEq/L
mEq/L
g/dL
g/dL
Calcium
6.3
Phosphorus
6.0
Cholesterol
58
Total Bilirubin
0.3
ALT
131
ALP
39
GGT
4
Plasma character: Slight hemolysis
L
H
L
H
9.2-11.3
2.0-5.0
133-338
0.1-0.4
9-58
5-129
0-5
mg/dL
mg/dL
mg/dL
mg/dL
U/L
U/L
U/L
ADDITIONAL DIAGNOSTIC TESTS:
Fecal evaluation (Sugar solution): No parasite ova were found
SNAP Parvo Test (IDEXX): Negative
®
Urine specific gravity obtained 9 hours after presentation and fluid therapy: 1.021
QUESTIONS:
1. What are differentials for the marked neutropenia? Mild thrombocytopenia?
2. How would you expect the hypothermia to affect hemostasis? What other
changes could be seen with hypothermia?
3. What questions would you ask the owner or additional diagnostics would you run
to help you develop a differential list?