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Ask A Vet Online – Help, I’ve got a stuffy-nosed Pug!

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Natalie Kent asked:

My 8 year old pug has just been diagnosed with Pseudomonas in his nose. He's been having problems with his nose for about a year,   discharge, blocked up etc. Vet did a nose swab and found this bacteria. He's been on marbocyl antibiotics for 2 weeks and it's not       completely gone away, still a bit of discharge and a bit stuffy but vet refuses to give any more tablets, what else would you suggest?

Reply:

Hi Natalie, thanks for your question. Because of the conformation of their skull and nasal passages, Pugs are prone to a range of different breathing problems, and may suffer from recurrent nasal infections, so I’ll start by discussing the anatomy of the nasal passages and the defects Pugs typically suffer from. Pseudomonas is a particularly nasty bacterium that can be very difficult to treat effectively, so I’ll also talk about appropriate antibiotic therapy and the reasons why the symptoms may not have resolved. Finally, I’ll look at different ways forward for your dog.

What is the “normal” anatomy of a dog’s nose and airway? When a dog breathes in, the air flows through the nostrils (also known as the “nares”) into the nasal chambers. The left and right sides are separated by a dividing wall (the “nasal septum”) so what affects one side doesn’t always reach the other; and they are separated from the mouth by the bone of the hard palate (the ridged roof of the mouth). These chambers aren’t open – they are almost filled with scrolls or swirls of bone called the conchae (because they look a bit like sea shells), leaving only a narrow space in between for air to flow. This is important because even a small amount of fluid or swelling of the tissues here can make a dog very congested and uncomfortable. Behind these 2 chambers is a common space where left and right nasal chambers meet called the nasopharynx; the floor of this is made up of a strong muscular band called the soft palate. When breathing, the soft palate prevents food from entering the nasal passages. The air then flows through the larynx (voicebox), down the trachea (windpipe) and into the lungs. Opening out of the airways in the skull are the sinuses; these are hollow spaces inside the bone that make the head lighter and easier for the dog to carry around. There are 2 sets – on each side of the skull is a frontal sinus (in the forehead) and maxillary sinus (in the upper jaw, just above the tooth roots). So what’s different about pugs? Dogs can be divided into 3 different groups of breeds, based on their skull shape:
  • Dolichocephalic – dogs with long noses, e.g. Greyhounds
  • Mesocephalic (also known as mesaticephalic) – dogs with medium noses (most dogs, e.g. Labradors)
  • Brachycephalic – dogs with short noses (e.g. Pugs).
As one of the most extreme brachycephalic breeds, Pugs almost always suffer from some degree of Brachycephalic Airway Obstruction Syndrome. This is a condition caused by selective breeding over many generations for an abnormally short skull, and includes a range of conditions such as:
  • Nostril Stenosis – narrowing of the nostrils.
  • Elongated Soft Palate – over-long soft palate that blocks the airway.
  • Everted Laryngeal Saccules – folds of flesh that stick out into the voicebox, blocking airflow.
  • Hypoplastic Trachea – where the windpipe is a little too narrow.
These are all caused by excessive amounts of soft tissue – in the course of breeding for the modern Pug, we’ve been very successful in shrinking their bones, but not so much the soft tissues around them. As a result, Pugs have loads of extra folds of tissue in their nasal chambers and airways, making breathing a little more difficult. That’s all very interesting, but why did my dog get the infection in the first place? There are a number of possible reasons, but let’s start with the most obvious – with lots of extra soft tissue in their noses, all those little crevices, nooks and crannies are perfect for bacteria to find a home and start to grow! Other possible underlying causes include:
  • Foreign bodies – dogs are particularly prone to getting things stuck up their noses, like grass seeds or even bits of food.
  • Tooth infection – because the roots of some of the upper teeth are right next to the maxillary sinuses, an infection of the tooth can cause sinusitis and nasal infection.
  • Fungal infections – fairly rare in the UK, but they do occur.
  • Polyps – benign growths in the nasal chambers or pharynx.
  • Tumours – malignant growths of the airways.
These conditions aren’t uncommon in dogs, and often result in secondary bacterial infection. Once the infection is resolved, however, the symptoms may persist or recur because the underlying problem has not been addressed. What is Pseudomonas? Pseudomonas is a Gram Negative bacterium (meaning it has a double cell membrane as well as a cell wall) that commonly causes skin, ear and sometimes nasal infections. It is a very tough organism, and is prone to rapidly developing resistance to antibiotics. This means that in most cases, a prolonged (usually 2-6 weeks) course is required to ensure that it is completely eliminated. Exactly what antibiotic to use will depend on the results of the culture and sensitivity swab which your vet did – judging by what you’ve said, it would seem that this particular infection was susceptible to marbofloxacin (Marbocyl), a fluoroquinolone antibiotic commonly used against these bacteria. So why hasn’t the treatment worked? There are a number of possible reasons. Firstly, it may simply be that the course wasn’t long enough – however, your vet is right to be cautious about just handing out more antibiotics; overuse of antibiotics in animals or people is one of the main drivers of antibiotic resistance. A second possibility is that the course was long enough, but the Pseudomonas is now resistant to marbofloxacin; I’ve seen this happen before when treating these infections. You give an antibiotic that the bacterium is proven to be sensitive to, and within a week or two, the test results show that they have gained resistance to it. Alternatively, there may have been other bacteria on that nasal swab that didn’t show up because there were so many Pseudomonas. In that case, if they weren’t susceptible to marbofloxacin, they’ll still be there causing problems even once the Pseudomonas are all dead. Finally, and given the duration of the problems you’ve been having I’d say this is the most likely, there may be another underlying problem (such as a nasal polyp, a foreign body, dental disease, or even his nasal conformation and anatomy) that is causing the symptoms. OK, what should I do next? I think the most important thing is to find out what’s going on inside your dog’s nose right now. You know that some weeks ago there was a Pseudomonas infection; however, you’ve got no idea if that’s still the case and that treatment has failed (and if so, why); or if the symptoms are ongoing despite the successful treatment because the Pseudomonas were themselves only secondary to something else. The first step would be for your vet to repeat the nasal swab (if possible, using the same laboratory) and see how the results are different – what bacteria are growing there now, and what antibiotics they are susceptible to. The next thing to consider would be direct visualisation of the nasal chambers under anaesthetic; this usually involves rhinoscopy (putting a camera or endoscope up the nose) and/or retrograde visualisation (looking at the back of the nose with an endoscope or mirror) to see if there’s anything stuck there, or any masses or polyps growing. This isn’t always easy in pugs and may require referral to a specialist; however, your vet will be able to perform X-rays of the skull and nasal chambers, as often polyps and tumours are often clearly visible on an X-ray of this region. I think it’s very important for you to discuss your concerns with your vet, and talk about further diagnostics – you really need to sort out what’s going on in that nose to make him comfortable again and to hopefully avert any more serious consequences! All the best, I hope you can get this sorted out quickly. David Harris BVSc MRCVS
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Do I need to worry about “Alabama Rot”?

You may have read in the news recently of another cluster of dogs affected with the exotically named “Alabama Rot”. Also known as “Cutaneous and Renal Glomerular Vasculopathy” (CRGV), this condition is still poorly understood. As a result, there’s a lot of worry and speculation, and vets are receiving increasing numbers of panic-stricken phone-calls from dog owners! So, what do we actually know about CRGV? What is it? Firstly, let’s specify what it isn't – for example, despite excitable media reports, it isn't a “flesh eating bug”. Nor is it a “superbug” or a variant of the Ebola (or any other) virus. Technically speaking, it is a form of thrombotic microangiopathy, a condition where blood clots form in the small blood vessels in the body, blocking off blood supply. For some reason, the skin and the kidneys are most sensitive; without a blood supply, the tissue dies, causing ulcers on the skin, and failure of the kidneys. Is it a new disease?                                      Not exactly – it was first diagnosed in the United States in the 1980s. However, the first cases in the UK were detected in November 2012; since then, cases have been seen from across the country (there’s a map of confirmed and suspected cases here). It is most common in the winter and spring – most cases are detected between November and May. What causes it? No-one knows. It is probable that a bacterial toxin (i.e. a poison made by bacteria, that causes disease even in the absence of the bacteria themselves) is involved, perhaps from E. coli; however, this has not yet been confirmed, and tests for E. coli shigatoxin (one possible culprit) have proved negative. There is, however, no evidence that it is caused by a toxic plant, heavy metal poisoning, or genetics (although it was once thought that only Greyhounds and other sighthounds were predisposed, this is not now thought to be the case). It has been suggested that contaminated pet food may be involved, but this seems improbable – there just aren't enough affected dogs for that to be likely. So what are the symptoms? Initially, the first sign is an ulcer or wound, usually on the legs. They typically look like small, round sores and usually occur on the legs, but may also be found on the body, face or tongue. The lesions range from 5 to 50mm (1/5” – 2”) in diameter. 1-9 days later (usually about 3), affected dogs will usually suffer acute kidney failure. The symptoms are of increased thirst, changes in urination (increased amounts of dilute urine, or in more severe cases, reduction or absence of urine production). This is accompanied by lethargy, anorexia, vomiting, depression and often bad breath (which may smell metallic). Once clinical signs of renal failure occur, the prognosis for recovery is poor. Dogs that, for whatever reason, do not progress beyond the skin lesion stage have a better prognosis, assuming no further complications develop. Overall, half of the dogs affected will suffer abnormal bleeding (thrombocytopaenia); about a third may show some degree of jaundice (yellow gums and eyes); and one in five are anaemic (with pale gums and difficulty catching their breath). How do dogs get it? Firstly, it doesn't seem to be contagious from dog to dog, or to or from humans. The current thinking is that there is an environmental link – most cases are associated with walking in muddy woodlands, and it may be that there is a toxin in the mud that is absorbed by the dogs. How can it be avoided? As we don’t know the exact cause, avoidance is difficult. However, thorough washing of your dog’s coat after walking in woodland (especially if muddy… like everywhere this year!) is a sensible precaution that should reduce the risk. In addition, it is likely that certain places pose a higher risk than others; if there has been a case in your area, it is probably wise to avoid areas where the affected dog(s) were walked in the days before they were diagnosed. It’s also really important to check your dogs over regularly – not just for sores or ulcers, but also for cuts, ticks, mats of hair or other injuries. How do I know if my dog is affected? Fortunately, most dogs with skin lesions don't have CRGV! However, if your dog does have any strange or unexplained sores or wounds, it’s important to get them checked out by your vet – in the vast majority of cases, they’ll be able to demonstrate a far less worrying condition. They can also do blood tests to check for kidney problems – although as it is often several days before these show up, repeating the blood tests in 48 hours may be necessary. How can CRGV be treated? Unfortunately, there is no specific treatment. However, treatment of the skin ulcers will minimise the risk of secondary infection; and if kidney failure occurs or appears imminent, hospitalisation and intensive care will maximise the affected dog’s chance of survival. In some cases, referral to a specialist hospital may be suggested, to give your dog the best available care and therefore chance of recovery. How dangerous is it? As a rough estimate, the condition is fatal in 80-90% of cases. However, early diagnosis and treatment is thought to maximise the chances of survival. Fortunately, it is still a very rare disease – in the last three months, there have only been 4 cases (in Staffordshire, Hampshire, Greater London and Lancashire). If you are concerned your dog may be affected, contact your vet for advice – however, the majority of skin lesions and sores will be due to cuts, insect bites or grazes, and are nothing to worry about. It’s also important to remember that, even if your dog is affected, prompt diagnosis and rapid treatment gives them a much better chance of survival. For more information please visit Anderson Moores Veterinary Specialists who are taking the lead in treatment and advice on the condition.
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A Christmas story from a vet on call & a reminder that if you do have a pet crisis over the holiday, a vet is always there to help

It was Christmas morning. The phone rang at 6.30am. It was the Barrs of Lauder Hill. ' Sorry about this, but we've a heifer stuck calving'. I was in my car within 10 minutes, and carrying out the Caesarian operation to remove the calf within half an hour. The Barrs welcomed me into their farmhouse afterwards for a Christmas breakfast. The calf had been a strong, healthy bull calf, and the farmers were delighted with their Christmas present. We were settling down to enjoy the full glory of a Scottish farmhouse breakfast when my bleeper sounded. It was only 8.30 a.m. and already another emergency had to be dealt with - a calf with bloat 15 miles away, at the Buchanans in Melrose. By lunchtime I had seen a horse with colic, six calves with acute pneumonia, a dairy cow with severe mastitis and a dog with a sudden onset choking cough. The afternoon was just as busy, and I was finally able to sit down with the family at seven in the evening. Two hours later there was another call to another difficult calving. Veterinary surgeons have an obligation to provide a full time emergency service for animals in need of their care, all year round, 24 hours a day. If an animal is in distress, then help is needed - illnesses and accidents do not know that it is Christmas Day. The mixed veterinary practice where I worked in the Scottish Borders was busy - there were six vets. We worked an 'on-duty' roster, with duties shared equally between all of the vets, so at least a hectic Christmas day was only experienced once in six years. And the Christmas Day service was certainly not taken for granted by anybody - everybody who telephoned spent as long apologising for disturbing the vet as they did explaining the problem with their animal. Small animal veterinary practice is less frantic out-of-hours compared to large animal. People tend to stay at home on Christmas Day, so pets are generally safely indoors, curled up by the fireside. There are still unpredictable emergencies - from bitches whelping to dogs having epileptic fits to cats collapsing from kidney failure. In the past decade, many small animal vets have referred their emergency work to dedicated Emergency Clinics, where vets and nurses are employed specially to work all the time during after-hours periods: their “working day” means night time and bank holidays. If you phone your local vet, you will be given clear advice on the arrangements for emergency service. Most vet clinics are closed for routine service on Christmas Day and Boxing Day. This year, the fact that Boxing Day is a Saturday means that the bank holiday is taking place on Monday 28th December, so many vets do not start back with routine clinics until Tuesday 29th December. If you aren't sure whether or not your vet is open, visit their website or Facebook page, or phone the normal clinic number. If you are not transferred directly to the vet on call, there will be an answer machine message giving you details of opening hours. The first day back after Christmas tends to be a busy time, with a build up of cases that have accumulated over the holiday break. There are some typical seasonal cases that we expect to see at this time of year. First, there is the 'turkey tummy syndrome'. People do not like to feel that they are leaving their pets out of the Christmas celebrations. Dogs and cats enjoy eating turkey, and many people make up a Christmas Dinner for their pets, using leftovers from the family celebration. Animals' stomachs are not well adapted to dealing with a sudden flood of an entirely new foodstuff, and the consequences are often a severe tummy upset soon after Christmas. Second, there is the 'Walking It Off' syndrome. Many people feel an urge to expend some energy after Christmas Day - so what better way to do this than taking the dog for a walk. The result is that hundreds of dogs congregate in popular dog walking areas. Inevitably there are the usual incidents, such as dog fights, dogs lacerated by sharp objects in rivers and animals involved in road accidents. Public holidays can be busy times for vets. The important message to remember is that if you do have an animal in real distress, your vet is never closed. And if the vet has to do a house call on Christmas or Boxing Day morning, a Christmas breakfast will always be appreciated! For peace of mind over the holiday period, if you are not sure whether your pet needs a visit to a vet, the Symptom Checker can also help!
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Is that “veterinary nurse” really a veterinary nurse?

Language and terminology is important. Our society recognises this fact, and in some walks of life, you cannot call yourself by certain terms unless you are appropriately qualified. The medical field is the area where so-called “protected titles” are most prevalent: there's a long list from “music therapist” to “dietician” to “clinical scientist” to “physiotherapist” and “paramedic”. If you read the list, you'll be surprised, and I suspect that you'll be reassured too: it's good to know that when you go to see a “hearing aid dispenser”, under law they must be properly trained and qualified. There are serious penalties for people who try to set themselves up as one of these practitioners when they are not entitled to do so: anyone using one of these titles must be registered with the Health and Care Professions Council, or they may be subject to prosecution and a fine of up to £5,000. Interestingly, not all professional titles are protected. The words “doctor” and “nurse” have been in general use for hundreds of years to describe a variety of people, and so they are not specifically protected. The title “doctor” is used far more broadly than just for medical doctors, with a number of professions (including dentists and now vets) using it as a courtesy title, as well as people who hold academic doctorates, such as PhDs. Similarly, the title “nurse” is not protected: as well as medical nurses, it's used by nursery nurses in nursery schools, and sometimes by veterinary nurses. The fact that the terms “doctor” and “nurse” are not protected can lead to issues where the public can be mislead by individuals who use the terms to their advantage (such as a person who is an academic doctor trying to pass themselves off as a medical doctor). For this reason, the terms “doctor of medicine” and “registered nurse” are protected titles, but for the public, arguably this is not sufficient to avoid confusion. There are some professions that would like to have protected titles, but for various reasons, this is not possible. Anybody can call themselves an “engineer”, a “scientist” or a “surveyor” because these terms are said to be in such widespread use. These professions have had to add prefixes to their titles to try to minimise confusion, such as “incorporated engineers”, “biomedical scientists” or “chartered surveyors”. Only properly qualified and registered vets are allowed to call themselves “veterinary surgeons”, but there is a major anomaly in the veterinary world: anybody, even without training or qualification, is allowed to call themselves “veterinary nurse”. The veterinary nursing profession has so far had to use the protected title “registered veterinary nurse” to be used exclusively by properly trained and qualified nurses, but there's a strong argument that this is not enough. Most readers, I'm sure, would agree that if they were dealing with someone calling themselves a “veterinary nurse”, they would assume that the person was qualified. Unless something changes, it's very likely that unscrupulous individuals will use this confusion to their advantage, misleading people into believing that they are qualified. What has to change? Clearly, the term “veterinary nurse” needs to be made a protected title. The Royal College of Veterinary Surgeons, the British Veterinary Association and the British Veterinary Nursing Association all believe that this is necessary. They are asking Parliament to change the law to protect the title “veterinary nurse”, and they need as much help as possible to achieve this. Please sign the official petition to register your support. The aim is to get 100,000 signatories which will trigger the issue will be considered for a formal parliamentary debate. The petition is currently at 20,594 signatures and the petition closes on 14th February 2016 so time is running out. The engineering profession tried a similar tactic to protect the word “engineer” last year, but the attempt failed after their petition only reached 6176 signatures. It makes clear sense that the term “veterinary nurse” should be trusted as the recognised name for a skilled, trained and qualified profession. If you agree, please sign this petition now, and ask as many as possible of your friends and contacts to do the same. Please follow this link to the petition. The RCVS has also produced a short animation stating the reasons behind the petition:  watch this by clicking here. Animals are the ones who will benefit from "veterinary nurse" being protected: so if you care, take action now.
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Grapes and raisins can kill dogs. Read this to find out how to keep your pet safe this Christmas.

Does your dog enjoy mince pies and Christmas cake? Beware: you could accidentally poison them.

For many people, it seems unbelievable that grapes and raisins can poison dogs. They're harmless to humans. We've all seen dogs occasionally eating foods containing raisins with no apparent ill effects. How can they suddenly be poisonous?

Why are grapes and raisins not always poisonous to dogs, and never poisonous to humans? First, like all poisons, the poisonous effect depends on the dose taken per kilogram of animal body weight. Large dogs can safely eat some raisins without problems. Secondly, the toxic ingredient in raisins seems only to be present intermittently, so a dog may eat raisins without problems on several occasions, then fall seriously ill the next time. What is the toxic ingredient in grapes and raisins? The actual toxic ingredient is still a mystery. The fact that grapes and raisins can be poisonous has only been deduced by circumstantial evidence, with many dogs developing acute renal failure for no obvious reason, with the only common factor being the previous ingestion of grapes or raisins. Samples of the fruit in such cases has been analysed, but a toxic agent has not yet been isolated. The best guess so far is that it is a water-soluble substance, and that it's in the flesh of the grape/raisin, but not the seed. One theory is that it is a mycotoxin (i.e. a poison produced by moulds or fungi on the grapes). The problem in dogs was first highlighted after a year with high levels of rainfall. This had led to damp grapes which were more likely to develop fungal growth. But why should humans be safe from this toxin? It's well known that cultured dog kidney cells in the laboratory are exquisitely sensitive to other types of mycotoxins. It makes logical sense that dog kidneys might also be more sensitive to damage by another mycotoxin, even its identity has yet to be established. So how much do owners need to worry about grape/raisin toxicity? If a terrier steals a mince pie, is a visit to the vet needed? If a Labrador has a slice of Christmas cake, do they need to be taken to the emergency vet? This is always a judgment that is not black and white. It seems sensible to look at the lowest recorded doses of grapes or raisins linked to acute renal failure in previous cases of poisoned dogs. This allows an estimate of the probable toxic dose depending on the animal's body weight. Grapes The lowest toxic dose is around 20g grapes per one kilogram of body weight. A typical grape weighs 2 – 5g, making a toxic dose is around 4 grapes per kg. So if a 5kg terrier eats 20 grapes, or a 30kg Labrador eats 120 grapes, there's a high chance of a serious problem, and veterinary intervention is definitely indicated. Raisins The lowest poisonous dose in confirmed cases has been around 3g/kg. An average raisin weighs around 0.5g, making a toxic dose approximately 6 raisins per kg. So if a 5kg terrier eats 30 raisins, or a 30kg Labrador eats 120 raisinsthey need to see the vet. Some studies have suggested that the toxic agent is neutralised by cooking, so cooked raisins (e.g. in pies and cakes) may not present such a high risk.

Important note

Please remember that the above doses mention quantities that have definitely caused serious kidney failure in the past. The decision on whether or not to take a pet to the vet is a personal decision, taken after balancing the possible risks. Many people prefer to take a conservative approach, to be as safe as possible. For example, if a dog has eaten even half of the above quantities, it may be safer to take them to the vet for “just in case” treatment.

What do vets do for dog that have eaten grapes/ raisins? 1) If ingestion has happened in the previous hour. This is the ideal situation: the vet can give an injection to cause the pet to vomit, emptying the stomach and removing the grapes/raisins before any toxic ingredients have had a chance to be absorbed into the bloodstream. 2) If ingestion has happened in the previous two days but the pet is still well Depending on the situation, vomiting may still be induced, activated charcoal may be given to limit absorption of the toxin, and intravenous fluids may be given to flush fluids through the kidneys in an attempt to minimise any damage. Blood and urine tests may be recommended to monitor kidney function. If the dog is well after three days, then the high risk period is over. 3) If ingestion has happened and the dog is unwell (e.g. vomiting, dull, inappetant) In such cases, the kidneys may have already been damaged by the toxin. Urine and blood tests will be carried out to assess the severity of the damage to the kidneys, and intensive care will be needed to save the pet's life, including high levels of intravenous fluids. The prognosis is guarded: unfortunately, some affected dogs die, despite the vet's best efforts.  Conclusion.
  • Keep grapes and raisins away from dogs.
  • If any dog eats them accidentally, phone your local vet (even if it's after-hours)
  • Tell your vet how many grapes/raisins were eaten along with the body weight of your pet.
  • Your vet will then advise you on the safest course of action.
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