Case Referral: Managing Comorbidities & Referrals During Curbside Care

Sponsored by VCA

Managing chronic conditions in pets can be tough enough without the added complications of new comorbidities. When such complications are combined with a pandemic and curbside restrictions, providing excellent care can feel harder than ever.

Explore this real-life case, in which a chronically ill pet developed the need for multiple specialists, and how this patient’s condition and quality of life improved through collaboration, communication, accessibility, and respect.

The Case

In 2018, Ivy, a 3-year-old spayed female Yorkshire terrier, was initially presented to her primary care veterinarian for chronic, intermittent diarrhea and other GI signs. After an initial diagnostic investigation and food trials were performed, her primary care veterinarian consulted with a VCA internal medicine specialist, who recommended fecal PCR testing for suspected Clostridium perfringens enterotoxicosis (CPE). The test confirmed a diagnosis of CPE, and treatment was initiated with tylosin and increased dietary fiber. Ivy’s condition improved quickly, and diarrhea resolved for ≈4 months.

However, Ivy’s GI signs—primarily intermittent diarrhea and decreased appetite—returned in 2019. Due to the patient’s history and clinical presentation, the primary care veterinarian and internal medicine specialist suspected an additional underlying condition. Inflammatory bowel disease (IBD), an earlier differential that was not pursued due to improvement in clinical disease, was considered a top rule-out.

The internal medicine specialist recommended GI endoscopy and procurement of biopsies to confirm the suspicion of IBD, but the owner was unable to pursue diagnostics due to upcoming travel. Ivy was started on budesonide, and her condition again improved rapidly. Ivy’s owner was pleased with the response, and later, the budesonide was reduced to an every-other-day, low-dose regimen.

One year later, in the fall of 2020, Ivy’s GI issues had returned primarily in the form of intermittent diarrhea; shortly thereafter, her owner noticed one morning that she had become acutely weak and presented Ivy to her primary veterinarian via curbside care due to the COVID-19 pandemic. Her owner was kept updated via text and phone while her evaluation was performed. A cardiac arrhythmia was identified, and her primary veterinarian and internal medicine specialist decided together to refer her to the cardiology department at the VCA referral hospital. Ivy was seen by the cardiologist that same day via curbside care.

Ventricular arrhythmia and syncope were confirmed. Testing included thoracic radiography, echocardiography, and serum troponin concentration. Elevated troponin levels were identified, indicating that the syncope was likely related to myocardial injury, although it was unclear which cardiac issue incited the other. Ivy was stabilized and returned home within 2 days.

Considering the timing of Ivy’s recent return of GI signs with the sudden onset of cardiac disease, the referral veterinarians were concerned that her GI disease may have contributed to the myocardial injury. The referral veterinarians planned a more detailed GI investigation to include a chronic enteropathy/IBD serum assay and upper and lower GI endoscopy for biopsies.

Prior to any testing, Ivy was sent home on cardiac medications. A nutritional plan was instituted, including a complete nutritional consultation with the owner and a VCA nutritionist. Ivy’s owner completed a detailed dietary history form, followed by a one-hour virtual meeting with the nutritionist. Based on the consultation, a low-fat, highly digestible, home-prepared diet was prescribed to meet Ivy’s needs and accommodate the owner’s preference for a fresh, less-processed diet. The diet change helped but did not completely resolve Ivy’s GI issues, which then included intermittent inappetence and diarrhea.

Upper and lower endoscopy with biopsies were performed, with assistance from the cardiology specialist to ensure minimal cardiac risk prior to the anesthetic procedure. Biopsy confirmed a diagnosis of lymphoplasmacytic enteritis, with no evidence of lymphangiectasia. Based on her history and diagnostic findings, Ivy’s referral veterinarian suspected her clinical signs were due to both IBD and concurrent CPE. Her medication regimen was adjusted to include budesonide and metronidazole, and her new diet was continued in addition to fiber supplementation.

At this time, 5 months postendoscopy, Ivy is doing well and is showing no clinical signs of GI or cardiac issues. Over time, budesonide will be tapered to the lowest effective dose, she will be weaned off metronidazole, and her homemade diet and fiber supplementation will be continued.

Conclusion

Ivy’s recent referrals were accomplished with curbside check-in and pick-up due to restrictions caused by the COVID-19 pandemic. Doctors and support staff communicated with Ivy’s owner at the car, as well as over the phone. Her primary care veterinarian and specialists communicated frequently and thoroughly, allowing for adequate collaboration on decision-making to meet both Ivy’s and her owner’s needs. The referral veterinarians expressed appreciation for the open communication. One specialist stated, “It was a real team effort,” and said he felt her diagnostic investigations were handled thoroughly and competently. Ivy’s owner was thrilled with the care that both he and Ivy received, especially under the unprecedented circumstances from the pandemic.

VCA referral veterinarians exemplified VCA’s 4 pillars of care (ie, collaboration, communication, accessibility, and respect), which, along with the openness and prompt decision-making on the part of Ivy’s primary veterinarian, ensured that Ivy’s case was well-managed and helped provide the best outcome. Ivy’s case demonstrates that collaboration and a team approach can help make even the most challenging situations easier to manage, even during the most uncertain of times.