Good evening everybody and welcome to tonight's webinar with the webinar vet. My name is Sophie and I'll be chairing tonight. So before I go and introduce our speaker, I'd just like to mention that you can ask questions throughout the webinar.

So to do so, just hover over the toolbar either at the top or the bottom of your screen, click the Q&A box at any point during the webinar, send your questions through to me and I'll read it out to Vicky at the end. So tonight we have the wonderful Vicki Black talking to us about the approach to the pyrexic dog and cat. Vicky graduated from the University of Cambridge in 2009, following two years in first opinion practise on the Norfolk coast.

She completed an internship at Davies Veterinary Specialist, followed by an ECVIMCA residency at Bristol Veterinary School. Where she still works now as a small animal internal medicine European diplomat in internal medicine and an RCVS specialist. Vicky has a special interest in evidence-based approach to small animal practise.

OK, Vicky, over to you. Lovely, thank you very much for the introduction, Sophie. So yeah, as Sophie said, we're gonna be talking about pyorexic dogs and cats today, which is one of my favourite topics, so I'm really glad to be invited to talk about this.

I don't have any relevant disclosures for the talk today. So in terms of what we'll cover, we'll start with the kind of background about pyrexia, and then we'll discuss in main detail the approach to the pyrexic dog, and then consider latterly, cats, because realistically, a lot of this is, is duplicated because it's all about the problem solving approach rather than necessarily discussing the final diagnosis per se. So in terms of some background, it's probably worth at this point just stating that actually pyrexia is a highly physiologically preserved adaptation to bacterial infections.

So it's there for a good reason. It occurs because, essentially inflammatory, markers sense, a, a potential pathogen, and release cytokines that then results in a change in the set point of your thermoregulatory centre in your hypothalamus. Resulting in changes in your catabolic state and also measures to preserve heat.

So it's there and it's preserved across all mammals for good reason, because actually improved survival is conferred with this when you're combating infections. It's an important point at this stage. It's important to recognise that there's obviously a difference between pyrexia and hypothermia.

And actually, in some circumstances, a simple sort of assessment of the patient and clinical exam can help distinguish between the two. A pyreexic patient like us when we're feverish, will be attempting to conserve heat because they've got, as we said, that change in their thermoregulatory set point, and actually they're trying to get the warmest. They, they're shivering and they feel cold.

So they, they'll have a different kind of behavioural . Stance to the the hypothermic animal, which will often be sort of stressed, perhaps orthopic, perhaps panting lots. And so there'll be a lot of clues to help you discriminate between the two, simply based on the circumstance of the patient.

It's not always easy to decide for sure, especially where you've got a very apprehensive patient where you could be sus suspicious of pyrexia as well. In those cases, simply admitting the patient and rechecking the temperature or sending the home the the owner home with a thermometer can be helpful. Or perhaps some simple early tests.

So, haematology might give you a clue, if Fiona is sort of motivated to do that. So if you find evidence of, an inflammatory focus or a decent neutrophilia and perhaps left shift, you'd be further suspicious that it's a true pyrexia. Alternatively, and certainly what's really popular with us now is the C reactive protein in dogs.

That's a sort of an acute face protein that that flags that there's an inflammatory focus when it's elevated. But the first thing when approaching an elevated body temperature is to decide if you think this is a true pyrexia or a a stress related hypothermia. The next thing to think about is what you'd do to address that.

And I know it's really tempting, and certainly I, I, I definitely felt the same and, and can understand the, the kind of logic that the first thing you want to do when you see a pyrexic patient is make them feel better by dropping their temperature. And hopefully, the take home point from today's talk will be. Actually, you should be ideally considering what you think is likely to be driving the high temperature and considering how you might empirically treat that or investigate that, rather than necessarily just addressing the high temperature and thinking that will make them feel better in isolation, because that's quite unlikely.

So you can see why a fan's not appropriate in a pyrexic patient. They've deliberately elevated their set point in their hypothalamus and increased their their body temperature. So, in fact, if you put a fan on a pyrexic patient, it's simply just the body's going to work harder to get it back up to that elevated temperature.

And so it's going to expend more energy in doing so. So actually it's counterintuitive, but a fan's a bad idea in a pyrexic patient, where clearly it's appropriate in a hypothermic one. The jury's out about whether you should be giving these animals antipyretics, as we discussed, if they've got a bacterial infection, that was a deliberate physiological adaptation to trying to fight that infection off.

So reducing the temperature is a little bit controversial. And certainly you might have come across that as a great programme on the BBC sort of discussing how whether cowpoche is wise in every circumstance. And the truth is that actually if you've got a child that's feeling really miserable with a fever, then clearly you can see the quick response and positive response to Calpol.

It is, it's justified in that circumstance. But perhaps more interestingly, in in the ICU critically unwell, people, they've they've had a look at the survival if you, if you address the high temperature or if you leave it alone. And in fact, in most cases, survival seems to be pretty similar.

If anything, perhaps there's improved survival in the absence of trying to control the temperature in specific scenarios. And that's unique obviously to when you've got an infection. Clearly, when you've got an animal with, when you think likely an autoimmune disease, then that's an inappropriate change in their body temperature.

They're not fighting off an infection. It's an, it's an autoimmune response and in those circumstances, clearly, antipyretics are perfectly appropriate. So it is situational situationally dependent, but it's just worth having a careful think.

Yeah, and, and re-emphasizing that whilst yes, the high temperature might be partly why they're feeling unwell, thinking about what's driving the high temperature and addressing that instead of just simply addressing the high temperature is gonna be a better way to approach these really sometimes tricky cases. And certainly we do recognise, pyrexia of unknown origin is a really common referral we see, and that's actually, probably reflects the fact that they can be really difficult to work up, and especially when advanced imaging or multidisciplinary approach isn't available. So I'd firstly say, I recognise that these are really difficult.

Some of them obviously gonna be simple and self-limiting or responsive. To empirical therapy, but some of them do represent really tricky cases and certainly in our hands, even in a poy of unknown origin, that seems like it's going to be simple. We are a little bit trepidatious that are they going to take us on a different journey?

Are we going to spend loads of money and not end up with a diagnosis? And to try and combat that, what we tend to recommend is a kind of step-wise logical approach. So start with a single a few tests, reflect on what you've got on in terms of your answers on those, and then either look to further diagnostics or hopefully, Being pleased that you've got to the bottom of what's going on.

And I think that logical approach is what we counsel the owners with in these cases, because sometimes it might take the sort of 9th or 10th test to get to the bottom of what's going on rather than guaranteeing you'll find the answer out on the 1st test. So in terms of the kind of different possible diagnosis for pyrexic patients, they can be broadly divided into these four categories. And so you've got infectious.

So here we're thinking things like, an infection of a particular organ. So say endocarditis, pyelonephritis, discospodylitis, migrating foreign body, pyothorax. Those kind of things like an abscess somewhere, that's one way of thinking about it.

The other kind of infection is one of those systemic infections that has pyrexia as well. Normally they're not so tricky to get to the bottom of. So, for example, a dog with leptospirosis might present with pyrexia.

But in fact, they're not too tricky in the sense that you've got the jaundice, you've got the hepatopathy, perhaps the azotemia. Plenty of clues and pyrexia is just one of the, one of the parts of the puzzle. So we obviously.

They're a lot easier to get to the bottom of than the ones when perhaps there seems to be something going on and it's tricky with bloods and the clinical exam alone to decide. The other thing that's worth mentioning in this case is where we're seeing more travelled dogs, then obviously some of the vector-borne diseases can cause pyrexia. Probably the most relevant ones in here would be Birbezia, but obviously then you've got hemolysis and other clues, or you've got anaplasma and Borrelia.

So those are the two tick-borne diseases. In theory, and certainly in the surveys of ticks in our, in this country, there is anaplasma and Borrelia in our ticks, endemic in our ticks, and we know that people get Lyme's disease. But interestingly, it's not something we particularly recognise in dogs, but we'll, we'll talk about that in a little, a little bit more detail later.

Then we've got immune-mediated disease. So here, the main ones that cause a pyrexia are gonna be your steroid responsive meningitis, your IMPA. Things like paniculitis, granulomattis, lymphadenittis.

We'll discuss these in a little bit more detail as we sort of tease things out. But, just worth mentioning at this stage that things like IMHA and immune immune hemolytic anaemia and IMTP, so immune media thrombocytopenia, those animals aren't, aren't commonly pyrexic in spite of their raging autoimmune disease that's occurring within their body. Inflammatory is a bit of a bucket for those that don't fit in the form of two diagnosis.

And here we're thinking about particularly pancreatitis because that doesn't neatly fit anywhere else. In some studies, they've categorised some of the disorders that are a bit more controversial here. So things like metasy, osteopathy, which will come on to talk to in a little bit more detail in a minute.

That in some studies has been categorised as inflammatory, and we'll discuss where that might fit better in a, in a little bit. Neoplasia can cause pyrexia in a number of different ways. Either it can be because there's a huge mass and it's necrotic in the centre, and so that that's an inflammatory focus.

Or some neoplastic processes can secrete cytokines, which result in a change in your catabolic state and obviously your metabolism and therefore temperature. And definitely we see this, I suppose, in particular, I'd say with lymphomas, we can see pyrexia, especially in those. Clearly, if you've got something like a neoplastic process, which has resulted in a septic, dog, like a septic peritonitis, then that's probably driving the pyrexia itself as well.

But those are the four categories. Now, they're really helpful to think of when you're, when you're approaching a par field, but they don't necessarily help you with then fine tuning and honing your diagnostic steps and your problem solving above and beyond just making sure you've always considered all 4. So we'll go into how it might be better to approach these cases in a bit.

Just to say there have been a number of studies that have looked into the final diagnosis in animals that presented with pyrexia of unknown origin. So these are 4 studies that were performed in dogs. So you can see the green represents non-infectious inflammatory, and in all 4 studies, most of these represented immune mediated disorders.

And then you can see the infectious disease was yellow. Miscellaneous is a sort of mauve and then pyrexy of unknown origin, so essentially either the animal resolved before a diagnosis is reached or no diagnosis is reached are the purple. So you can see, these are 4 studies in referral settings, and even in that context, almost a quarter of animals, have we failed to achieve a diagnosis in.

But it's just interesting to see, as you can see that infectious, in spite of the fact that often when we have a pyrexia we worry about infection, it doesn't end up being all that common in the PUOs. I suspect that that's for a number of reasons. It could be one that you guys are pretty good at picking up the infections.

These 4 studies were referral populations. So actually those ones, perhaps you've been really good at ruling that out either with further tests or perhaps with empirical antimicrobial trials, or it reflects that actually infectious disease aren't all that common as a cause of of pyrexia of unknown origin in dogs. And so I think it's probably difficult to to say based on these studies alone that you shouldn't be trialling antibiotics in pyrexic animals, but it's just food for thought and and perhaps just carefully justifying in your mind, you know, what is your, your logic for antimicrobials in this particular patient.

Pyrexia alone isn't a justification in itself, but perhaps more information about that particular case means that it is justifiable. And I think the first thing to think about when you've got approach to a pyre animal is thinking, what's the signalling of my case? And here I'm specifically talking about dogs.

So what's the age and the breed? As you can see on this study, the, the sort of the, the The corner, the bottom right, you see loads of the juvenile dogs actually had, immune mediated diseases. So actually, if a dog's less than 18 months old, the chances are it it's, it's fairly likely, assuming there's no obvious source of infection, to be an autoimmune or inflammatory disease.

Also, the breed can be really helpful, and perhaps most of you encountered it, but for those of you that haven't been familiar with this, beagles are really prone to steroid responsive meningitis arthritis. So if you have a beagle that's less than 2 years of age, with pyrexia, carefully examine it for neck pain, and actually tail pain. Some of them interestingly present with lumbar pain or tail pain alone.

But yeah, carefully examine them because SRMA is up there as the a cause in that breed. You can see that also we see IMPA in the in these dogs. So this, this is taken from the study in juvenile dogs.

And then, yeah, there are certain breeds that we know are are predisposed to these autoimmune conditions. Having said that, perhaps in a springer spaniels, you've got a 4 year old springer spaniel, with pyrexia. We know that they're grassy magnets.

So there you might be thinking of a migrating from body, Pythorax, and then failing that, yes, we know they're also prone to autoimmune diseases. So there's certainly, we recognise, definitely immune polyarthritis, particularly in, in spaniels in our hospital population. So yes, this is just to say, look at this, it's really interesting.

80, if you're under 18 months of age in a pyrexic dog, definitely think, that firstly, non-infectious inflammatory disease, and then latterly, but much lower in levels infectious disease than by far and away the most common. And if we examine those pyrexic dogs further to see exactly what they had as their final diagnosis, within this population, you can see SRMA was by far and away the most common diagnosis. So this is, yeah, steroid responsive meningitis arthritis.

We'll discuss it in a little bit more detail in a minute. IMPA again, we'll discuss in more detail. That's actually in our hands, more commonly recognised in a slightly older population of dogs, so perhaps a sort of middle age, so here we're thinking 2 to 5 years of age is the the most common presentation in our hands for MPA.

Then we've got metasy osteopathy, which is also called hypertrophic osteodystrophy, and we'll discuss that in a little bit more detail in a minute as well, cos it's another important one. Pier granulomatous lymphadenitis, we're not gonna mention further. So just briefly in case you haven't heard of that.

That is a condition where you have often generalised lymphadenomegaly in dogs. You sample their lymph nodes and you get back neutrophilic and macrophagic inflammation. Now, once you've got that, that clinical picture, it's important to bear in mind that you can see that, in a number of infections.

In particular, Mycobacteria, which is pretty uncommon in dogs, especially involving lymph nodes alone, but important to mention, Elia, so especially important in travelled dogs, and Leishmania, again, same goes for that. In toxoplasma, and Bartonella in theory, and fungal disease. So, granulomatous lymphadenitis, is, is a diagnosis in itself.

Interestingly, a really nice, study recently demonstrated that springer spaniels are very prone to this, and it appears to have a favourable favourable response to press steroids. So I think if I had a spaniel, so a young to middle aged spaniel, and I sampled multiple lymph nodes that were enlarged and got io granulos, lymphadenitis and all of them. I think I'd counsel the owners, look, we ought to screen for infectious disease, but I'd be thinking about whether I immunosuppress that dog in the absence of any obvious infectious focus.

It's an interesting one, and certainly watch this space with that. Probably worth mentioning at this stage that they can just affect only the mesenteric lymph nodes, this granulomatous lymphadenitis. And in those dogs you have large lymph nodes within their abdomen, and their granulomatos on sampling.

And the same were rule out supply. Obviously these are the dogs that you're really worried about lymphoma so FNA of the lymph nodes is really important. So moving on to our next practical tip, the next question that you're thinking about in your animal is after you've considered it signalment, is, is there any travel history or risk of tick exposure?

And you, you may well be familiar with the 4DX which is this sort of IDEX test that screens for most of the tick-borne diseases. It's gonna screen for the ones that are important for pyrexia of unknown origin, so here in the plasma and the Borrelia are the important ones. And as I said.

Babezia, which isn't part of the 4DX, can also present with pyorexia. Those are patients that are presented with hemolysis as well, so perhaps less of a concern that you'll miss it. So in our hospital, we do tend to do a 4DX in our pyrexic patients.

But the truth is, I think the number needed to test to achieve positive diagnosis in an untraveled dog is gonna be really high, because in our hands, it just doesn't seem to be the case. It's really interesting, as I said earlier. We recognise Lyme disease, in, in UK and people, and it's certainly in the ticks, but we don't seem to recognise Borrelia in terms of the presentation of a symptomatic dog, at all.

I've not seen a dog, an untraveled dog that's been diagnosed really. I've seen travelled dogs that have. So whether there's something about our particular strain or our ability to pick up on it, I'm not sure.

Anaplasma as well, in theory, as I said, is in our ticks, but we haven't seen one that in an untraveled dog either. Those ones should also be thrombocytopenic. So I think you could reserve this 4DX test in pyretic animals, those that present with thrombocytopenia as well, because that is a little bit of a clue that perhaps there could be a vector borne disease going on.

The other thing I think, so once you thought about the signalment and the travel history, is to do a really, really thorough clinical exam and observe your patient. Because if, as soon as you can localise any of their clinical signs to a specific location, it gives you something to chase. Sometimes, so the picture on the left is just a quiet, this was a 6 month old golden retriever, it's just really quiet.

And it was quite tricky to get any any specific localising signs. In this case, actually, because we've got, it's a young dog, and we've got these autoimmune diseases like SMA and IMPA really high on our list, we'll carefully examine them and then test them to see if they seem painful. Some of these dogs can be really, really stoic.

So your history history are asking the owners, has there been any difficulty with going up and down stairs or jumping up and down from the car or onto furniture can be the only clue you'll have. And so sometimes in these patients also we'll walk them up and down the stairs to see if we can elicit we can identify any discomfort or resentment with that to try and give us more clues. And then sometimes, as the picture on the right, again, obvious localising signs of this dog, perhaps it's quite tricky to see, it's quite furry.

There was actually marked ligament laxity. So, in fact, the, the dog's carpi were almost touching the floor. And that was because it was, stiff.

It had an IMPA, so immune media polyarthritis, resulting in, in the ligament laxity, the destruction of those. Another one that's really useful is getting the owners to take videos, and here's a good video of a case. So this, this dog had actually been presenting to the vets, for pyrexia, and like poorly localised signs for a number of months.

But the difficulty was, it's a spaniel. When it arrive at the vets, it would have pretty subtle signs. It was pretty difficult to localise.

And perhaps it would limp on one leg in the consult room. And then obviously you're not necessarily thinking of autoimmune diseases, you're thinking of things like degenerative joint disease in the elbow. But actually in this case it's pretty obvious as you watch this, that there's a shifting lameness, you can say yes the left four seems pretty badly affected but actually dog's not very keen on putting the right down.

It's shifting on its back legs. So I think sometimes in these cases where you're really not getting a lot of clues in the in the console, but the owner's describing a completely different dog at home, getting videos now that we have the the use of smartphones is going to be a really useful tool that we have in our armoury in the more difficult patients where they're not giving anything away. So, yeah, like I said, the most common presentation we have for our paraorexic patients is a stiff gait.

And here, the main considerations we have are, depending on the age, metas osteopathy, SRMA IMPA, aseptic joint and discosinylitis. I'd say a lot of our pyrexic patients that we work up here end up with one of these diagnoses and certainly the likely the 1st 3. Obviously some of them can be unusual, so they can have things like a pyothorax and perhaps I said you're doing a great job of ruling those out, and that's why I'm gonna end up talking so much about the auto mean ones.

But perhaps it's relevant to talk about them nonetheless because they're clearly the trickier ones to get to the bottom of in practise. So metaphysia osteopathy, or as I said, hypertrophic osteodystrophy, as it was formerly known as, is the condition of growing dogs. You can see I've got some radiographic examples where you've got, yes, you've got the line of the growth plate, but you can see just proximal to that.

You've got another really radio loose and almost moth-eaten line, visible on those radiographs in particular affecting the radius, but it's also visible on the ulna. And that's, that's sort of a hallmark of this condition. So the, so it's an infiltrate of inflammation at that particular location.

We're not sure exactly why it happens. It's, we know that Weimaraners are particularly prone to it, and there was one paper that suggested that it was a history of vaccination seemed to make to be associated with onset of metas osteopathy. Though sometimes you might come across Weimaran breeders or owners that have been advised by breeders to sort of spread out the vaccinations breed in light of this, there's actually probably not desperately, well certainly not very strong evidence that that's necessarily useful or or that there's a strong link there.

I think it's worth recognising that actually metasio osteopathy affects dogs under 6 months of age, especially in the first few months of life, which is when we're gonna be vaccinating them. So perhaps it's a bit of a a tenuous link there. One of the interns here from Langford Vets, where I'm currently working, did a nice study sort of reviewing from a, a number of centres, the condition was.

And what I thought was really interesting and something to report to you guys was loads these dogs actually presented to neurology or or certainly the the vets were concerned neurologically because the dogs were often non-ambulatory, . And sometimes that affected their back legs before their front, so they can be quite tricky cases. So they're often pyrexic and as I said, non-ambulatory.

And in those pyrexic dogs, that are under 6 months of age, that present an ambulatory, giving them a careful clinical exam, including sort of gently and then then more firmly, perhaps, pressing close to their joints, not around their joints, but just sort of proximal that area. And if you elicit a strong pain response in that area, then it should raise the alarm. Could this be metaphys osteopathy?

A lot of these dogs are really, really painful with this condition. So often they're hospitalised and on opiate analgesia. And in my experience, even the opiates aren't are often inadequate to achieve sort of ambulation in these patients, and it's in fact, once you get remission of the disease that you, you become on the sort of home straight with that.

Diagnosis is achieved with radiographs, as I said before, and you see that characteristic radiolucent line. It's really interesting in our study, we found actually back legs were more commonly affected than for legs, and that was clinically and radiographically. So if you're just gonna do one radiograph and a dog and you think it's metastas osteopathy, then provided it's sort of doable, focusing on the sort of tarsal region is going to be the most interesting, the most likely to get a diagnosis.

I say that, but to be honest, sometimes the car is just a lot easier to capture because of you don't need patient restraint in terms of sedation, just analgesia often to achieve those images. So weigh things up in your patient. The important thing to mention and what came out in the Weimar study is some dogs where you're really suspicious of metasta osteopathy and you radiograph them, there's no sign, actually give it a couple more days and then repeat radiographs.

So because we think that radiographs lag behind the clinical signs in some of these patients. Both our study and this metastasy osteopathy study interestingly found that steroids were superior to non-steroidals in achieving remission in these patients. And it seemed like probably 1 mg per kg per day would be adequate, rather than needing the 2 mg per day immunosuppressive doses.

So worth bearing in mind in these patients. So next, SRMA or steroid responsive meningitis arthritis, which is, an inflammatory disease suspected to be immune mediated. I'm not sure, you know, geographically how how locally you are, sort of, in terms of recognising this condition in the sort of where I come from, so the the Somerset area, our vets see this quite often.

There seems to be something geographically there, but they're great at picking up it, so most of them are familiar with this. As I said, we think it's a mediated and it's often in dogs under 2 years of age, and they can have tail pain as well as the classic neck pains. Diagnosis achieved from a CSF tap, and I guess in terms of limitations on performing CSF taps in practise, firstly, it is quite it's a procedure that's not without risk, especially obviously trauma to the brain stem.

So it has to be done carefully. But also actually, the CSF we think ought to be looked at fairly promptly. And so most people have the limitation where they're not able to courier the the samples straight to a lab the same day to then have the highest likelihood of achieving the diagnosis where the cell preservation appears to be compromised when it's overnight.

Some labs will have a specific ways that they can recommend in terms of trying to preserve the sample. But we do think that it's most useful if it's same day without pres preservatives to allow us to interpret not only the cell count, but the protein count. We know that there are certain breeds that are particularly prone to SRMA so here, obviously you can see the beagle, as I mentioned before, but also collies, boxers and whippets are definitely prone to it.

The prognosis is generally very good. I'd say in our hands, we often see dogs that are presented with neck pain, pyrexia. The vets are highly suspicious of SRMA and some of those dogs actually seem to, resolve before we even attempt to diagnosis.

And that's, that seems to be the clinical cause of SRMA and it'll often wax and wane in that kind of vein. And it seems to be reassuringly that the dogs will actually tend to grow out of it after 2 years of age. So we'll say to the owners, look, you may have relapses.

The good news is once you achieve the diagnosis, we know what we're dealing with. It's not necessarily important to repeat tests, but that hopefully they'll grow out of it. The prognosis is generally very good, and treatment is recommended with prednisolone.

Now, if you read the sort of literature and the textbook recommendations, historically, we advised 6 months of immunosuppressive steroid therapy in these dogs. Now, in our hospital, and certainly what we've recognised more and more is probably that's, that's too much steroid for these dogs. And when you're thinking about recommending such a long course of steroids in a dog under 2 years of age, it's gonna impact its quality of life.

It's something to be careful about. In in some of our cases, we've even trialled sort of 6 weeks of therapy. And, interestingly, in that cohort, it seems to be adequate.

I would say that we don't, we do see relapse quite often, so about 20% of the dogs appear to relapse. But actually, whether or not they're on steroids doesn't seem to protect them from this relapse event. So is there not an argument then to pulse them?

And then back off quickly and then obviously do the same again if they suffer a relapse. And I think that's, that's not yet answered in the in the literature and but hopefully that will be achieved. What I would say is, and certainly something that, you might struggle with, what do you do with this dog?

So you've got a 6 month old beagle with paring neck pain, but they've not got the money to refer. What would, what would I do in that, in that circumstance? I think what I firstly do is obviously be really, try and be as happy as I could be that that that was, there was definitely neck pain, for example, and you're happy that you're on the right lines with that.

And if that was the case, I think I'd count the owners and say, look, this is by far and away most likely SRMA. What I would suggest you trial is just a short course of steroid to see if it's a positive response. I think in SOMA a lot of them seem to respond just 1mg per gig.

So I think I would just do a short course of 1 me of steroids in 5 days, and then withdraw and see if that was adequate. So I don't think I'd be wanting to recommend longer courses in the absence of a diagnosis. And I think most, most cases that that shouldn't be an issue, provided you're fairly secure with localising your problem.

Next, coming on to immune-mediated polyarthritis. So there are two categories, non-erosive and erosive. So non-erosive basically, is the most common, and here we don't see changes to the bones around the joints that are involved, whereas erosive we do, and erosive is closer to rheumatoid arthritis in people.

To diagnose immune media polyarthritis is based on joint paths, and you should have more than 3 joints. It's really nice, obviously, most of you probably wear BSAVA procedures guide has really nice top tips on how to get joint cuts. And what I'd say is actually the risk of this procedure is pretty low, and I'd encourage you to all have a go if you haven't already.

The main frustration is when you get blood contamination, and that can influence your ability to, to, interpret your results. The, there's a nice study into IMPA to see which joints are most likely to achieve a diagnosis. And it's found to be most often in the tarsus and then the carpus, which is good news because carpus is probably one of the easiest to tap, whereas the tarpus Tarsus can be a little bit trickier.

And the diagnosis is based on the presence of neutral inflammation in multiple joints. And it's just worth bearing in mind that neutrophilic information in one joint could be a septic joint, but in multiple joints, it's probably more likely to be IMPA. an important rule out would be some of the infectious diseases can do that, and we'll come on to that in more detail in terms of the triggers.

Like I said, in terms of our workup, we will tend to image a distal limb to look for evidence of boatly change suggestive of erosive disease. It's not essential in terms of workup. Cos actually, it doesn't change the treatment, but we think it's associated with the poorer prognosis because these dogs appear to be more likely to suffer with ligament laxity and therefore need things like pancarpal aphrodisis longer term.

So in terms of thinking about IMPA, so once you've achieved a diagnosis of neutrophic inflammation in multiple joints, you're not done. You've actually got to then reflect on whether you think there's a trigger for this IMPA because as we had on a previous slide, IMPA represents a presence of antigen antibody complexes in our joints. So any kind of chronic grumbling situation in the body could result in the build up of those complexes that philtre out into the joints.

So it's important for us to consider whether we think there's a trigger. And certainly of all the immune diseases like IMHA ITP SRMA of all of those conditions that I recognise in my referral case load, definitely IMPA is the most, the one that's most commonly got a trigger. So where IMHA ITP, I don't think it's, it's wrong, provided the owners of council to kind of cut corners with the screening for triggers.

In IMPA I do get a little bit more nervous about doing this because, because of the kind of pathophysiology, it makes more sense, they're more likely to have a trigger. So yeah, in terms of the possible causes, there's primary, there's no underlying cause. And even though I'm saying there's like there can be a trigger, that represents about 85% of dogs star MPA.

So still, it's by far and away the most often, but still 15% of them do have a trigger. Infectious. So here again, things like plasma, leishmania, and then a grumbling infection in the body will come on to in more detail.

GI disease, neoplasia, and then drug induced and vaccine related, which will come on to in more detail in the moment. So with IMPA, sorry, with infectious triggers, you can have arthrobodborne disease. So here, like I said, Lymes and plasma, or a specific organ that's infected.

So in these cases, think of an, an infected organ with a grumbling infection. That's long enough to allow this buildup of antigen and antibody complexes then philtre out into the joint, so it's often an infection that's been grumbling on quite a while. Although I have put pyometer and prostatitis here, it's much less common in those.

Whereas endocarditis, discospondylitis, and pyelonephritis, certainly we do recognise IMPA being triggered by those, especially endocarditis. And this was just a video loop of an endocarditis valve lesion on a mitral valve. So here this, you can see a pretty obvious sort of lesion on the, on the valve there.

So in terms of crack or pips when thinking about screening an IMPA, what do we, you know, what do we actually look for? As I said, you can screen for Bria. I would say, you know, the 4DX is, is fine.

Having said that, unless the dogs have ticked exposure, I'm not convinced it's a very highly like a rewarding test in the sense that certainly in my hands. Haven't seen very many, but I guess if we don't test, we'll never find. So if one to bear in mind, but if cost of limitation, I'd probably bench the Borrelia.

And then, when to do a heart scan, I think if you've got a novel heart murmur, an arrhythmia, or if you choose to do troponins, they're markedly elevated, it might be worth just doing an echo. And here you're, you're simply looking at those valves for lesions. Thinking about the mechanism, if the most common valves to be affected is the mitral valve and then the aortic valve.

In mitral valve endocarditis, it's gonna cause insufficiency in the mitral valve. So you're gonna have a left apical systolic murmur. Whereas if you think about it, if you have lesions on the aortic valve, you're gonna have a basillam, but it's gonna be diastolic because the incompetence of the aortic valve, it's gonna be diastolic murmur.

So I think just listening carefully to these dogs hearts, especially over the basilar region. For diastolic and then obviously the apical region for a systolic murmur and considering whether you think it's gonna be worth echoing, depending on your index of suspicion. And then yeah, thoracic and abdominal imaging is gonna look for things like a pyothorax or a pyometra.

And then we do, as part of our screening, do a urinalysis for culture to look for triggers. And I think in people, they, they specifically look for proteus infections because Proteus has a similar antigen on the surface to the joints, so it makes sense. Whether an asymptomatic UTI in a dog could be responsible for triggering IMP.

It is a little bit harder to prove, especially where we know that asymptomatic UTIs are pretty common, and we think, you know, about 15% of dogs walk around with these. It's an important consideration about the clinical significance of the urine, a positive urine culture. In, in people, there's a strong link that's known to be between arthritis and inflammatory conditions of the bowel, and we think it's probably similar in dogs.

So if there's a history of gastrointestinal signs, as well as this pyrexia and diagnosis of IMPA consider whether you think it could be that actually the GID disease has triggered this IMPA. If you become suspicious, you might be interested in doing bloods to look for. Carbalamine and folate, or even a diet trial and here we're thinking exclusion diet in these cases.

In terms of the final kind of trigger, so neoplasia, my practical tips would be to FNA lymph nodes if they're big. And then obviously thoracic and abdominal imaging. So long story short, in an IMPA you're probably gonna want to do thoracic and abdominal imaging to screen for triggers that are infectious or neoplastic in origin.

Perhaps an echo or quick valve check depending on your clinical suspicion, not essentially in all of them. And then obviously the 4DX, the travelled ones. I think in terms of practical ticks with drug history, obviously withdraw any offenders, we know that cephalosporins are probably the biggest, the biggest, strongest link in terms of autoimmune disease and obviously TMPS.

If that's been the trigger, ideally the sign should resolve in 7 days. And then it's tricky with vaccination. There have been recent, kind of studies that have just, tried to explore the link between autoimmune disease and vaccination, and they failed to find a link, but that might be because the studies are underpowered.

And perhaps, you know, for some patients it's important. So if the animal was vaccinated within 30 days, then consider whether it could be actually, a vaccination reaction and whether actually next time you'll do tier testing instead of, vaccination in that in that particular individual. In terms of treatment, obviously, if there's a trigger, then you're gonna treat that.

And also you immunosuppress. And by far in a way, the most common immunosuppressive therapy that we use is gonna be prednisolone. But just bearing in mind that actually you've got a dog that's got IMPA it's reluctant to exercise and quite immobilised.

The steroid side effects can be quite undesirable in those because of the muscle muscle wastage that comes hand in hand. So it's not uncommon for us to reach for an adjunct like leflunomide or mycophenolate in these in these dogs to try and reduce the steroid dose sooner and therefore improve their quality of life in terms of steroid side effects. That bit more undesirable in our IMPA population.

In terms of the prognosis with IMPA, it is a bit different to SMA. Unlike this really excellent response to steroids, some animals, about 15%, don't respond to immunosuppression. And unfortunately, a further sort of 15 to 20% will relapse either during tapering of therapy or, once they're off.

So about 60% will have a reasoned outcome after tapering of therapy, but further population will suffer, will either fail to achieve remission or suffer relapses. And as I said, the drug side effects are important to bear in mind. And this is why I think when you've got a dog you're thinking is IMPA.

I think this is the condition that I would encourage owners to pursue a diagnosis of, even if it's just a joint perhaps, because actually what can go wrong on these dogs is maybe they don't respond to your prednisolone that you've treated them for. And yeah, OK, you thought it was IMP on day one, but when you've not seen a response after 7 days of too maybe have steroid with, when you haven't achieved a diagnosis, you're gonna start getting really nervous that you got, you got the diagnosis right. And actually, it would have been much nicer to have known on day one to then be able to rethink yourself, no, I've got the diagnosis right, but this dog hasn't responded yet.

I need to add further immunosuppression. So that's why I'd encourage in IMPAs, you, you, you get yourself in knots if you don't sort of achieve that diagnosis early on, although I appreciate there are limitations to that. And here's just as a nice little finisher, in terms of this, here's that dog that we had, sort of limping at the beginning just after two weeks of steroids for a couple of weeks.

And I think the owners have forgotten because unfortunately been going on quite a while because the dog was so tricky to get to the bottom of, delighted to see their dog, returned. So very quickly, disco spondylitis is really rare. It can present with neurological deficits and certainly back pain.

And the therapy for this is extended course of antimicrobials, but here we're talking sort of 6 months of antibiotics. You really want to get a diagnosis rather than just empirical therapy. Some, neurologists will sample the disc space to try and achieve culture guided, antibiotics, and some animals will have instability of their spinal cord to require fixation.

Septic joints can be tricky to decide between IMPA because of. You're still gonna get neutrophilic information. Joint cultures are really challenging and often negative.

But certainly it's worth, it's worth submitting for culture. But bear in mind, if the culture's negative, it doesn't mean that it's not a septic joint. We know DJD is a risk factor for septic point, so bear in mind your, your animal in particular.

And then obviously the therapy again, is extended course of antimicrobial therapy and removal of any prosthesis, where relevant. It normally affects one joint unlike IMPA. So even when I have a dog with one swollen joint, we'll often tap plenty of joints to see if, cause if we get neutrophilic loads of them, it's a different story to if we just get neutrophilic and the one that's swollen, where we start thinking septic to it are much more likely.

This is just a just quick word to say, the CPLI obviously, in practise, we think it's generally quite useful to establish pancreatitis, and pancreatitis is definitely a cause of pyrexia. But actually, it's not, it's not always that helpful in these paric patients. We definitely recognise in our IMPA dogs, often they've had a CPI that's been positive for the vets, and that's, that might have changed, influenced the vet's thought process.

It's also a nice JAP paper found that it's actually increased in dogs with this disease. And that's really frustrating because sometimes it can be really difficult to decide if an animal has abdominal pain or back pain. And you think a CPLI would help you, but I, I'm afraid not in all populations.

And yes, CPI is elevated by MHA. So we think it probably is elevated in IMPA as well, so it might not always be that useful. And then endocarditis in its own right, so here we're considering it instead of just considering it in the context of IMPA.

As I said, it's most common in the mitral valve and chronic infections or mitral valve disease are risk factors. As I said, I'd, I'd consider this in a dog with a novel heart murmur, with polysystemic signs, and that's a bit vague, but here I mean, maybe a dog with joint pain, back pain, and a few weird neurological signs, and maybe, some skin nodules. So when a few different organs can be infected, or arrhythmia, and I think that's really anecdotally, but certainly in my experience, endocarditis dogs seem to quite often have arrhythmias.

And in this population, troponins might be useful. When it's a touch elevated, so a bit above reference, I say double, we don't know how useful it is, but when it's sky high, in these paraxic animals, then you would be thinking and the poit was plausible. So finally, and just briefly, what about cats?

I, there's a really nice study that reviewed the kind of most common diagnosis in cats that present with pyrexia. And here, in contrast to dogs, it looks like infectious causes are by far and away the most common. But importantly, at the top of the list here it was FIP.

So yes, infectious was common, but not antimicrobial responsive infections. But actually, interestingly, yes, Pyothorax is, is there as well. And neutrophilic cholangitis, bronchopneumonia?

Pancreatitis seems more commonly present with pyrexia in cats than it was cats and dogs, and then obviously the neoplasias and, intestinal disease. Here, interestingly, 3 cats IMHA had pyrexia and, and that seems to be quite such a feature in dogs. So what's the brief sort of take home message for cats?

I say careful clinical examination again. And then ophthalmological and orthopaedic examination. And then consider early cat flu.

We certainly see quite a few of these cats where we haven't actually presented with many cat flu signs, just pyrexia and appetence lethargy. A couple of days later it is really much more obvious because they're sneezing, they've got nasal discharge and oral ulcers. So consider early cat flu in this population.

And I think the ones we see most commonly are either the FIPs, and I think probably in fairness, our reputation as a centre for researching FIP does generate some of those referrals. And then also I think certainly neutrophilic cholangitis is a big offender for posing cats. And so these ones tend to present with change the hepatic enzymes.

Don't forget ALP's got a really short circulating half-life in cats. So actually often the only clue for the hepatic enzyme picture is that high ALT. And then bilirubin, obviously, so if you have a pyrexic cat that's jaundiced, here you're thinking neutrophilic cholangitis, pancreatitis or FIP would be your big rule outs.

And then obviously imaging is needed. What I do find with cats is when they've got pars in origin, sometimes their clinical course is the most useful. So maybe you've not got a lot to, give you a clue on the first day you examine the cat, and perhaps you give symptomatic therapy.has are non-steroidal in them.

Certainly m media is less likely, so I don't think that's wrong if they're hydrated. And then see them back and see if they give you any more clues if they're not improving. And this is at that stage test.

Frustratingly sometimes in these cats. We end up repeating tests, so maybe you've got a normal serum biochemistry on day 2, but actually they've persistently para you repeat it on day 4, and then you've got the hepatic enzyme changes lead you down that line. What I would say about this studying cats is it was again, a drawback is it's a referral population and I bet you guys see loads of cat by abscesses that we're not seeing.

And I think it's another message to say we'd love to see more first opinion research in in these kind of fields where you can give us the insights into what you're seeing on a daily basis. So, just a final slide. In summary, I'd say there's an emphasis when approachingyexic patients, you should be carefully considering the aetiology, so.

Instead of thinking, gosh, this animal's hot. I want to make it feel better by dropping its temperature, thinking to yourself, this animal's hot. What could be driving this?

And then it's not wrong still to do the same thing, so to reach for the non-steroid or to try and address the pyrexia. But just be mindful that you've had that little step in your head about why you're doing it. And that perhaps think cautiously about the ones you select antimicrobial therapy for.

In light of, our, our newfound appetite for stewardship in that respect. And then a step by step approach. So I think that's the, the key is you say, look, you run in origin on these patients can be tricky to get to the bottom of.

It, it might be we get it in the first test, or it might be that we have to do quite a few, or we might not get to the bottom of it. And just having that conversation early doors is definitely something I'd advise. And as I said, in some cases, symptomatic anticyretic therapy and more time can help with investigations.

Yeah, thank you for your attention and that that's my final slides. I'd like to invite any questions. Thank you very much, Vicky.

Absolutely brilliant webinar, really, really good. And you've managed to cover so much in just one hour, which is great. We don't seem to have any questions so far, but I'd just like to remind you all if you do have any, just hover over the toolbar.

It's either on the top or the bottom of your screen, click the Q&A box and send it through to me and I'll ask Vicky any questions that you might have. I quite often use the BSAVA procedures manual for many different things. I find it really useful.

Is it quite good for things like joint taps? Oh yeah, I completely agree. I think it's a fantastic manual.

And when I was doing joint taps in practise, that's what I would refer to. It's brilliant, isn't it? It's really, really accessible, user friendly manual.

Yeah, it is really good. BSAVA have released an app recently as well and you can now find the procedures manual on your phone, which is great. Nice.

Yeah, you can just use it while you're in practise, nice and handy. OK guys, we'll just stay on for another few minutes just to see if you do have any questions. Don't be shy, please send them through.

No, it doesn't look like we have any. So on that note, I'll just say a massive thank you to you, Vicky, and thank you everybody for joining us tonight. It was an absolutely brilliant webinar and I hope you'll join us again.

Thanks very much, Sophie. Thank you. Bye bye, bye.