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Year: 2011

Thrombosis of the cranial vena cava in a cow with bronchopneumonia andtraumatic reticuloperitonitis

Gerspach, Christian; Wirz, Mirjam; Knubben-Schweizer, Gabriela; Braun, Ueli

Abstract: This paper reports the clinical findings, surgical and medical management, and necropsy ofa 6 year old cow with thrombosis of the cranial vena cava and thrombo embolic pneumonia followingtraumatic reticuloperitonitis. The clinical diagnosis was confirmed by necropsy. Thrombosis of the caudalvena cava is a well known disorder of cattle, whereas thrombosis of the cranial vena cava is relativelyuncommon (1-7). Liver abscesses that break into the caudal vena cava are the most common cause ofthrombosis of the vessel (3,8). Thrombosis of the cranial vena cava is usually attributable to embolismof a jugular vein thrombus and is less often due to haematogenous spread of infection (6). Thrombosisof the vena cava is often associated with metastatic bronchopneumonia with characteristic clinical signs.Wyssmann (1), Breeze (9) and Bueno (10) described respiratory syndrome and signs of congestion incattle with thrombosis of the cranial vena cava. This case report describes the clinical findings in asix-year-old Swiss Braunvieh cow with thrombosis of the cranial vena cava.

Posted at the Zurich Open Repository and Archive, University of ZurichZORA URL: https://doi.org/10.5167/uzh-56078Journal ArticleAccepted Version

Originally published at:Gerspach, Christian; Wirz, Mirjam; Knubben-Schweizer, Gabriela; Braun, Ueli (2011). Thrombosis ofthe cranial vena cava in a cow with bronchopneumonia and traumatic reticuloperitonitis. CanadianVeterinary Journal, 52(11):1228-1231.

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Thrombosis of the cranial vena cava in a cow with 1 bronchopneumonia and traumatic reticuloperitonitis 2 3 C. Gerspach, M. Wirz, G. Schweizer-Knubben, U. Braun 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

C. Gerspach, DrMedVet., G. Schweizer-Knubben, DrMedVet., U. 36

Braun, DrMedVet., Department of Farm Animals, M. Wirz, MedVet, 37

Institute of Veterinary Pathology, University of Zurich, 38

Winterthurerstrasse 260, CH-8057 Zurich 39

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Abstract 40

This paper reports the clinical findings, surgical and medical management, and 41

necropsy of a 6 year old cow with thrombosis of the cranial vena cava and thrombo-42

embolic pneumonia following traumatic reticuloperitonitis. The clinical diagnosis was 43

confirmed by necropsy. 44

45

Thrombosis of the caudal vena cava is a well known disorder of cattle, whereas 46

thrombosis of the cranial vena cava is relatively uncommon (1-7). Liver abscesses 47

that break into the caudal vena cava are the most common cause of thrombosis of 48

the vessel (3,8). Thrombosis of the cranial vena cava is usually attributable to 49

embolism of a jugular vein thrombus and is less often due to haematogenous spread 50

of infection (6). Thrombosis of the vena cava is often associated with metastatic 51

bronchopneumonia with characteristic clinical signs. Wyssmann (1), Breeze (9) and 52

Bueno (10) described respiratory syndrome and signs of congestion in cattle with 53

thrombosis of the cranial vena cava. 54

This case report describes the clinical findings in a six-year-old Swiss Braunvieh cow 55

with thrombosis of the cranial vena cava. 56

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Case description 58

The cow had calved three months ago. Three weeks ago she had a reduced appetite 59

and was treated by the referring veterinarian with a magnet and procaine penicillin 60

because of suspected traumatic reticuloperitonitis. There was a transient response to 61

treatment, but two weeks later milk production decreased and rumination ceased. 62

She was then referred to the Department of Farm Animals, University of Zurich, for 63

further diagnostic work-up. 64

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The general condition and mental status of the cow were markedly abnormal, the 65

cow was depressed. The cow had a body condition score of 3/5. The rectal 66

temperature was 38.7 °C, and the heart rate was 108 bpm. Both jugular veins were 67

distended and there was brisket edema (Fig. 1). The respiratory rate was 48 68

breaths/minute, and the cow had abdominal breathing and coughed spontaneously. 69

Auscultation of the lungs revealed increased breath sounds. Ruminal motility was 70

slightly decreased with two contractions per three minutes, and there was a reduced 71

amount of ruminal content. The withers’ pinch, pole test and deep palpation of the 72

cranio-ventral abdomen were consistently positive, and the glutaraldehyde test was 73

shorter than normal at 3 minutes (normal > 10 minutes). 74

Further diagnostic work-up included haematological and biochemical analyses and 75

ultrasonographic examination of the lungs (11), heart (12), reticulum (13), liver (14) 76

and abdomen (15). Radiographs of the lungs and reticulum were also taken (16). 77

The most important haematological and biochemical findings were an increase in the 78

concentrations of total protein at 84 g/l (normal 60-80 g/l) and fibrinogen at 8 g/l 79

(normal 4-7 g/l) and increased activities of glutamate dehydrogenase at 39.1 U/l 80

(normal 0-25 U/l), sorbit dehydrogenase at 37.2 U/l (normal 0-20 U/l) and γ-glutamyl 81

transferase at 41 U/l (normal 0-20 U/l). The albumin concentration was normal (29 82

g/l; normal 21-36 g/l). 83

Ultrasonographic examination of the reticulum (13) showed one weak incomplete 84

contraction per 3-minute period (normal, 3 complete biphasic contractions per 3-85

minute period). Echogenic fibrin deposits containing pockets of hypoechogenic fluid 86

were seen on the reticular wall and extended from the left to right side of the 87

abdomen and from the ventral abdomen to the level of the elbows. An 11-cm 88

abscess with a hypoechogenic centre surrounded by an echogenic capsule was 89

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seen caudal to the reticulum. Fibrin deposits were seen on the ventral margin of the 90

liver. The pleura had comet-tail artefacts on both sides of the thorax, and a layer of 91

anechoic fluid with a diameter of 1 cm was seen between the visceral and parietal 92

pleura on the right side. The heart valves, liver parenchyma, caudal vena cava, 93

portal vein and gallbladder were unremarkable. Transcutaneous, ultrasound-guided 94

biopsy of the liver was done because of the elevation in liver enzyme activity; 95

histological evaluation of the sample did not reveal pathologic changes. 96

On laterolateral radiographs of the thorax the lungs, caudal cardiac silhouette and 97

caudal vena cava were clearly seen. A non-delineated soft-tissue opacity was seen 98

in the caudoventral lung field, and the dorsal lung area appeared normal. This finding 99

was interpreted as localised pneumonia. Radiographs of the reticulum revealed two 100

magnets on the ventral aspect of the reticulum. One magnet had two linear foreign 101

bodies, one of which appeared to be at an angle to the magnet and possibly 102

penetrating the reticular wall. There was localised loss of detail in the region of the 103

caudal reticular contour. 104

Traumatic reticuloperitonitis and bronchopneumonia were diagnosed based on all 105

the findings. The cause of distension of both jugular veins was suspected to be 106

obstruction of the cranial vena cava by a thrombus or compression of the vein by a 107

mass. Cardiac insufficiency was ruled out based on echocardiography. 108

The albumin concentration was normal, therefore a low oncotic pressure as a cause 109

of edema could be ruled out. 110

The owner requested a laparotomy, since the cow was valuable. 111

A laparorumenotomy was performed using a standart laparotomy incision in the left 112

paralumbar fossa. Anesthesia of the paralumbar fossa and abdominal wall was 113

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achieved by a proximal paravertebral nerve block. Prior to the rumenotomy an 114

abdominal exploratory was performed. 115

The ruminotomy was performed using a Weingarth’s ring. 116

The exploratory revealed massive adhesions involving the spleen, reticulum, cranial 117

blind sac of the rumen, omasum and those parts of the liver that could be palpated 118

from the left flank incision. Two magnets with a 7.5-cm nail and loop of wire were 119

removed from the reticulum. An abscess, which was palpated on the caudomedial 120

wall of the reticulum, was lanced and drained into the reticulum and lavaged with an 121

iodine solution (Betadine). 122

Postoperative treatment consisted of 10 litres of 0.9 % saline with 5 % glucose 123

administered intravenously daily, 1.2 x 106 IU/100 kg procaine penicillin (Procacillin) 124

administered IM every eight hours and 1.1 mg/kg flunixin meglumine (Fluniximine) 125

administered intravenously every 24 hours for 3 days. 126

Four days postoperatively, there was marked worsening of the brisket oedema (Fig 127

2) and development of mandibular oedema and swelling of the nose. In order to rule 128

out an allergic etiology of the swelling of the nose, the cow was given 2.5 mg 129

flumethasone (Cortival) IV every 24 hours and 50 mg/100 kg tripelenamine 130

(Vetibenzamin) IM once. Oedema of the front limbs and ventral abdomen (Fig 3) 131

developed seven days postoperatively. Ultrasonographic examination of the thorax 132

revealed severe pleural and pericardial effusion. Thoracocentesis yielded a 133

transudate with a specific gravity of 1.010 and no measurable protein. 134

Based on these findings, thrombosis of the cranial vena cava was suspected and the 135

cow was given 45,000 IU heparin IV every eight hours and 1 mg/kg furosemide 136

(Dimazon) intravenously for three days. However, over the following three days, the 137

oedema worsened, breathing became laboured when the cow was recumbent, and 138

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there was intermittent mouth breathing. Because of a poor prognosis and failure to 139

respond to treatment, the cow was euthanased. A postmortem examination was 140

carried out. 141

Postmortem examination confirmed the ultrasonographic diagnosis of massive 142

adhesions involving the reticulum. A friable, beige, rough, 8 cm x 3 cm thrombus was 143

fully occluding the lumen of the cranial vena cava (Fig 3). Histopathology of the 144

thrombus revealed gram positive (Brown-Brenn staining) coccoid bacteria. Culture 145

of the thrombus has not been performed. 146

The walls of the right atrium and ventricle of the heart were thicker than normal at 1 147

cm. The pericardial sac contained 100 ml of light red watery fluid. On cut surface, the 148

pulmonary vessels contained several friable rough structures, up to 2 cm in length 149

(Fig 4). The pulmonary parenchyma surrounding these areas was yellow. Culture of 150

these lung lesions revealed Streptococcus ssp. 151

The hepatic bile ducts contained massive numbers of small liver flukes. Specimens 152

of the lungs, kidneys and thrombus in the cranial vena cava were examined 153

histologically. Based on the findings, the cow was diagnosed with thrombosis of the 154

cranial vena cava, severe multifocal necrotising pneumonia with multiple pulmonary 155

thrombi, ischemic renal infarction, Dicrocoelium dentriticum infestation and localised 156

peritonitis in the region of the reticulum. 157

158

Discussion 159

Our patient had signs of thrombosis of the cranial vena cava. The differential 160

diagnosis for sudden distension of both jugular veins includes obstruction of the 161

cranial vena cava by a thrombus, compression of the vein by a mass and cardiac 162

insufficiency. Because the cow had an elevated heart rate, echocardiography was 163

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carried out and pericarditis, cardiomyopathy and endocarditis were ruled out. 164

However, it was not possible to determine clinically whether there was obstruction or 165

compression of the cranial vena cava. Radiography and ultrasonography showed no 166

evidence of compression of the vein by a space-occupying lesion. Thus, obstruction 167

of the cranial vena cava with a thrombus, which has been described in cattle 168

(1,9,10), was diagnosed by exclusion of the other differential diagnoses. 169

In principle, thrombi, which result from increased coagulation or reduced blood 170

flow, are differentiated from thrombi, which are attributable to suppurative 171

inflammation. Wyssmann (1) described a thrombus, which was determined to be 172

associated with a reticular abscess based on histological evaluation. In the present 173

case, the thrombus causing distension of both jugular veins and impaired venous 174

return with resultant oedema of the head and neck region was suspected to be 175

septic based on histopathology. 176

The most common cause of thrombosis of the cranial vena cava is 177

thrombophlebitis of the jugular vein (6). Septic emboli may also originate from other 178

foci of infection, including mastitis, endometritis and claw disease (6,17). The most 179

common pathogens are Fusobacterium necrophorum and Actinomyces pyogenes, 180

but staphylococcus spp., streptococcus spp. and Escherichia coli may also be 181

cultured from thrombi in the vena cava (18). No abnormalities were found on 182

ultrasonographic examination of the jugular veins in our patient. The most likely 183

source of infection was traumatic reticuloperitonitis with abscessation of the reticular 184

wall. Peritonitis, mainly in the reticular region, in conjunction with thrombosis of the 185

cranial vena cava was also described by Bueno (10) and Wyssmann (1). It is 186

plausible that bacteria from the traumatic reticuloperitonitis were transported via the 187

cranial epigastric and internal thoracic veins to the cranial vena cava. 188

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The cow also had severe multifocal necrotising pneumonia with formation of multiple 189

pulmonary thrombi. Metastatic bronchopneumonia caused by embolisation of part of 190

a thrombus in the vena cava has been described (2,3,5,6,9). The clinical signs of 191

thrombosis of the caudal vena cava and its sequelae are described as respiratory 192

syndrome attributable to metastatic pneumonia, pulmonary thromboembolism or 193

embolic pulmonary aneurysm (17). Selman (2) and Breeze (9) described respiratory 194

syndrome due to thrombosis of the caudal vena cava and cranial vena cava, 195

respectively. Pulmonary thrombi may lead to aneurysm and rupture of the vessel 196

with subsequent epistaxis and sudden death. The lung lesions in the present case 197

were consistent with thromboembolism. The most likely source for septic emboli 198

traveling to the lungs was the septic thrombus in the cranial vena cava. A similar 199

organism cultured from different lesions could prove that these lesions were related. 200

Streptococcus ssp. could be cultured from the lung lesions, but no culture was 201

performed from the thrombus in this case. However, histopathology of the thrombus 202

revealed gram positive coccoid bacteria. 203

The clinical signs in our patient were attributable to oedema of the head and 204

neck. Bueno (10) and Wyssmann (1) also described brisket and mandibular edema 205

and bilateral jugular vein distension in cattle with thrombosis of the cranial vena 206

cava. Oedema was not a clinical feature in the patient described by Breeze (9). 207

However, all affected cattle had respiratory signs (1,9,10). 208

In human medicine, congestion of the cranial vena cava is usually the result of 209

compression of the vessel, which in more than 80 per cent of patients is attributable 210

to a malignant tumour (65% bronchial carcinoma). The lead sign in human patients is 211

oedema of the head and neck (19). To the authors’ knowledge, compression of the 212

cranial vena cava causing congestion has not been reported in cattle. 213

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Ultrasonography is an important diagnostic tool for assessment of the vena 214

cava. Diagnosis of thrombosis of the vena cava directly by visualisation of the 215

thrombus (7,20) or indirectly by identification of dilatation of the caudal vena cava in 216

the region of the liver (5,21) is rare. A definitive diagnosis of thrombosis of the cranial 217

vena cava can only be achieved by direct visualisation of the thrombus via 218

ultrasonography. Bueno et al. (10) detected a thrombus visible within the right atrial 219

lumen, extending into the cranial vena cava. However, we were not able to detect a 220

thrombus in our patient. This was probably due to insufficient penetration into the 221

thorax and lack of access to the cranial thorax because the examination area is 222

delimited by the caudal margin of the thoracic limb. The cranial vena cava originates 223

from the right atrium, traveling through the mediastinum to the thoracic inlet, where it 224

bifurcates into the jugular veins. The cranial vena cava is covered by the lung lobes 225

cranial to the heart. The vein can only be imaged adjacent to the heart. 226

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Authors’ contributions 232

Drs. Gerspach, Schweizer-Knubben, and Braun were the clinicians responsible for 233

the case and described clinical and ultrasonographic findings and Dr. Wirz 234

performed the necropsy and described the pathological findings. 235

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311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332

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333 334 335 336 337 338 339 340 Figure legents 341

342 Figure 1 343 Physical appearance of the cow with brisket edema. 344 345 346 Figure 2 347 Physical appearance of the cow with distended jugular veins and brisket edema 348 349 Figure 3 350 Anatomical appearance of a friable, beige, rough, 8 cm x 3 cm thrombus from the 351 cranial vena cava, bar = 1 cm. 352 353 Figure 4 354 Anatomical appearance of a thrombus within a pulmonary vessel, bar = 1 cm. 355 356 357