An 11-month-old 18-kg (39.6-lb) mixed-breed female dog was evaluated by the Emergency Service at the University of California-Davis William R. Pritchard Veterinary Medical Teaching Hospital because of a 2-day history of episodes of acute-onset vocalization and falling into sternal recumbency, described as collapse by the owners. Nine days prior to this examination, the dog was found chewing a barbecue-cleaning brush with metal bristles. It had vomited twice that same day and was monitored at home the following day. On the next day, the dog was evaluated by the primary care veterinarian because of lethargy, an episode of yelping during a meal, and slower eating of its dry food.
No physical examination abnormalities were identified. Results of a CBC, serum biochemical analysis, and canine pancreas-specific lipase testa revealed no clinically important abnormalities. Evaluation of abdominal radiographs revealed 3 approximately 2.5-to 3-cm-long thin wire foreign bodies in the region of the stomach, with 1 positioned cranial to the stomach; 1 was in the region of the pyloric wall, and 1 was in the region of the liver. No further abnormalities were identified on abdominal radiographs. Evaluation of thoracic radiographs revealed a similar wire foreign body in the region of the esophagus in the thoracic inlet. The remaining examination results were unremarkable. The dog was discharged from the hospital by the referring veterinarian, and the owners were instructed to administer amoxicillinb (27.8 mg/kg [12.6 mg/lb], PO, q 12 h) for 5 days and to monitor the dog for signs of general illness or gastroenteritis (eg, lethargy, anorexia, vomiting, or diarrhea).
The following day, the dog was reported to have difficulty swallowing its dry food until the kibble was softened with water, and it was brought to a veterinary referral center for evaluation. No abnormalities were identified on physical examination. Thoracic and abdominal radiography was repeated, with findings similar to those noted on the previous day. The dog underwent general anesthesia, and endoscopic examination of the esophagus and proximal portion of the gastrointestinal tract was performed by a board-certified veterinary internal medicine specialist, revealing no abnormalities. The dog recovered from anesthesia uneventfully and was discharged from the facility. The owner was instructed to administer omeprazolec (1.1 mg/kg [0.5 mg/lb], PO, q 24 h) for 7 days and maropitant citrateb (1.3 mg/kg [0.6 mg/lb], PO, q 24 h) for 4 days and to closely monitor the dog.
Seven days after endoscopy was performed, the dog was brought to the emergency service of the veterinary medical teaching hospital. The owners reported that the dog had acutely collapsed twice, approximately 16 hours and 2 hours before this examination. The episodes were each characterized by an acute, loud vocalization, after which the dog remained in sternal recumbency and was unable or unwilling to rise. The signs rapidly improved after the first episode without intervention, and the dog was carried to a vehicle for transportation to the hospital after the second episode. On evaluation at the emergency service, the dog had no physical examination or detectable gait abnormalities. The dog was sedated, and cervical, thoracic, and abdominal radiography were performed. A single thin, linear metallic foreign body was identified at the thoracic inlet, partially superimposed on the left first rib, intercostal space, and scapula in the ventrodorsal view of the thorax and thought to be in the region of the left brachial plexus (Figure 1). Evaluation of abdominal radiographs revealed a thin, linear metallic foreign body superimposed on the right cranial aspect of the peritoneal cavity. No further abnormalities were identified on cervical, thoracic, or abdominal radiographs.
Ventrodorsal radiographic view of the thorax of an 11-month-old mixed-breed dog evaluated after 2 acute episodes of vocalization and collapse. A thin, linear metallic foreign body is superimposed on the left first rib, intercostal space, and scapula (white arrow). A microchip is also present immediately to the right of midline between the second and third ribs (black arrow). R = Right.
Citation: Journal of the American Veterinary Medical Association 256, 6; 10.2460/javma.256.6.696
Ventrodorsal radiographic view of the thorax of an 11-month-old mixed-breed dog evaluated after 2 acute episodes of vocalization and collapse. A thin, linear metallic foreign body is superimposed on the left first rib, intercostal space, and scapula (white arrow). A microchip is also present immediately to the right of midline between the second and third ribs (black arrow). R = Right.
Citation: Journal of the American Veterinary Medical Association 256, 6; 10.2460/javma.256.6.696
Ventrodorsal radiographic view of the thorax of an 11-month-old mixed-breed dog evaluated after 2 acute episodes of vocalization and collapse. A thin, linear metallic foreign body is superimposed on the left first rib, intercostal space, and scapula (white arrow). A microchip is also present immediately to the right of midline between the second and third ribs (black arrow). R = Right.
Citation: Journal of the American Veterinary Medical Association 256, 6; 10.2460/javma.256.6.696
Approximately 4 hours after sedation and radiography, the dog acutely developed a grade 4/5 left thoracic limb lameness while still hospitalized. Within approximately 30 to 60 seconds after the lameness was detected, the condition progressed to complete non-weight-bearing lameness. Subsequent neurologic evaluation by a board-certified veterinary neurologist revealed signs of pain on palpation of the left triceps brachii muscle and elbow extension but no evidence of neurologic abnormalities to the extent that this could be assessed. At this time, the dog was unwilling to bear weight on the affected limb, and postural reactions could not be assessed for that limb. Apparent pain was localized to musculoskeletal structures; however, the possibility of a neurologic condition could not be ruled out.
The dog was sedated, and contrast-enhanced CT was performed with transverse, 1.3-mm-thick slices from the level of C3 to L5. A 3-cm-long, linear metallic object oriented transverse to the vertebral column was embedded in the soft tissues of the left axilla. The medial aspect of the wire abutted the cranial and proximal aspect of the body of the left first rib, with the lateral aspect immediately dorsal to the infraspinatus branch of the left axillary artery and thickened left subscapular nerve (Figure 2). A small, ovoid, peripherally contrast-enhancing fluid pocket was observed adjacent to the foreign body and tracking through the belly of the scalenus muscle group, which was mildly enlarged and heterogeneously contrast enhancing. The left axillary lymph node was mildly enlarged and peripherally contrast enhancing. The related CT findings were summarized as a left axillary metallic foreign body with adjacent intramuscular abscess formation, subscapular neuritis, and reactive axillary lymphadenopathy. A 3.5-cm-long metallic wire was also identified in the omental fat immediately caudal to the pyloroduodenal junction (not shown). No reactive changes were observed.
A 3-D CT reconstruction (ventrodorsal orientation) of the thorax of the dog in Figure 1. A metallic linear foreign body is seen directly adjacent to the vascular bundle in the left axilla. The vestiges of the clavicles were identified ventromedial to the cranial border of the right scapula and dorsal to the vasculature adjacent to the left of C5-C6.
Citation: Journal of the American Veterinary Medical Association 256, 6; 10.2460/javma.256.6.696
A 3-D CT reconstruction (ventrodorsal orientation) of the thorax of the dog in Figure 1. A metallic linear foreign body is seen directly adjacent to the vascular bundle in the left axilla. The vestiges of the clavicles were identified ventromedial to the cranial border of the right scapula and dorsal to the vasculature adjacent to the left of C5-C6.
Citation: Journal of the American Veterinary Medical Association 256, 6; 10.2460/javma.256.6.696
A 3-D CT reconstruction (ventrodorsal orientation) of the thorax of the dog in Figure 1. A metallic linear foreign body is seen directly adjacent to the vascular bundle in the left axilla. The vestiges of the clavicles were identified ventromedial to the cranial border of the right scapula and dorsal to the vasculature adjacent to the left of C5-C6.
Citation: Journal of the American Veterinary Medical Association 256, 6; 10.2460/javma.256.6.696
Overnight, the dog was treated with hydromorphone hydrochlorided (0.06 mg/kg [0.03 mg/lb], IV, q 6 h) and crystalloid fluids (1.7 mL/kg/h [0.77 mL/lb/h], IV). On physical examination the following morning, no lameness was detectable. General anesthesia was induced and maintained for surgical removal of the 2 linear metallic foreign bodies. Preoperative ultrasonography of the left axillary region was performed, and the hyper-echoic linear foreign body was identified underlying the brachial artery and vein and the enlarged axillary lymph node. Under ultrasound guidance, new methylene bluee was injected at the margin of the foreign body to help guide surgical dissection.
In the operating room, fluoroscopy was used to localize the foreign body in the region of the left axilla. A skin incision was made in a dorsoventral direction caudal to the caudal border of the left scapula to facilitate the identification of the triceps brachii muscle bellies. Blunt dissection to the scalenus muscle group was performed, and the caudal aspect of the metallic foreign body was identified (Figure 3). The wire, oriented in a craniomedial direction medial to the lateral and long heads of the triceps brachii muscle, was grasped with mosquito forceps and removed without complications. The site was lavaged, and a swab sample was collected in addition to the removed foreign material for anaerobic and aerobic microbial culture. The surgical site was closed routinely. Laparoscopic examination of the abdomen was subsequently performed with a 2-port technique, and the second foreign body was retrieved from the mesentery without complications.
Intraoperative photograph showing the axillary foreign body prior to removal. The long head of the triceps brachii muscle (white asterisk), rectus thoracis muscle (black asterisk), scalenus muscle group deep branch (white caret) and superficial branch (black caret), and the metallic foreign body (white arrow) are indicated.
Citation: Journal of the American Veterinary Medical Association 256, 6; 10.2460/javma.256.6.696
Intraoperative photograph showing the axillary foreign body prior to removal. The long head of the triceps brachii muscle (white asterisk), rectus thoracis muscle (black asterisk), scalenus muscle group deep branch (white caret) and superficial branch (black caret), and the metallic foreign body (white arrow) are indicated.
Citation: Journal of the American Veterinary Medical Association 256, 6; 10.2460/javma.256.6.696
Intraoperative photograph showing the axillary foreign body prior to removal. The long head of the triceps brachii muscle (white asterisk), rectus thoracis muscle (black asterisk), scalenus muscle group deep branch (white caret) and superficial branch (black caret), and the metallic foreign body (white arrow) are indicated.
Citation: Journal of the American Veterinary Medical Association 256, 6; 10.2460/javma.256.6.696
The dog recovered from anesthesia uneventfully and was discharged from the hospital the next day. Prior to discharge, the dog had no abnormal clinical findings and was walking without any gait abnormalities. Treatment with amoxicillin-clavulanic acidb (20.8 mg/kg [9.5 mg/lb], PO, q 12 h) for 10 days, carprofenb tablets (2.1 mg/kg [0.95 mg/lb], PO, q 12 h) for 14 days, and trazodone hydrochloridef (5.6 mg/kg [2.5 mg/lb], PO, as needed up to q 8 h) was prescribed. Aerobic and anaerobic culture results were negative, and the antimicrobial treatment was discontinued after 10 days. On follow-up by telephone 8 months after foreign body removal, the owners indicated that the dog had not experienced any complications from the procedure and had no gait abnormalities observed.
Discussion
This report describes a unique set of clinical features associated with the presence of a migrating wire foreign body in a dog. The main clinical signs were vocalization and intermittent collapse with unwillingness or inability to rise. Migrating foreign bodies are common in small animal veterinary patients. Most reports of migrating foreign bodies in these patients pertain to plant material (eg, seeds, awns, twigs, or sprigs).1–3 Previously reported clinical signs associated with migrating foreign bodies are related to the anatomic site affected or associated secondary changes such as development of an abscess or draining tract.4–6 Clinical signs associated with foreign body migration have included nasal discharge, dyspnea, stranguria and hematuria, altered mentation, neurologic deficits, open wounds, abscesses, and general signs of illness such as lethargy and inappetence.1–3,7–9 Metallic foreign bodies have less frequently been reported in the literature, with documented locations including the myocardium, thorax, abdomen (not otherwise specified), omentum, liver, spleen, retro-pharynx, gastrointestinal tract, vertebral canal, and brainstem. The clinical signs reported previously in dogs and cats with migrating metallic foreign bodies include restlessness, vomiting, abdominal pain, ptyalism, coughing, dyspnea, lethargy, signs of cervical discomfort and hyperesthesia, delayed postural reactions, and hemiparesis.2,9–14
The non-weight-bearing lameness and signs of severe pain in the affected limb of the dog described here may have been caused by direct impingement of the nerves of the brachial plexus by the foreign body or the subsequent inflammation and resulting neuritis. Given the delayed clinical course and apparently intermittent signs, the authors suspected that intermittent lameness and pain were associated with the development of secondary inflammation and abscess formation in the region of the axilla after wire migration. Previous reports4,6 have identified the potential for abscess or draining tract formation secondary to foreign body migration and foreign body reactions. However, a delayed onset of the lameness attributable to the amount of time required for the object to reach the axilla could not be ruled out. The described negative endoscopy results approximately 7 days after ingestion of the foreign material may have indicated passage through the esophagus or rapid migration out of the gastrointestinal tract. There is a single report15 of foreign body reaction and granuloma formation subsequent to migrating plant material in the axilla resulting in pain, lameness, and partial Horner syndrome in a dog. The clinical course of that case was described as progressive, and the diagnosis was made at necropsy.
Local inflammatory changes surrounding the brachial plexus and the exiting nerves may have resulted in stimulation of nociception resulting in the vocalization, unwillingness or inability to rise, and severe lameness observed in the dog of this report. The CT-identified contrast-enhancing tissue was suggestive of perineural abscess formation, which likely contributed to neuritis and subsequent clinical signs. In a survey16 of people with traumatic brachial plexus injuries, most respondents reported chronic pain affecting their daily lives and functions.
Precise localization of migrating foreign bodies is recommended to decrease surgical time, the potential for negative findings for wound or cavitary exploration, and continued illness or complications in the patient. The intraoperative use of ultrasonography and fluoroscopy has been described to facilitate accurate location and removal of foreign bodies in people,17–19 with fluoroscopy reported to have a high success rate during a single procedure.19 Intraoperative injection of new methylene blue has been reported to significantly increase surgical success rates and decrease surgical time in children18 with small metallic foreign bodies. Currently, there is a paucity of data regarding the use of these methods to facilitate removal of metallic foreign bodies from soft tissue structures in veterinary patients.
Owing to concerns about further aberrant migration of the intra-abdominal wire bristle and its subsequent effects, removal was elected. A retrospective study13 performed to investigate clinical outcomes for dogs and cats following sewing needle ingestion revealed that 7 of 65 (11%) animals in the study had extragastrointestinal foreign bodies that were not causing clinical signs. However, ingested foreign bodies that have perforated the gastrointestinal system can pose a risk for further injury. This potential lies in the ability of such objects to perforate viscera, propagate infection, and cause abscess formation. Initial diagnostic tests performed by the referring veterinarian identified multiple intra-abdominal foreign bodies that, aside from the wire that was removed endoscopically, were not found when diagnostic imaging was repeated. These additional foreign bodies were suspected to have passed through the gastrointestinal system. The history of foreign body ingestion was considered compatible with the initial clinical signs reported by the owners, but this was not confirmed until advanced imaging was performed. The clinical course and outcome for this dog after ingestion of multiple wire foreign bodies, of which one was suspected to pass uneventfully through the distal portion of the gastrointestinal tract, one had migrated to the omentum by perforating the gastrointestinal tract, and one had migrated to a distant site to cause severe clinical signs that warranted surgical intervention, supported that appropriate investigation, monitoring, and follow-up are warranted for patients following ingestion of foreign bodies, regardless of the initial imaging findings.
Footnotes
Spec CPL, Idexx Laboratories, Westbrook, Me.
Zoetis Inc, Kalamazoo, Mich.
Dexcel Pharma Technologies Ltd, Yokneam, Israel.
Elkins-Sinn, Cherry Hill, NJ.
American Regent Inc, Shirley, NY.
Teva Pharmaceuticals Inc, North Wales, Pa.
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