Pseudo Gout

[Nal0114]

So my girl recently after started having a lot of swelling in her joints so I instantly suspected gout. Origin not known (primary, secondary, or pseudo).

Yesterday she had labs done.

Her results are attached. I’m still waiting to hear back to see if they think Pseudo gout could be the cause.

Does anyone have experience with pseudo gout, what are the treatments for something like that?

I attached pics of her at the doctor as well so you can see the swelling in her ankle.

 

[MissSkittles]

I don’t know about gout or pseudo gout, (uric acid and calcium levels are within range) but her liver function is way high and some of her other values are quite concerning, like potassium being high and sodium low. One of the kidney markers is also a bit high. I’m just a nurse with Google, but I believe the combined high AST with the high CPK are from some sort of tissue damage or injury. She looks gravid to me. Has she been trying to dig or more restless in her enclosure? Maybe she somehow injured her ankle? It’ll be very interesting to know what the vet says.

 

[Nal0114]

She laid 44-eggs August 4th. She’s never been with a male so they weren’t fertile. I am taking her back to work with me tomorrow for X-rays.

I have 2 doctors that said gout. I will keep everyone posted. One of the doctors said Pseudo gout is in end stage kidney failure. And her uric acid levels aren’t suggestive of that.

 

[kinyonga]

I’m not a vet or a nurse but speak from experience and what I’ve learned from reading..
@MissSkittles said…”the combined high AST with the high CPK are from some sort of tissue damage or injury”…this is what I’ve read too.

You might find some of this interesting…
“stress leads to increased release of stress hormones from pituitary and adrenal glands that in turn lead to excessive losses of potassium, phosphorus, calcium, magnesium and zinc”…
http://www.chameleonnews.com/02NovDonoghue.html

 

[jamest0o0]

Usually when I see high K and phosphorus paired with some possible edema I’m thinking kidneys(in humans at least), but kidneys and liver can go together. Overexertion/injury could lead to rhabdo(CPK elevated), which could damage the kidneys and with potassium/phosphorous being mostly stored in cells. So when there is break down a lot is released into the bloodstream (K+ phosphorous elevated), and can also cause elevated liver enzymes. That’s my guess, but I’d go with what the vet says. If it were a liver issue I would think the albumin would be very low and usually have screwed up clotting+ generalized edema among other things.

Someone correct me if I’m off on anything! Interesting stuff, I wish you and your girl all the best OP.

 

[Nal0114]

Update on Shady Jade. I had her back in at work with me. We did X-rays to see what her joints looked like. They’re filled with fluid. I opted to send the fluid off to the lab to see if there crystals in it and what the fluid is whether it be bacterial or not.

She was started on a low dose of Aluminum Hydroxide to bring her phosphorus levels down. She continues to get low doses of Metacam I do it every other day. Per the vet I am to hold off on starting Allopurinol until we see what her joint cytology reveals - incase it’s septic joints.

Next week we will be rechecking her values to see if any progress has been made anywhere.

 

[kinyonga]

In every photo, her gulag pouch is expanded/extended…is it always like that? If so, how long has it been like that?

 

[Nal0114]

In every photo, her gulag pouch is expanded/extended…is it always like that? If so, how long has it been like that?

No it’s not always like that. She’s been incredibly mad about being at work. Naturally, they are solitary leave me alone animals.

 

[Nal0114]

The verdict:

Conversation still continuing I’ll post the rest once it’s done

 

[MzLaurie]

Well I do not know about gout or suedo gout in chams but I do know about it in humans as I have suedo gout in both hips and knees! Gout is caused by crystallized uric acid in the synovial fluid in the joint and suedo. gout is caused by crystallized calcium in the synovial fluid. Once each of these crystallized they turn into tiny shards of glass that imbed in tissue and cause pain and swelling. They are treated the same way, colchicine. Uric acid is regulated by the kidneys. Calcium with me is from growths on the bones. The fluid in the joint you are have sent off will show what is in it. In humans you can see it in X-Ray but I imagine the crystals are too tiny to.pick up in a cham xray. There is no cure for either. Even if you GeT the kidney filtering properly, once it is in the synovial fliud, there is no way to remove it all even with a joint replacement. Fun fun fun!

 

[MzLaurie]

So sorry to hear the results. But hey there are a lot of us one meds for life. Doesn't mean we are done yet! As long as there is life, there is value

 

[Nal0114]

I’m not giving up on her. We will keep going until we cant

 

[javadi]

Kind of late here, and I'm not sure how much this adds, but I figure I would chime in. For background, folks are listing their credentials so I'll list mine too-I'm a practicing human doctor with a PhD in hepatology (liver) who contributes to and studies veterinary science and publishes papers in that field, with collaborators and partner in exotics veterinary practice, but I am not a trained DVM.

1) Lots of correct ideas are posted here about the CPK, potassium and AST elevation, but given the relatively low magnitude of CPK increase, this is probably representative of trauma during the actual blood draw process. Chameleons often thrash around while getting blood drawn and sometimes need to be stuck a few times (muscle damage) to get the blood. AST is not specific to the liver and is also released by damaged muscle, which further corroborates this idea. The liver isn't in synthetic failure yet based on other labs here. The liver is probably not the issue here, although to be fair some other labs could have/maybe should have been included to really assess liver damage if that was the goal. Anyway, these CPK and AST findings probably don't matter much for prognostication and are probably just an artifact of the blood draw damage itself.

2) The reference ranges here are a little funky. Not to throw shade at this vet's practice in any way, as this is a very common practice, but the reference ranges aren't well-defined in chameleons and plus at places that don't see many chameleons, often the reference ranges are derived from just what has been seen there. So for instance, the calcium is actually getting pretty high even though it's not technically high based on the reference range.

3) Even if phosphorous elevation precedes uric acid, if we are calling it gout (not pseudogout) then the uric acid crystals would still need to be precipitating from somewhere. The fact the uric acid level is not high means it's not likely to be uric acid-induced gout. So it's a good idea to NOT use allopurinol at this stage. It could be pseudogout indeed, given that the calcium is high so potentially that could be what one would find in the joints. Unfortunately this is not well-characterized in reptiles/chameleons at all so treatment would basically still just be painkillers/anti-inflammatories.

4) Pain control/anti-inflammatories are a good idea (what you are doing already). Impressive that they can get a joint tap in this chameleon. That will indeed be helpful. I would add to this, see if you can get a CBC. The joint tap will tell you if this is reversible with antibiotics. It's possible there is a kidney infection or infection elsewhere that is reversible and is leading to this clinical picture though (although admittedly I don't know the whole clinical picture). So I might suggest getting a CBC if there is enough volume of blood next time. This could nudge towards or against an infectious cause.

5) I would agree that regardless, this is not a great prognosis. However, that doesn't mean there is no chance for her. Make sure her hydration is optimized. By the way, not proceeding with medications isn't giving up on her IMO. You have already done a lot of good work for her and whatever choice you make has merit under these difficult circumstances.

Please rest easy knowing you've done a great job being diligent with her care and asking the right questions while also consulting with the right people. Hang in there, her too!

 

[Nal0114]

I appreciate your reply.

Her decline is pretty steep and if she makes it thru the weekend I will probably take her to work to be humanely euthanized.

Her sass is gone, when I reach in at her she literally don’t care where as before she would throw her little tantrum. Her belly is distended and her eyes are starting to sink in.

She’s suffering and I don’t want to watch it.

 

[MissSkittles]

I appreciate your reply.

Her decline is pretty steep and if she makes it thru the weekend I will probably take her to work to be humanely euthanized.

Her sass is gone, when I reach in at her she literally don’t care where as before she would throw her little tantrum. Her belly is distended and her eyes are starting to sink in.

She’s suffering and I don’t want to watch it.

I’m so sorry.

 

[kinyonga]

Sometimes the kindest thing is euthanasia.

 

[jamest0o0]

Kind of late here, and I'm not sure how much this adds, but I figure I would chime in. For background, folks are listing their credentials so I'll list mine too-I'm a practicing human doctor with a PhD in hepatology (liver) who contributes to and studies veterinary science and publishes papers in that field, with collaborators and partner in exotics veterinary practice, but I am not a trained DVM.

1) Lots of correct ideas are posted here about the CPK, potassium and AST elevation, but given the relatively low magnitude of CPK increase, this is probably representative of trauma during the actual blood draw process. Chameleons often thrash around while getting blood drawn and sometimes need to be stuck a few times (muscle damage) to get the blood. AST is not specific to the liver and is also released by damaged muscle, which further corroborates this idea. The liver isn't in synthetic failure yet based on other labs here. The liver is probably not the issue here, although to be fair some other labs could have/maybe should have been included to really assess liver damage if that was the goal. Anyway, these CPK and AST findings probably don't matter much for prognostication and are probably just an artifact of the blood draw damage itself.

2) The reference ranges here are a little funky. Not to throw shade at this vet's practice in any way, as this is a very common practice, but the reference ranges aren't well-defined in chameleons and plus at places that don't see many chameleons, often the reference ranges are derived from just what has been seen there. So for instance, the calcium is actually getting pretty high even though it's not technically high based on the reference range.

3) Even if phosphorous elevation precedes uric acid, if we are calling it gout (not pseudogout) then the uric acid crystals would still need to be precipitating from somewhere. The fact the uric acid level is not high means it's not likely to be uric acid-induced gout. So it's a good idea to NOT use allopurinol at this stage. It could be pseudogout indeed, given that the calcium is high so potentially that could be what one would find in the joints. Unfortunately this is not well-characterized in reptiles/chameleons at all so treatment would basically still just be painkillers/anti-inflammatories.

4) Pain control/anti-inflammatories are a good idea (what you are doing already). Impressive that they can get a joint tap in this chameleon. That will indeed be helpful. I would add to this, see if you can get a CBC. The joint tap will tell you if this is reversible with antibiotics. It's possible there is a kidney infection or infection elsewhere that is reversible and is leading to this clinical picture though (although admittedly I don't know the whole clinical picture). So I might suggest getting a CBC if there is enough volume of blood next time. This could nudge towards or against an infectious cause.

5) I would agree that regardless, this is not a great prognosis. However, that doesn't mean there is no chance for her. Make sure her hydration is optimized. By the way, not proceeding with medications isn't giving up on her IMO. You have already done a lot of good work for her and whatever choice you make has merit under these difficult circumstances.

Please rest easy knowing you've done a great job being diligent with her care and asking the right questions while also consulting with the right people. Hang in there, her too!

One person listed their credentials, but whatever you are, I’m happy to read what you have to say!

 

[jamest0o0]

I appreciate your reply.

Her decline is pretty steep and if she makes it thru the weekend I will probably take her to work to be humanely euthanized.

Her sass is gone, when I reach in at her she literally don’t care where as before she would throw her little tantrum. Her belly is distended and her eyes are starting to sink in.

She’s suffering and I don’t want to watch it.

Sorry to hear this, the responsible decision is often not the easy one

 

[Nal0114]

Sadly Jade passed away sometime in the middle of the night Saturday morning.

 

[ERKleRose]

I’m so sorry! She fought until the end and is free of pain now. Try to remember the good times with her, it helps you heal. Let me know if I can do anything to help you through this!