Shadow’s Remarkable Clinical Story

On March 22, a 1-year-old German Shepherd crossbreed named Shadow was referred to Veterinarium from another clinic. History taking from the owner revealed that the patient had been experiencing diarrhea for approximately 1 month, which had not improved despite prior treatment. This resulted in rapid and critical weight loss, with body weight decreasing from 35 kg to 21 kg within 1 month. In addition, Shadow had been febrile (40-41°C) for several weeks.

This complex clinical case was admitted and managed by Veterinarium’s internist, Mariam Berishvili, with the support of the clinical team.

On physical examination, the patient presented with decreased appetite and energy, yellow-colored diarrhea and flatulence, occasional coughing, tremors, tachypnea (increased respiratory rate), and hypersalivation. Given the severity of the condition, comprehensive diagnostic testing was performed in Veterinarium’s laboratory:

• Complete blood count revealed marked leukocytosis (WBC 56.6 ×10⁹/L; reference range: 6-14), a stress leukogram, and anemia with low hematocrit, indicating an ongoing severe inflammatory process 
• Electrolyte analysis demonstrated critical imbalances in all major electrolytes: sodium (Na) 120 mmol/L (ref: 140-152); potassium (K) 2.9 mmol/L (ref: 3.8-5.0); calcium (Ca) 1.62 mmol/L (ref: 2.33-3.03); magnesium (Mg) 0.45 mmol/L (ref: 0.66-1.0); chloride (Cl) 94 mmol/L (ref: 102-117) 
• Biochemical analysis showed severe hypoproteinemia (total protein 36 g/L; ref: 50-72) and hypoalbuminemia (albumin 12 g/L; ref: 26-40) 

It is important to note that even minor deviations in electrolytes (particularly potassium, calcium, and sodium) can pose a life-threatening risk, as they directly affect muscle function, including myocardial activity, as well as nervous system homeostasis.

Albumin is the primary plasma protein responsible for maintaining oncotic pressure within blood vessels and retaining fluid intravascularly. In the case of albumin deficiency, fluid leaks from the vasculature into tissues and body cavities, resulting in peripheral edema and/or ascites (free fluid in the abdominal cavity), as well as pleural effusion. Hypoalbuminemia can arise from various causes; in Shadow’s case, it was secondary to chronic diarrhea - specifically protein-losing enteropathy (PLE). Furthermore, decreased albumin levels also contribute to reduced total calcium concentration.

Abdominal ultrasonography performed by Veterinarium’s internist and ultrasound specialist, Nutsa Besashvili, confirmed the presence of ascites. Additionally, generalized intestinal lymphadenopathy and widespread inflammatory changes of the intestines were observed, including thickening of the mucosal and muscular layers and dilation of the intestinal lumen.

Clinical examination also revealed bradyarrhythmia (cardiac rhythm disturbance, heart rate 60 bpm), likely secondary to severe electrolyte imbalance.

Overall, Shadow’s clinical and laboratory findings confirmed the severity of his condition and indicated the urgent need for intensive therapeutic intervention aimed at correcting hypoalbuminemia and electrolyte imbalances.

Correction of hypoalbuminemia requires albumin transfusion. As canine albumin is not available in Georgia, human serum albumin (HSA) was selected for use. Although this is a well-documented approach in veterinary medicine, it carries significant risks, including the possibility of acute allergic (anaphylactoid) reactions in rare cases.

However, the clinical challenge extended far beyond this. Multiple pathological processes were occurring simultaneously, requiring highly precise and carefully controlled infusion therapy, taking into account the following critical factors:

1. Calcium and potassium balance: Albumin transfusion increases serum calcium levels. Elevated calcium, in turn, promotes intracellular shifting of potassium, further reducing its already critically low plasma concentration. Therefore, continuous potassium supplementation alongside albumin administration was essential. 
2. Fluid and blood pressure management: Albumin infusion rapidly increases oncotic pressure, drawing fluid from tissues back into the vascular compartment. To prevent volume overload and severe hypertension, precise adjustment of concurrent electrolyte infusion rates was required to maintain overall fluid balance. 
3. Magnesium correction: Increased calcium levels can further decrease magnesium concentration (already low in this patient). Magnesium supplementation was necessary to correct bradyarrhythmia associated with hypomagnesemia. Additionally, without correcting magnesium levels, potassium retention is impaired, rendering potassium supplementation ineffective. 
4. Sodium correction: Correction of severe hyponatremia required careful control, as rapid increases in serum sodium can lead to irreversible neurological damage, including osmotic demyelination syndrome. 

It should also be emphasized that electrolyte infusions require extreme precision, as even slight overdosing can result in life-threatening complications.

Given Shadow’s critical condition, all treatment decisions were made collaboratively by the Veterinarium team (“A feast to which many contribute is better than a dinner provided out of a single purse”). 

On March 23, Shadow underwent a 12-hour albumin transfusion, and correction of electrolyte imbalances was initiated. This night was particularly critical; therefore, Veterinarium’s internists Mariam Berishvili and Nutsa Besashvili, together with assistant Luka Ghlonti, remained with the patient overnight.

Due to the severity of the case, frequent electrolyte monitoring was essential.

Repeat analyses performed on March 24 and 25 confirmed a positive response to the selected therapy, including restoration of most electrolyte imbalances and an increase in albumin levels from 12 to 22 g/L. However, the case remained complex. In the following days, electrolyte disturbances led to pronounced bradyarrhythmia (heart rate 45 bpm). In addition to electrolyte imbalance, this may have been associated with Shadow’s underlying condition - intestinal lymphangiectasia and chronic enteropathy - which can lead to excessive activation of the parasympathetic nervous system, particularly the vagus nerve. This presentation can be considered a classic manifestation of the “gut–heart axis,” where severe gastrointestinal pathology directly impacts cardiac function, leading to decreased heart rate.

To rule out cardiac conduction block and other primary cardiac diseases, electrocardiography and echocardiography were performed by Veterinarium’s cardiologist, Natia Robakidze. No structural or functional abnormalities were detected on echocardiography.

Shadow remained hospitalized for several days under continuous monitoring in both day and night care settings. Despite the absence of a dedicated overnight inpatient facility at Veterinarium, the veterinary team made the decision to hospitalize him for five consecutive nights, organizing a staff rotation schedule to ensure continuous care.

The following team members participated in Shadow’s treatment and monitoring: Nino Kushitashvili, Richard Tavdgiridze, Mariam Berishvili, Nutsa Besashvili, Mariam Kapanadze, and Luka Ghlonti. 

Within a few days, follow-up ultrasonography confirmed marked improvement in lymphangiectasia, correction of electrolyte imbalances, stabilization and further increase in albumin levels, and a significant reduction in leukocytosis. 

Shadow continues treatment for chronic enteropathy and lymphangiectasia at home, as this is a long-term management process. It is important to note that successful treatment requires both continuous veterinary supervision and significant commitment from the owner, including time, emotional involvement, and adherence to treatment protocols ensuring a truly collaborative effort toward recovery.