NorthStar VETS Cool Case Thorn

This is a story about Thorn, a patient of Drs. Portner and Berkowitz of the Emergency and Critical Care team along with Dr. Tracy, our Neurologist and Dr. Lewis, our veterinary Dentist.

About Thorn:
Thorn PresentationThorn presented to Dr. Portner of the Emergency and Critical Care team on referral from another emergency and specialty hospital for treatment of suspected Tetanus infection. At the time of presentation, he was a 20 week old, intact male, dachshund puppy who had sustained a fall from the couch 5 days prior. The day after the fall he was a little lethargic and then progressively started to become more and more stiff throughout the weekend. Thorn was seen at another emergency and referral hospital, but was referred to us at NorthStar VETS for continued treatment and care under the expertise of our Emergency and Critical Care doctors.

Tetanus occurs when spores from the bacterium Clostridium tetani. Spores are very hardy and can be found commonly in the environment, especially in soil and can survive for years under certain conditions. When spores are introduced into a wound that provides an anaerobic environment, allowing the spores to become vegetative, and produce tetanospasmin, the toxin responsible for the severe neurologic clinical signs that we see. Clinical signs usually develop within 5 to 10 days from the inoculating wound, but up to 18 days has been reported.

Michelle and ThornTetanus in dogs is very uncommon (even more uncommon in cats) because dogs and cats have a natural resistance to the effects of tetanospasmin; localized clinical signs are more common than generalized tetanus, likely owing to this inherent resistance. It takes nearly 200 times the amount of toxin for a dog to be affected than a human and 3,600 times the amount of toxin for a cat. Thorn presented with very classic signs of generalized tetanus including severe trismus, and we could only open his mouth a couple of millimeters, his ears were erect and pinned to the top of the head (some patients will also show a ridgeline in the skin longitudinally between the ears), stiffness leading to a sawhorse type stance and his tail held straight out, he had a lateral strabismus (eyes looking outward instead of looking straight ahead) and constricted pupils, and his third eyelids were elevated because the muscle behind the eye was retracting the globe.

Thorn’s progress:
Tooth probeThorn was admitted to the Intensive Care Unit and watched very closely while he was supported through his illness. Treatment with antibiotics, most specifically metronidazole, was started to begin treatment for C. tetani infection. We monitored his blood gases and electrolytes and blood sugar along with his vital signs very closely, ready to provide ventilator support if he was unable to maintain his breathing well enough on his own. After a few days of treatment, including the administration of Tetanus Antitoxin, we were able to open his mouth a few more millimeters and identified the source of his infection: a fractured deciduous tooth. The tooth was extracted by Dr. Lewis of our Dentistry and Oral Surgery team and a gram stain of the bacteria from the tooth showed “tennis racket” shaped bacteria most consistent with Clostridium bacteria, confirming our diagnosis.

Thorn EatingWe were prepared to begin nutritional support for Thorn with either a nasogastric feeding tube or intravenous nutrition, but thankfully, Thorn began opening his mouth enough to begin eating on his own if fed in very small amounts. It was a painstaking process to feed him such small amounts at a time, but even though he could barely move from stiffness, he would begin tremoring and wagging his tail, very excited about being able to eat. Thorn spent 9 days in the hospital with his family coming to visit him every day. Once he was able to eat enough on his own and maintain his own body without intravenous support, his family was able to take him home and continue his supportive care and recovery there. Dr. Portner rechecked Thorn the next day and he was even more relaxed at home, only becoming stiff when stimulated, but he was able to sleep comfortably and even started being able to urinate outside when he was carried out and held up in the grass.

ThornThorn was rechecked again 1 week later with Dr. Tracy and he was continuing to show considerable improvement. With some support, he was able to start taking some steps and was eating well at home. Dr. Berkowitz contacted Thorn’s family one month after he first showed signs of problems and they reported: “He is amazingly fine! Completely normal, thanks to you and your staff.” We are so happy with Thorn’s progress and he will go on to live a normal, happy life with a terrific family.

Learn more about the Emergency and Critical Care service at NorthStar VETS.

Joshua Portner, DVM, DACVECC - Medical Director, Maple ShadeJoshua Portner, DVM, DACVECC – Medical Director, Maple Shade
Dr. Portner grew up in Southern New Hampshire. He obtained his bachelor’s degree in Biology/All-College Honors from Canisius College in Buffalo, New York, and his veterinary degree from Tufts University School of Veterinary Medicine in Massachusetts in 2004. After graduation from Tufts University, Dr. Portner completed a rotating internship in small animal medicine and surgery at Alameda East Veterinary Hospital in Denver, Colorado, and went on to complete his residency in Emergency and Critical Care at Ocean State Veterinary Specialists in Rhode Island in July of 2008. In 2009, Dr. Portner passed the specialist certification examination and became board certified in Emergency and Critical Care Medicine.

Dr. Portner has special interests in mechanical ventilation, nutrition for critical patients, and transfusion medicine. Along with membership in the Veterinary Emergency and Critical Care Society (VECCS), American Veterinary Medical Association (AVMA), and the New Jersey Veterinary Medical Association (NJVMA), he has also been a member of the International Veterinary Academy of Pain Management (IVAPM) and the International Sled Dog Veterinary Medical Association (ISDVMA), as well as several state associations. During his residency, he was a member of the Rhode Island Disaster Response Team, which is an organization responsible for providing medical care to sick and injured animals during a state of emergency.

Dr. Portner serves as the Medical Director for NorthStar VETS in Maple Shade, NJ.

Steven Berkowitz, DVMSteven Berkowitz, DVM
Dr. Steven Berkowitz attended St. Georges University and did his clinical year at the University of Illinois. Berkowitz joined NorthStar VETS after serving as the Chief of Emergency and Critical Care at another specialty hospital. Prior to that, he completed a three-year residency in Emergency and Critical Care medicine at the Oradell Animal Hospital in Paramus, NJ. His residency was completed at one of only a few recognized veterinary trauma centers in the United States. Prior to his residency, he was a staff Emergency Veterinarian at Animal Specialty Center in Yonkers, NY as well as serving as an emergency doctor at Animal Emergency and Referral Associates in Fairfield, NJ for 3 years. Dr. Berkowitz can be seen on seasons 5 and 6 of “Animal Precinct” on Animal Planet, which was filmed during his internship at The Bergh Memorial Animal Hospital of the ASPCA in New York City.
Dr. Berkowitz has special interest in the management of metabolic and endocrine derangements, trauma, as well as management of the septic patient.

John Lewis, VMD, FAVD, DAVDCJohn Lewis, VMD, FAVD, DAVDC
Dr. Lewis graduated from University of Pennsylvania School of Veterinary Medicine in 1997 and spent five years in general practice prior to returning for a residency in dentistry and oral surgery. He became a Fellow of the Academy of Veterinary Dentistry (AVD) in 2004 and a Diplomate of the American Veterinary Dental College (AVDC) in 2005.

At the University of Pennsylvania, Dr. Lewis has served as Associate Professor of Dentistry and Oral Surgery, associate director of the Mari Lowe Center for Comparative Oncology, and more recently, as Chief of Surgery. His research interests include oral surgical oncology, maxillofacial fracture repair, maxillofacial reconstruction, new therapies for treatment of feline oral squamous cell carcinoma, and lasers in oral surgery and dentistry.

Dr. Lewis is a past president of the American Veterinary Dental Society, and has served as examination chair of the AVDC and credentials chair of the AVD. Prior to joining NorthStar VETS full time in October 2013, Dr. Lewis was the residency director of the world’s first academic residency in veterinary dentistry and oral surgery at The University of Pennsylvania.

Dr. Lewis received the AVDC Outstanding Candidate award in 2004, the Hills AVDS Education and Research Award in 2012 and the AVD Fellow of the Year award in 2013.

Dr. Lewis is the proud father of six boys, two dogs, and two cats, all of whom keep him busy outside of work.

Gaemia Tracy, DVMGaemia Tracy, DVM
Gaemia Tracy was born and raised in Pittsburgh, PA. Dr. Tracy attended The University of Pennsylvania and graduated in 2008 with a Bachelor of Arts (Biology) degree. While there, he played baseball and Sprint Football. He attended The Ohio State University School of Veterinary Medicine from 2008-2012. Immediately after graduating veterinary school, Dr. Tracy completed a rotating small animal medicine and surgery internship at Carolina Veterinary Specialists in Charlotte, NC. Dr. Tracy then completed a Neurology and Neurosurgery residency in Jacksonville, FL at North Florida Neurology with Dr. Andrew Hopkins and Dr. John Meeks as his mentors. Dr. Tracy completed his residency before joining Northstar VETS.

Dr. Tracy’s professional interests include IVDD, spinal surgery, management of seizures and inflammatory diseases of the brain and spinal cord.

Dr. Tracy currently lives with his wife, son, and their two cats, DD and Bunny. In his free time, Dr. Tracy enjoys taking in any baseball game, and cheering for the Buckeyes and Steelers!

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