J. smalldnim. Pract (1982) 23,13-17.

Primary lymphoedema in a dog-a case report J A M E S G I L L * A N D R O B I N L E E

Department of Surgery, University of Glasgow Veterinary School, Bearsden, Glasgow G6 1 1QH

A B S T R A C T

Primary lymphoedema is a swelling of a part or parts of the body due to a congenital defect in the lymphatic system. This report describes our experience with a case in a Rough Collie.

I N T R O D U C T I O N

There are several reports in the literature of individual cases and small groups of dogs with congenital lymphoedema. It has previously been reported in Poodles (Patterson & Medway, 1966), English Bulldog (Ladds, Dennis & Leipold, 1971), a German Shorthaired Pointer (Sanders, 197 l), a Labrador (Griffin & MacCoy, 1978), a Borzoi, a German Shepherd, and Belgian Tervuren and crossbred pups (Leighton & Suter, 1979) and a Great Dane, a Labrador, a Retriever and an Old English Sheepdog (Davies et al., 1979).

At least some of the cases of primary lymphoedema in dogs are considered to be due to a dominant autosomal gene with varying degrees of expression (Patterson & Medway, 1966).

Most reports of treatment was dealt with conservative management, using antibiotics, corticosteroids, diuretics and supportive bandaging.

Surgical treatment has been described in the dog (Griffin & MacCoy, 1978; Leighton & Suter, 1979) and even though the results have been variable it is considered to have advantages over the prolonged and meticulous care required with conservative therapy.

C A S E R E P O R T

A 16-week-old male Rough Collie pup was referred to the Veterinary Hospital, University of Glasgow, with painless pitting oedema of the hindleg from the foot to

* Present address: 1 Richmond Street, Wentworthville, N.S.W. 2 145. Australia.

0022-45 10/82/0100~0013$02.00 0 1982 BSAVA

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just below the stifle. The owner had not noticed the swelling when the pup was acquired eight weeks previously, but it was assumed to have been present at that stage. No other abnormalities could be detected on clinical examination and throughout the course of treatment the dog continued to grow normally. Routine haematological and biochemical examinations were unremarkable.

The pup was anaesthetized and the leg clipped and prepared in a sterile manner. A short incision was made over the lateral surface of the metatarsals and once the copious flow of lymph was controlled one of the numerous enlarged lymph vessels was cannulated. The lymphatics had been rendered visible by the injection of Evans blue dye into the web of the foot approximately ten minutes earlier. Initially 10 ml of Conray 280* was injected and lateral and anteroposterior radiographs of the hindleg taken to assess lymphatic drainage. Following a rapid removal of the Conray from the lymphatic system, 10 ml of Lipiodolt was injected and the radiographic examination repeated. The passage of the dye into the sublumbar lymph nodes and the abdominal lymphatics was also followed.

The radiographs demonstrated numerous dilated and tortuous lymphatic vessels in the leg up to the level of the stifle. The popliteal lymph node was not delineated by the contrast agents and was therefore assumed to be absent. There were only three of four vessels identified in the thigh region, and the inguinal and sublumbar lymph nodes were outlined in a normal manner (Fig. 1). No complications were encountered following this examination.

One week later the first stage of atteinpted surgical correction was performed using the techniques described previously (Leighton & Suter, 1979). The surgical objective was to obliterate the dilated subcutaneous lymphatic vessels and so encourage drainage by the deep lymphatics in the hope that muscular contraction would result in a more efficient drainage and so prevent oedema formation.

An incision was made over the medial aspect of the leg from just below the stifle to the mid-metatarsus. The incision was extended caudally at the proximal and distal ends and a skin flap produced by dissecting the skin away from the subcutis. Constant swabbing was required to absorb the voluminous flow of lymph and to control the haemorrhage which was also considered to be excessive. The dilated lymphatics and much of the subcutaneous fascia were then dissected free from the underlying deep fascia. Care was taken to preserve the major blood vessels and nerves. The incision was closed using 2/0 chromic catgut to appose the skin to the deep fascia, and interrupted Supramid$ sutures were placed in the skin. Post-operatively the leg was bandaged using a modified Robert Jones dressing and the dog was treated prophylactically with antibiotics (ampicillin 250 mg b i d . for three days). The dressing was changed every other day.

Six days after surgery the skin began to slough at the surgical site. Antibiotic

* Meglumine iothalamate 60% (May & Baker). t Lipiodol Ultra fluid (May & Bakcr).

$ Supramid-B Braun, Melsungen AG.

P R I M A R Y L Y M P H O E D E M A IN A D O G 15

FIG. 1 . Lateral radiograph of the affected hind limb following cannulation of one of the metatarsal lymphatics and the injection of 10 mi of Conray. The contrast has outlined a large subcutaneous plexus of dilated lymphatics extending proximally to the level of the

proximal tibia.

therapy was reinstituted and the wound, debrided and cleaned, healed by second intention.

Four weeks after the initial surgery it was thought that there was some clinical improvement in the oedema on the medial aspect of the limb. The surgical procedure was then repeated on the lateral aspect but this time undermining of the skin was less extensive and a skin flap was not produced. The wound healed uneventfully but one week post-operatively the dog became depressed, anorectic and febrile. It responded rapidly to a further course of antibiotic therapy.

The dog was reassessed one month after the second operation at which time

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there was still extensive lymphoedema of the hindleg and it was decided that surgery had made little difference to the condition.

The owners were advised that palliative treatment with diuretics and the use of a supportive crepe bandage should the degree of swelling become excessive, was the only therapy remaining. It is likely that the use of a supportive bandage will be the most effective means of controlling the limb swelling and this is how the dog is currently being managed.

D I S C U S S I O N

Lymphangiography revealed hyperplasia of the lymph vessels with absence of the popliteal lymph node which is similar to some of the cases described previously (Griffin & MacCoy, 1978; Leighton & Suter, 1979). However, in this case it was possible to trace the lymphatics into the abdomen. To the authors’ knowledge there are no related dogs affected by a similar condition.

The wound breakdown on the medial aspect was, at that time, considered to be due to excessive under-running of the skin during the dissection. At the second operation removal of an excessive amount of subcutaneous tissue was avoided and no problems were encountered with wound healing. In retrospect infection may have been an important factor in the wound breakdown. In some of the previous reports a predisposition to infection has been noted, even to the extent of a fulminating cellulitis and septicaemia following what would normally be considered to be trivial infections. This predisposition may have played a role in the initial wound breakdown and in the febrile episode following the second surgery. It is therefore important that special attention be paid to the maintenance of sterility during lymphangiography and surgery.

The reasons for the lack of success of the surgery may be twofold. The first factor may be an inadequate removal of the subcutaneous fascia and thus a failure to create sufficient drainage into the deep lymphatics through the deep fascia which is considered to be quite important (Leighton & Suter, 1979). The second factor may have been an inherent defect in the deep lymphatics in this particular case. Until further work is done in this area and a detailed classification of the abnormalities undertaken this will remain undetermined.

In human surgery numerous techniques have been described, none of which are entirely satisfactory. Conservative therapy is the first choice and if surgery is performed, long term post-operative medical therapy is often required to maintain a satisfactory result (cited by Griffin & MacCoy, 1978).

R E F E R E N C E S DAVIES, A.P., HARDY, R., LARSEN, R., LEES, G.E. & HAYDEN, D.W. (1979) Primary lymphedema

GRIFFIN, C.E. & MACCOY, D.M. (1978) Primary lymphedema: a case report and discussion. J. in three dogs. J. Am. vet. med. Ass. 174, 1316-1320.

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P R I M A R Y L Y M P H O E D E M A IN A D O G 17

LADDS, P.W., DENNIS, S.M. & LEIPOLD, H.W. (1971) Lethal congenital edema in Bulldog pups. J.

LEIGHTON, R.L. & SUTER, P.F. (1979) Primary lymphedema of the hindlimb of the dog. J . Am.

PATTERSON, D.F. & MEDWAY, W. (1966) Hereditary diseases of the dog. J . Am. vet. med. Ass.

SANDERS, D . (1971) Congenital hereditary lymphoedema. S. West. Vet. 24,124-140.

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