Veterinary medicine is a very collaborative field. For Ravioli, I got every brain I could to give their opinion. I provided that information to Kim to make the most informed decision. Those two days made the difference for Ravioli. It was very much a collaboration, Kim and I working together trying to make the best decisions as a team, and Ravioli did all the heavy lifting.
Pregnant Dog Survives Liver Failure Despite Long Odds, Many Unexpected Twists And Turns
FHSA’s ECC team tapped into specialists across Cummings School to save the puppies and return Ravioli to health
Ravioli comes from a litter of pasta named Hungarian Vizslas—Cavatappi, Rigatoni, and Tortellini, to name a few. Two weeks before Ravioli was due to deliver her own set of puppies last summer, her liver began to fail.
Kim Barry, Ravioli’s owner and a veterinary technician, noticed her dog’s outgoing, playful personality was muted. She was eating less and had a yellow tinge to her coloring. After their veterinarian found her liver levels elevated, Barry brought Ravioli to the emergency room at Henry and Lois Foster Hospital for Small Animals (FHSA) at Cummings School of Veterinary Medicine at Tufts University.
Bloodwork confirmed Ravioli’s dangerously high liver values; pinpointing why they were so high was the challenge. Acute fatty liver of pregnancy is a rare complication in humans and has never been reported in dogs.
Dr. Junes Ossman, Emergency Medicine & Critical Care (ECC) resident in the Department of Clinical Sciences at Cummings School, took the lead on Ravioli’s case. “We booked Ravioli in to support her as best we could, and then it was a race trying to figure out what was the cause,” she says.
Ravioli’s liver failure could be the result of the pregnancy, an autoimmune response, infection, or cancer, but the team had limited diagnostic and treatment options. She could not be sedated for imaging or biopsy due to her pregnancy, and any medications would filter to the puppies, leaving the course of action, whether to deliver the puppies prematurely or wait it out, a difficult call.
Ossman reached out to multiple specialists within FHSA and across Cummings School—theriogenologists, criticalists, pathologists, immunologists, and hepatologists—for their input on the case before discussing the options with Barry. The doctor and pet owner formed a trusting bond that would endure over the next few months as they were continually presented with unexpected, complex turns in Ravioli’s health.
“It was not a straightforward case. There was no right or wrong answer,” says Ossman.
Together, they decided to keep Ravioli at FHSA on supportive care with intravenous nutrition while awaiting her due date, without undertaking any interventions unless her condition worsened.
Dr. Alexia Berg, assistant clinical professor in the Department of Clinical Sciences at Cummings School, was the attending clinician on the ECC team at FHSA. “Ravioli was a tricky case. Early on in the course of her care, every decision could have resulted in the loss of not one but nine patients. It is not a responsibility we took lightly, and there were a lot of variables to consider at every turn.”
A week and a half later, Ravioli gave birth to seven small but healthy puppies. In a happy surprise, an eighth puppy was born half an hour after returning home. While the puppies were faring well, Ravioli was not eating. Over the next six weeks, her nutrition was delivered through a feeding tube. She relapsed and was hospitalized at FHSA. Her liver values were still high, and a biopsy came back inconclusive, leaving the course of action again vague.
Concerned that an autoimmune issue could be at the root of the still elusive cause of her liver failure, the ECC team treated Ravioli with steroids to suppress the immune system. While her liver levels dropped back down over the following weeks, her body could not tolerate the steroids.
Ossman again consulted with hepatologists and other specialists across Cummings School and settled on reducing the dosage and adding an additional low-dose immunosuppressant to blunt the severity of the side effects.
In an unexpected turn a few days into the new medication, Ravioli was suddenly unable to walk and visibly and audibly in pain. Abscesses formed all over her body. After detecting a heart murmur and conducting a liver biopsy, Ossman diagnosed Ravioli with discospondylitis, an inflammatory disease that had spread to her heart and bones. To fight the infection, they would need to stop suppressing her immune system and treat her with an aggressive antibiotic that could be toxic to the kidneys over the course of the six-week treatment.
“That put us in a bind,” says Ossman. “Kim brought Ravioli in with the intent to say goodbye because of how much pain she was in. She was the sickest I’d ever seen her.”
Again, Barry and Ossman were faced with a difficult choice. They decided to stop the steroids and try the antibiotic, and if Ravioli was still declining after a few days, they would euthanize her.
“She was dying but still wagging her tail and seeming happy,” says Barry. “Dr. Ossman was wonderful every step of the way. She said, ‘If you’ve had enough, it’s okay to make that call, or we can try this antibiotic and see how she does.’ Ravioli’s a hunting dog, we wanted to take her hunting one last time before we put her down.”
To their surprise, and finally, in a positive twist, Ravioli started to recover in those two days. She was eating better, the pain subsided, and her abscesses cleared up. Barry administered injections of the antibiotic to Ravioli daily and took urine cultures, checking in regularly with Ossman over the next several weeks.
Barry and Ossman were shocked to see Ravioli’s kidneys tolerating the antibiotics, her liver values return to normal, and the infection dissipate. Ravioli’s heart, miraculously, is now completely healthy. The only remnant of the infection is soreness in her back, being treated with pain medications and physical therapy. Ravioli regained all the weight she lost and then some. Barry now has her on a diet.
“Everything that could have happened to her happened to her,” says Barry. “Ravioli would not be here without Tufts [Cummings School], there’s no doubt in my mind. Every single person at Tufts [Cummings School], from the receptionist to the finance people to the doctors to the techs, has been absolutely amazing—kind, professional, and caring.”
Like their mother, the puppies are thriving. All went to new homes except the surprise eighth puppy. The Barrys kept her and named her after Ossman, who incidentally is the eighth of ten kids in her family. Junes is already a strong competitor in dog show rings.
“Ravioli had a slim chance she’d survive three separate times, and she beat the odds,” says Ossman. “I never got to meet this Ravioli until a month ago, this wiggly dog who climbs on people, jumps with excitement and is obsessed with food. She’s fat and happy—and so am I.”
Berg agrees, “We are beyond thrilled. Hopefully Ravioli has lots of happy hunts in her future.”
Ossman credits Ravioli’s recovery to the ECC team, support staff, and all the specialists that weighed in on the case—but especially Barry and Ravioli.
“Veterinary medicine is a very collaborative field,” says Ossman. “For Ravioli, I got every brain I could to give their opinion. I provided that information to Kim to make the most informed decision. Those two days made the difference for Ravioli. It was very much a collaboration, Kim and I working together trying to make the best decisions as a team, and Ravioli did all the heavy lifting.”
Department:
Foster Hospital for Small Animals