Case Report  Rapport de cas

Infectious canine hepatitis associated with prednisone treatment

Valerie M. Wong, Candace Marche, Elemir Simko

Abstract — An 11-week-old, female Alaskan husky dog housed outdoors in the Yukon, Canada, was diagnosed
with infectious canine hepatitis. The predisposing factors in this puppy for such a rare disease included inappropri-
ate vaccination program, potential contact with endemic wildlife, and immunosuppression due to prednisone
treatment.

Résumé — Hépatite canine infectieuse associée au traitement par la prednisone. Une chienne Husky d’Alaska
âgée de 11 semaines logée en plein air au Yukon, au Canada, a été diagnostiquée avec l’hépatite canine infectieuse.
Les facteurs prédisposants chez ce chiot pour une telle maladie rare incluaient un programme de vaccination
inadéquat, le contact potentiel avec des animaux sauvages indigènes et l’immunosuppression en raison du traitement
avec de la prednisone.
(Traduit par Isabelle Vallières)
Can Vet J 2012;53:1219–1221

Case description (ALP) activity. Since there were concerns about canine erhlichio-

A
sis due to a history of traveling with dogs housed in the same
n 11-week-old, female Alaskan husky dog was presented
kennel, doxycycline treatment was initiated. Specific testing
at the Prairie Diagnostic Services (PDS) at the Western
for ehrlichiosis was not performed due to financial constraints.
College of Veterinary Medicine (WCVM) for postmortem
Vitamin K was also given. Prednisone and cephalexin treatments
examination. Kept outdoors in the Yukon, this puppy and her
were discontinued. A week later, the puppy deteriorated and
4 littermates had been vaccinated by the owner against canine
became increasingly depressed. She developed petechiation and
distemper virus, canine adenovirus (CAV) type 2, canine par-
hemorrhagic diarrhea. Prednisone therapy was initiated (same
vovirus, and parainfluenza virus at 4 and 6 wk of age. At 7 wk
dosage as before). The puppy was found dead in the kennel
of age, she and 2 littermates developed facial pyoderma and
within a day. Blood samples obtained shortly before death
responded to antibiotic treatment (amoxicillin and clavulanate,
showed a mild non-regenerative anemia [hematocrit: 0.298 L/L,
dosage unknown) administered by the owner. At 9 wk of age
reference interval (RI): 0.365 to 0.573 L/L] and no reticulocytes
the puppy developed facial pustules again and responded well
detected on manual cell count (automated reticulocyte count
to treatment with prednisone [0.9 mg/kg body weight (BW)
unavailable), which was consistent with acute blood loss and
PO, q12h] and cephalexin (20 mg/kg BW, PO, q12h) for sus-
chronic inflammation. The mean corpuscular hemoglobin
pected juvenile cellulitis. A week later, the puppy was presented
concentration (MCHC) was mildly decreased (310 g/L, RI:
with anorexia, depression, and facial edema, with no pyrexia.
335 to 357 g/L), which could suggest iron deficiency, but this
Biochemistry and complete blood (cell) count (CBC) obtained
was considered less likely because mean corpuscular volume
on in-house analyzers showed poorly regenerative anemia,
(MCV) was well within the reference interval. Small num-
thrombocytopenia, and markedly increased alkaline phosphatase
bers of keratocytes were noted and were suggestive of fibrin
strand injury. Marked thrombocytopenia (50.3 3 109/L, RI:
Department of Veterinary Pathology, Western College of
200 to 900 3 109/L) was present and was attributed to platelet
Veterinary Medicine, University of Saskatchewan, Saskatoon,
clumping, as observed on the blood smear, but increased con-
Saskatchewan (Wong, Simko); Alpine Veterinary Medical
sumption due to disseminated intravascular coagulation could
Centre, Whitehorse, Yukon (Marche).
not be ruled out. There was a moderate left shift (segmented
Address all correspondence to Dr. Valerie Wong; e-mail: neutrophil count: 5.1 3 109/L, RI: 3.0 to 10 3 109/L; band
vwong@uoguelph.ca cell count: 0.469 3 109/L, RI: 0.0 to 0.1 3 109/L), which
Dr. Wong’s current address is Department of Pathobiology, was consistent with inflammation, and moderate lymphopenia
Ontario Veterinary College, University of Guelph, Guelph, (0.402 3 109/L, RI: 1.2 to 5.0 3 109/L), which was attrib-
Ontario N1G 2W1. uted to stress and/or exogenous glucocorticoids. Biochemistry
Use of this article is limited to a single copy for personal study. showed moderate hyperbilirubinemia (10 μmol/L, RI: 1.0 to
Anyone interested in obtaining reprints should contact the 4.0 μmol/L; fractionated bilirubin measurements were not avail-
CVMA office (hbroughton@cvma-acmv.org) for additional able), markedly increased ALP (2623 U/L, RI: 9 to 90 U/L),
copies or permission to use this material elsewhere. mildly increased gamma-glutamyltransferase (GGT) (11 U/L,

CVJ / VOL 53 / NOVEMBER 2012 1219

R A P P O R T D E CA S
Figure 1.  Cross section of the liver shows multifocal zonal
necrosis. Bar = 1 cm.
Figure 3.  Electron microscopy shows adenoviral particles within
the nucleus.
RI: 0 to 8 U/L), and markedly increased sorbitol dehydrogenase
(SDH; 141.7 U/L, RI: 0.0 to 4.0 U/L) activities, which were
consistent with hepatocellular injury and cholestasis. Hemolysis
could have contributed to increased bilirubin measurement as
well. Increased ALP activity may be due to the increased bone
turnover (i.e., age-related), increased steroid-induced isoforms,
and cholestasis. Activity levels of alanine aminotransferase (ALT)
and glutamate dehydrogenase (GLDH) could not be evaluated
due to interference by marked hemolysis. All reference intervals
were generated from adult dogs.
Necropsy showed generalized icterus, marked hemorrhage
in the thymus, cervical subcutaneous tissues, stomach, renal
cortex, and brainstem, and petechiation at all levels of the
intestines. The liver was diffusely enlarged and friable, and had
a zonal pattern with alternating red and pale tan areas (Figure 1).
Histopathology showed that the lymph nodes, thymus, brain,
and small intestines were affected by multifocal hemorrhage.
The bone marrow was severely hypocellular with decreased cellu-
1220
Figure 2.  Hematoxylin & eosin-stained liver sections show
hepatic necrosis, intranuclear inclusion bodies with margination
of chromatin (arrows), and cholestasis (arrowheads).
Bar = 50 μm.
Figure 4.  Hepatocytes show positive nuclear staining for
CAV-1. Immunohistochemical staining for CAV-1. Bar = 50 μm.
larity in all cell types. The liver had marked coagulation necrosis
with neutrophilic infiltration. Many hepatocytes and Kupffer
cells contained marginated chromatin and intranuclear inclu-
sion bodies that were round to ovoid, magenta, and 4–8 μm
in diameter (Figure 2). Based on these findings, the diagnosis
of infectious canine hepatitis was made. Electron microscopy
revealed viral particles resembling canine adenovirus in the
nucleus of hepatocytes (Figure 3). Hepatocytes also showed
strong nuclear staining on immunohistochemistry using anti-
bodies against CAV-1 (Figure 4).
Discussion
In dogs, there are 2 types of adenoviruses: canine adenovirus
type 1 (CAV-1) and canine adenovirus type 2 (CAV-2). The
CAV-1 may cause a severe generalized disease called infectious
canine hepatitis (ICH), whereas CAV-2 typically causes a mild
respiratory disease (1). Infectious canine hepatitis usually affects
dogs less than 1 y of age (2) and is transmitted nasal-orally via
CVJ / VOL 53 / NOVEMBER 2012
direct contact, fomites, and ectoparasites (3). Viral replication
initially occurs in the tonsils, followed by dissemination of
viruses to other tissues and saliva, urine, and feces (1). CAV-1
is known to have tropism for vascular endothelium and hepato-
cytes (1). Virions assemble in the nucleus and form intranuclear
inclusion bodies that may occupy the entire nucleus. Viruses are
released by cellular lysis. Most infected dogs are asymptomatic
or have mild tonsillitis (4). Animals that show clinical signs are
presented with fever, lymphadenopathy, abdominal pain, icterus,
anterior uveitis, or petechiation that may indicate disseminated
intravascular coagulation. Death from ICH is sporadic (4). In
the case presented here, the puppy showed signs associated with
inflammation, liver disease, and dysregulation in coagulation,
but lacked the classic ocular signs.
Diagnosis of ICH is often made on histopathology, as ante-
mortem diagnosis is difficult. Other tests available include
complement fixation, hemagglutination inhibition, enzyme-
linked immunosorbent assay (ELISA), viral isolation, immuno­
histochemistry, and polymerase chain reaction (PCR) (1).
Neonates are protected against adenoviral infection by mater-
nal antibody, the level of which generally begins to decline by
5 to 7 wk of age (3). Inactivated and modified-live vaccines
(MLV) are both commercially available. Inactivated vaccine does
not produce disease in dogs, but has to be given frequently to
maintain protective titers (3). Life-long immunity is provided
by MLV. Vaccination with CAV-1 MLV is associated with ocular
and renal disease, whereas vaccination with CAV-2 MLV is not,
but may sometimes result in mild respiratory signs (3). Since
CAV-2 MLV is safer than CAV-1 MLV and cross-protects against
CAV-1, it is the most commonly used vaccine.
Since the advent of the aforementioned vaccines, IHC has
become a rare disease in dogs in Canada. The demise of the
puppy in this case was likely due to a combination of factors.
Firstly, appropriate handling of the vaccines given to the puppy
cannot be verified because the vaccines were administered by
the owner. Secondly, the puppy was vaccinated at 4 and 6 wk
of age, a time during which interference by maternal antibodies
was likely to have occurred. Thirdly, the primary series of vac-
cination was never completed. The recommended vaccination
schedule for puppies less than 16 wk of age consists of 3 doses
CVJ / VOL 53 / NOVEMBER 2012
given at 6 to 8, 9 to 11, and 12 to 14 wk of age (5). Fourthly,
prednisone treatment for puppy cellulitis might have resulted
in immunosuppression, rendering the puppy more susceptible
to infection than her littermates. It was previously shown that
German shepherd dogs with experimentally impaired cellular
immunity were more likely to die from adenoviral infection
CA S E R E P O R T
compared with control dogs (6). Fifthly, it is known that
CAV-1 is endemic in the wildlife in Alaska and Yukon. Among
1122 wolves that were tested, more than 84% had antibodies
against CAV-1 (7). Being housed outdoors, the puppy could
have acquired the infection via contact with infected wolves
or contaminated fomites. Since the entire litter was exposed to
all of these predisposing factors, except for prednisone therapy,
it is reasonable to assume that immunosuppression associated
with prednisone therapy was a crucial contributing factor to
development of fatal ICH in this puppy.
In summary, we report a case of ICH in the Yukon. Infectious
canine hepatitis should be considered in young dogs with acute
hepatic disease housed in rural areas of Alaska and Yukon. To
our knowledge, this is the first clinical case report of ICH associ-
ated with prednisone treatment at immunosuppressive doses in
the presence of the aforementioned predisposing factors. CVJ
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