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== 讨论 ==

Pericardial effusion is a potentially life-threatening condition due to an increase in the intrapericardial pressure, resulting in varying degrees of hemodynamic compromise (Gidlewski and Petrie, 2005). Common causes of pericardial effusion in dogs include peritoneopericardial diaphragmatic hernia, congenital cysts, infectious pericarditis, right-sided heart failure, uremia, left atrial rupture, idiopathic pericardial effusion, cardiac neoplasia, and hemorrhage secondary to neoplasia (Kirsch et al., 2000). Pericardial effusion caused by rodenticide intoxication has been rarely reported in the veterinary literature (Petrus and Henik, 1999; Park et al., 2011). Petrus and Henik (1999) reported successful pericardiocentesis in a dog that ingested brodifacoum rodenticide; they drained the pericardial fluid into the pleural space without retrieving it for cytologic analysis. Similarly, Park et al. (2011) described hemorrhagic nonclotting pericardial fluid without clots removed from the pericardial space (Park et al., 2011). There are no reports about a spontaneous and immediate resolution of the pericardial thickening and pericardial effusion few hours after the administration of vitamin K without pericardiocentesis in dogs as in this case report. In human medicine, anticoagulants, such as warfarin, have been used for prevention and therapy of coronary artery diseases and previous reports describe the development of pericardial effusion associated with this anticoagulation therapy in humans (Miller, 1969; Granot and Shinar, 1982; Lee and Marwick, 1993). Despite strong evidence favoring a causative role of anticoagulation in the genesis of late cardiac tamponade from intrapericardial bleeding (Belic et al., 1978; Jones et al., 1979), there is no definitive evidence that anticoagulant treatment promotes development of pericardial effusion (Malouf et al., 1993). For this case report, CBC, blood chemistry, and coagulation profile have been essential for the precise and confident diagnosis of anticoagulant rodenticide intoxication because there was no known history of toxin exposure.

由于心包内压升高，心包积液是一种可能危及生命的疾病，导致不同程度的血流动力学损害（Gidlewski 和 Petrie，2005 年）。狗心包积液的常见原因包括新心包膈疝、先天性囊肿、感染性心包炎、右心衰竭、尿毒症、左心房破裂、特发性心包积液、心脏肿瘤和继发于肿瘤的出血（Kirsch 等人，2000 年）。由杀鼠剂中毒引起的心包积液在兽医文献中很少报道（Petrus和Henik，1999;Park等人，2011）。Petrus 和 Henik （1999） 报道了一只摄入溴敌畏杀鼠剂的狗的心包穿刺术成功;他们将心包积液引流到胸膜腔中，而没有将其取出进行细胞学分析。同样，Park等人（2011）描述了出血性非凝血性心包积液，而没有从心包间隙中去除凝块（Park等人，2011）。没有关于在狗服用维生素 K 而不进行心包穿刺术后几个小时心包增厚和心包积液自发和立即消退的报道，如本病例报告所示。在人类医学中，抗凝剂（如华法林）已被用于预防和治疗冠状动脉疾病，以前的报告描述了与人类这种抗凝治疗相关的心包积液的发展（Miller，1969;Granot 和 Shinar，1982 年;Lee和Marwick，1993）。尽管有强有力的证据表明抗凝治疗在心包内出血引起的晚期心包填塞的发生中具有致病作用（Belic 等人，1978 年;Jones 等人，1979 年），没有明确的证据表明抗凝治疗会促进心包积液的发展（Malouf 等人，1993 年）。对于本病例报告，全血细胞计数、血液化学和凝血特征对于准确和可靠地诊断抗凝剂杀鼠剂中毒至关重要，因为没有已知的毒素暴露史。


Clinical examination showed a central '''cyanosis''' and an '''abnormal jugular pulse''' due to the reduction of the cardiac output and a venous congestion secondary to the pericarditis. Hematological exams showed hypochromic anemia, decreased hematocrit (Hct) values, leukocytosis with neutrophilia, thrombocytopenia, enhanced erythrocyte sedimentation rate, and decreased mean corpuscular volume. Biochemical profile showed mild hypoproteinemia and hypoalbuminemia, hyperglycemia, bilirubinemia, and increased urea concentration, signs of the toxic effect of anticoagulant rodenticides on liver parenchyma (Boermans, et al., 1991; James et al., 1998; Robben, et al., 1998; Kohn, et al., 2003; Binev et al., 2005). Coagulation profile abnormalities were prolonged PT and PTT (Kohn et al., 2003; Binev et al., 2005). The intoxications with anticoagulant rodenticides in animals are relatively frequent (Park et al., 2011), but this is the first case describing pericardial thickening and pericardial effusion responsive to vitamin K supplementation. Previous reports describe severe thickening of the urinary bladder wall and of the gastric wall secondary to a systemic bleeding disorder and the ultrasonographic appearance of the wall thickening reported in these cases is similar to the thickening of the pericardium identified in the patient of this case report (O’Brien and Wood, 1998; Marks et al., 2001; Londoño et al., 2015). It cannot be definitely proven that the pericardial changes were attributable to bleeding, and anticoagulant rodenticide intoxication was not confirmed; however, the complete resolution of both pericardial thickening and effusion following vitamin K therapy supports the presumptive diagnosis of pericardial hemorrhage and effusion secondary to rodenticide intoxication. Histologic analysis of the pericardium would have been required to confirm the diagnosis and rule out other differentials, but a biopsy was not obtained due to concerns regarding the coagulopathy and the quick resolution of both clinical and echocardiographic signs. For these reasons, in dogs with diffuse thickening of the pericardium and pericardial effusion, pericardial hemorrhage should be considered a possible differential diagnosis in addition to neoplasia and inflammation and testing for an underlying bleeding disorder is recommended. In conclusion, in veterinary medicine, if pericardial effusion is identified and suspected to be potentially related to rodenticide intoxication, it is important to confirm the presence of the pericardial effusion by using echocardiography, and to associate echocardiographic findings with CBC, blood chemistry, coagulation profile, and clinical findings to evaluate all the possible therapeutic options before performing a routine pericardiocentesis that could put the patient’s life at risk by generating further bleeding.

临床检查显示中心性'''紫绀'''和'''颈静脉搏动异常'''，这是由于心输出量减少和继发于心包炎的静脉淤血所致。血液学检查显示低色素性贫血、血细胞比容 （Hct） 值降低、白细胞增多伴中性粒细胞增多、血小板减少、红细胞沉降率增强和平均红细胞体积减少。生化特征显示轻度低蛋白血症和低白蛋白血症、高血糖、胆红素血症和尿素浓度升高，这是抗凝剂杀鼠剂对肝实质毒性作用的迹象（Boermans等人，1991;James等人，1998;Robben 等人，1998 年;Kohn 等人，2003 年;Binev等人，2005年）。凝血特征异常延长了 PT 和 PTT（Kohn 等人，2003 年;Binev等人，2005年）。动物中抗凝剂灭鼠剂的中毒相对常见（Park等人，2011），但这是第一个描述对维生素K补充有反应的心包增厚和心包积液的病例。先前的报告描述了继发于全身性出血性疾病的膀胱壁和胃壁的严重增厚，并且这些病例中报告的尿壁增厚的超声外观与本病例报告患者中发现的心包增厚相似（O'Brien 和 Wood，1998 年;Marks等人，2001年;Londoño等人，2015）。不能明确证明心包改变可归因于出血，抗凝剂杀鼠剂中毒未得到证实;然而，维生素 K 治疗后心包增厚和心包积液的完全消退支持了继发于杀鼠剂中毒的心包出血和积液的推定诊断。需要对心包进行组织学分析以确认诊断并排除其他鉴别诊断，但由于担心凝血功能障碍以及临床和超声心动图体征的快速消退，因此未进行活检。由于这些原因，对于心包弥漫性增厚和心包积液的狗，除了肿瘤和炎症外，心包出血应被视为可能的鉴别诊断，并建议检测潜在的出血性疾病。总之，在兽医学中，如果发现心包积液并怀疑可能与杀鼠剂中毒有关，重要的是使用超声心动图确认心包积液的存在，并将超声心动图结果与全血细胞计数、血液化学、凝血功能和临床表现相关联，以评估所有可能的治疗方案，然后再进行可能危及患者生命的常规心包穿刺术产生进一步的出血。

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