Dalmatian - seziures? obesity? ACTH stim?

Re: Dalmatian - seziures? obesity? ACTH stim?

Rob Davis — Tue, 08 Jan 2013 13:11:55 GMT

[quote user="Claire McConnell"]having done much internet research himself was very distressed as he feels he his dog needs a CT/CAT scan and will not consent to an ultrasound as he "doesn't see the point"[/quote]

[quote user="Claire McConnell"]He always thinks we are a poor vet practice for not having a CT scanner in house.[/quote]

[quote user="Claire McConnell"]the vet stuck a pin in his tummy to check for fluid - why would she do that - its so nasty of her[/quote]

etc.....

At this point I would suggest that as he does not appear to have any confidence in your practice he should seek a second opinion elsewhere. If he didn't want to do this but still would not allow sensible investigations because of what he has read on the internet then I would sack him as a client - you don't need the hassle of clients like this!

Re: Dalmatian - seziures? obesity? ACTH stim?

Hannah Wynne Richards — Tue, 08 Jan 2013 11:21:59 GMT

Is the owner fat?

Wynne

Re: Dalmatian - seziures? obesity? ACTH stim?

Claire McConnell — Mon, 07 Jan 2013 19:51:48 GMT

[quote user="Mark Hedberg"]

[quote user="Claire McConnell"]

owner really finds dieting impossible

[/quote]

Good old CBA? :) (Can't be arsed)

[/quote]

I think a mixture of not believing his dog is over weight, blaming it on castration and his hypothyroidism and your above suggestion!

Re: Dalmatian - seziures? obesity? ACTH stim?

Claire McConnell — Mon, 07 Jan 2013 19:50:34 GMT

[quote user="Rajat"]

Clare

2 more thoughts-

Did the dog lose weight since starting Soloxine, even if he put it back on later? Or were there other improvements in clinical signs?

It may be worth getting chest radiographs as well if you can. Pericardial disease sometimes presents oddly and it will be a good screening for cardiac size (may be enlarged by fat) and for r/o neoplasia.

[/quote]

I honestly don't know the full answer to all your questions there - unsure about improvement in clinical signs (although nothing in notes suggests otherwsie) - . He did loose weight (a few kg) when originally started on soloxine (but still overwieght at 38kg) but then gained further weight after castrated last year (went from 42-46kg i believe from memory).

Re: Dalmatian - seziures? obesity? ACTH stim?

Claire McConnell — Mon, 07 Jan 2013 19:45:56 GMT

[quote user="Nicola Lawlor"]

What was the pulse quality and rhythm like? What you describe could also potentially be a syncope, maybe related to arrhythmia? I have seen cases where the arrhythmia can come and go so not always present when you examine the patient. Just maybe the "post ictal" period is actually the dog still being affected by a rhythm disturbance that settles later? Worth monitoring the pulse when the dog is in for the day to see if anything shows and maybe an ECG??

[/quote]

Pulse quality and rhythm were normal. The more the man describes the episode the more I am thinking the dog is just acting a bit odd - poss old dog brain - doggy dementia? Staring into space whilst panting.....i would def like to ecg if possible but ideally needsa a 24hr-72hr holter monitor. we have an old fashioned "painful clips onto dogs skin" that gives an immediate trace on paper you feed through rather than an ongoing computerised trace which isnt ideal.

Anyway update of day is that we were going to admit dog for us scan abdomen (+- chest for pleural effusion etc), chest xrays, acth stim (before other diagnsotics!!).

However owner is rather "odd" to be polite and having done much internet research himself was very distressed as he feels he his dog needs a CT/CAT scan and will not consent to an ultrasound as he "doesn't see the point". This is regardless of the fact that the point of the ultrasound was discussed at length - e.g to check for free abdo fluid, to check liver and other abdo architecture and structure, to chcek for pleural fluid etc. He also however does not want a referral for MRI/Ct etc as finances do not allow. But as his internet research tells him he does not need an US scan he will not let us do one. He always thinks we are a poor vet practice for not having a CT scanner in house.

He will not consent to any GA due to potential risks involved even though discussed that although GA risk is real and present is very low, probably lower than potentially not diagnosing/missing any heart/chest disease.

He also is very annoyed that his dog varies on his treatment between thyroxyl/soloxine and is astonished to find we put his dog on thyroxyl which is apparently a human medication for weight loss. (By varies I mean the dose stays the same but twice in the past has had to have soloxine instead of thyroxyl due to lack of availability). This again was explained at length (as was at the time of chnamging) that they are the same active drug, just a different brand, both for his hypothyroidism. He basically seems to thinkwe have tricked him into giving his dog human weight loss medication and have made up the thyroid problem.

He also voiced upset by the fact that on friday "the vet stuck a pin in his tummy to check for fluid - why would she do that - its so nasty of her". This was explained at the time on friday but re-explained again today however he still did not think it was necessary.

He did give us permission to run an ACTH stim which was highly suspicious of Cushings along with appropriate clinical signs, which we are starting to treat for as owner declines further confirmation with LDDST. The tentative diagnosis of Cushings does at least fit with PU/PD, abdo distension/pot bellied look, panting and exercise intolerance, lethargy and polyphagia.

He has agreed to bring dog back in 2 weeks for full biochem, electrolytes and repeat ACTH as well which is good. It is like the owner wants me to say "the dog will be fine, this is his problem, and we can fix it with x and he will definately not have anything else wrong with him" but without letting us do any diagnostics.

Re: Dalmatian - seziures? obesity? ACTH stim?

Claire McConnell — Mon, 07 Jan 2013 19:45:55 GMT

[quote user="Nicola Lawlor"]

[/quote]

Anyway update of day is that we were going to admit dog for us scan abdomen (+- chest for pleural effusion etc), chest xrays, acth stim (before other diagnsotics!!).

Re: Dalmatian - seziures? obesity? ACTH stim?

David Mills — Sat, 05 Jan 2013 21:18:12 GMT

Tough case, mainly due to owner, it sounds like. Couple of points:

1. Trying to diagnose seizures by descriptions from owners such as these can be a fool's errand. If he's adamant he can't video them then offer to hospitalise the dog daily until you see one yourself (with appropriate costs) then put an ECG on (if possible) when they occur. I always tell owners that its like being asked to diagnose skin disease with a blind fold on otherwise.

2. Careful with throwing tests around that only answer one question. If you're having him in for a scan then quickly scan the heart as well.

3. Keppra is a great drug if 1) doesn't work to prevent seizures and its onset is rapid as opposed to phenobarb so you can if pushed use this as a diagnostic tool. If its intracranial disease, however, it may not work at all.

Good luck.

Re: Dalmatian - seziures? obesity? ACTH stim?

Rajat — Sat, 05 Jan 2013 17:49:00 GMT

Sorry just saw you were planning on chest rads

Re: Dalmatian - seziures? obesity? ACTH stim?

Rajat — Sat, 05 Jan 2013 17:47:52 GMT

Clare

2 more thoughts-

Did the dog lose weight since starting Soloxine, even if he put it back on later? Or were there other improvements in clinical signs?

Re: Dalmatian - seziures? obesity? ACTH stim?

Rajat — Sat, 05 Jan 2013 17:44:31 GMT

[quote user="Claire McConnell"] Sorry, it has been seen regularly (we are very strict at seeing patients at least every 6 months) however O had declined follow up bloods at each appointment even though recommended. Sorry if I didn't make that clear.[/quote]

No worries, I probably didn't read it closely enough..:)

[quote user="Claire McConnell"]Would I have reasonably confidently ruled these out witha normal bilirubin and normal liver enzymes except ALKP? I guess not without Bile acid stim - would you agree?[/quote]

Not always, so BA stim is needed ...abdo US will be good but not always easy in these large dogs especially the deeper aspects of the liver. I very often take a look intercostally to image it.

[quote user="Claire McConnell"]I hate deciding whther something is a seizure or not from a poor description from an owner when it isnt a typical tomnic clonic sounding one - but I guess partial seizure is most likely.[/quote]

Yes especially the reduced mentation for sometime after the incident is much more suggestive for a partial seizure/TIA type event than cardiogenic syncope.

[quote user="Claire McConnell"]I a little scared of trialling ohenobarb due to s/e of PP etc in an alreday obese dog whose owner really finds dieting impossible (even though discussed at length on numerous occassions!)[/quote]

And I doubt he'll let you monitor that (treatment of potential seizures) adequately either. I would try to investigate as much as O will allow first rather than what could end up using up precious time and resources...so I am with you on not complicating the issue further by adding in drugs right now!

Re: Dalmatian - seziures? obesity? ACTH stim?

Mark Hedberg — Sat, 05 Jan 2013 17:19:00 GMT

[quote user="Claire McConnell"]

owner really finds dieting impossible

[/quote]

Good old CBA? :) (Can't be arsed)

Re: Dalmatian - seziures? obesity? ACTH stim?

Claire McConnell — Fri, 04 Jan 2013 22:38:09 GMT

[quote user="Rajat"]And re the dog not being seen since 2009 [/quote]

Sorry, it has been seen regularly (we are very strict at seeing patients at least every 6 months) however O had declined follow up bloods at each appointment even though recommended. Sorry if I didn't make that clear.

[quote user="Rajat"]metabolic dzs eg liver failure and hepatic encephalopathy (possibly)[/quote]

Would I have reasonably confidently ruled these out witha normal bilirubin and normal liver enzymes except ALKP? I guess not without Bile acid stim - would you agree?

I hate deciding whther something is a seizure or not from a poor description from an owner when it isnt a typical tomnic clonic sounding one - but I guess partial seizure is most likely.

I a little scared of trialling ohenobarb due to s/e of PP etc in an alreday obese dog whose owner really finds dieting impossible (even though discussed at length on numerous occassions!)

Re: Dalmatian - seziures? obesity? ACTH stim?

Nicola Lawlor — Fri, 04 Jan 2013 21:59:31 GMT

Re: Dalmatian - seziures? obesity? ACTH stim?

Rajat — Fri, 04 Jan 2013 21:49:15 GMT

Hi Claire

Nice detailed notes and history, I like !!

TO me this sounds like a non compliant owner with little funds and a complex case in a geriatric dog who already has one or two lifelong problems...so this will not turn out well..esp as there are neuro signs which often require an MRI...

I think I would struggle to tell the 'pot belliedness' of a nearly 50kg dalmatian however cushings is a decent rule out given the symptoms.

The dog appears to be having partial seizures. This could be related to either to:

its pituitary mass re cushings (uncommon) or

due to thyroid disease (very rare- I don't even know if there is a degree of poorly controlled hypoT which results in partial seizures as opposed to myxedema coma) or

due to intracranial disease (more likely) or

metabolic dzs eg liver failure and hepatic encephalopathy (possibly)

I am sure there are other ddx and this could be something like an abdo mass that has met'd to the brain too..

Remember also to get a urine sample and do microscopy (you may find some cool urate crystals!)

I like UCCR but it has to be home collected. It can rule out cushings if negative but never rule it in.

Re the thyroid testing it is often useful to have TT4 fT4eqD and TSH together. TSH and TT4 together prob needed for a dog on treatment (according to my 2 labs anyways)

And re the dog not being seen since 2009 - v unfortunate - our policy is not to give the tablets out if owner refuses a check up for something like hypoT at least every 6 months - I am sure the owner could have got these tablets without a prescription if he really wanted though

Best of luck and big welcome to VS! Good on ya for getting stuck with posting!

Re: Dalmatian - seziures? obesity? ACTH stim?

Claire McConnell — Fri, 04 Jan 2013 21:29:45 GMT

I do apologise if by thorough you mean "wrote too much". I was quite shocked when I finished my post, viewed it and was like "oh it takes up a whole page!!" So I am sorry for that.

I have chosen fT4 (by ed) for 2 reasons - firstly it is the method of diagnosis back in 2009 so nic eto get a number to compare to but secondly I believe I was taught that TT4 is often low in non thyroidal illness and fT4 less effected by non thyroidal illness just to get as accurate an idea of how well hypothyroidism is currently controlled.

Yes I did think about doing cort:creat ratio. I think the only reason I didnt suggest it is because I am unfamiliar with interpretatiion of results, which is a rubbish excuse bearing in mind the lab usualy interpret for you.

Claire

Re: Dalmatian - seziures? obesity? ACTH stim?

Michael Woodhouse — Fri, 04 Jan 2013 21:24:53 GMT

Claire

You have been very thorough!

If money is an issue I do tend to use urine cortisol:creatinine as a cheap screen (and no need for hospitalisation).

I wouldn't scrimp on haematology (what is it, an extra £10/12) as it can give a lot of info. I also pretty much always do a profile that includes electrolytes if I even vaguely suspect an endocrinopathy.

Why have you chosen the ed T4 rather than the cheaper total T4?

They don't sound like classic seizures. Anyway onset of seizures at 10 is rarely good.

Best of luck with the case, keep us informed.