Hypercalcaemia and Cushings

RE: Hypercalcaemia and Cushings

Melanie Atkinson — Wed, 16 Dec 2015 10:28:01 GMT

Hello,

I'm wondering what the resolution to this case was as I have something very similar at the moment- controlled HAC (on clinical signs and ACTH stim from Monday) but his Calcemia has increased at every blood test. Phosphate is normal. Cinically he seems well and there is no clinical evidence of neoplasia. My plan is to do PTH+ ionised Calcium if the owner can afford it, and a rectal exam as he is ME.

Anything you can add?

Cheers!

Re: Hypercalcaemia and Cushings

shanley barber — Wed, 08 Jan 2014 13:26:39 GMT

Hi all,

The Phophate is normal (1.22).

His lymph nodes are all normal, he's castrated, and I have palpated his abdomen and there are no abnormalities, but I must admit I haven''t check his anal glands recently. He had an ultrasound of his liver 8 months ago, and it was normal size, although there was some dilation of hisbile ducts, bilirubin was normal, PP BA were elevated, again this was 8 months ago. T4 slightly low and TSH normal.

I agree Cushings is difficult to diagnose, but this dog clearly appears Cushingoid, and his physical signs have improved with the Vetoryl (hair regrowth, energy levels), and his ACTH stims are perfect now. I assume that if he wan't Cushingoid, then the Vetoryl would have caused Addison's by now, as he has been on Vetoryl for months.

I agree I need to check his anal glands again, and repeat the ultrasound of his abdomen, then PTH//PTHrp if all normal.

Thanks again,

Shanley

Re: Hypercalcaemia and Cushings

Rory Bell — Wed, 08 Jan 2014 10:14:02 GMT

Hi Shanley

I'd agree with what John and others have said regarding further investigation. Cortisol actually tends to have a hypocalcemic effect, and it's thought that the increased PTH concentrations are a compensatory response to this. It would therefore be unusual for an untreated Cushingoid dog to have hypercalcemia as a consequence of hyperadrenocorticism. In dogs with HAC that are treated with trilostane, calcium concentrations tend to increase, but usually not in excess of the normal range, and this increase in calcium concentrations occurs in concert with (and perhaps as a consequence of) a decline in PTH concentrations.

For those reasons, and because the ddx for hypercalcemia include some significant diseases, I'd be very keen to investigate further. As John and others have said, a thorough clinical exam (including rectal), and depending on those findings, survey imaging possibly including PTH and PTHrp assays would be a good way to go.

Hope this helps

regards

rory

Re: Hypercalcaemia and Cushings

John Flynn — Wed, 08 Jan 2014 07:26:05 GMT

I'd investigate the hypercalcaemia independently if finances permit.

Start with thorough exam to include rectal, lymph nodes, abdominal palpation, neck palpation etc.

Then consider whether can do PTH/PTHrp testing (Dechra Specialist Labs): speak to lab first before sampling.

Alternatively survey imaging.

Might be worth reconsidering whether truly cushingoid also? Hypercalcaemia will cause PUPD for instance and cushings is notoriously difficult to diagnose in an ill animal (at least on blood tests alone), so unless the signs are absolutely classic I'd consider could they be due to another disease process related to the hypercalcaemia?

Re: Hypercalcaemia and Cushings

Michael Woodhouse — Tue, 07 Jan 2014 23:29:34 GMT

Have you checked the anal glands and the prostate?

Re: Hypercalcaemia and Cushings

Sammy82 — Tue, 07 Jan 2014 22:35:19 GMT

Could the Cushing's be due to an adrenal tumour and the hypercalcaemia therefore neoplastic syndrome? Not sure if this is common with adrenal Aden(carci)nomas.

Re: Hypercalcaemia and Cushings

Rob Loxley — Tue, 07 Jan 2014 22:19:13 GMT

[quote user="shanley barber"] worried that I should be giving something to treat the high Ca now[/quote]

What's the phosphate

[quote user="shanley barber"]the Ca hasn't gone down with treatment, but has remained stable at about 3.10 until his most recent ACTH stim test, when it was 3.55[/quote]

I'd be wondering if there's something else going on with the Ca - PTH/PTHrp would be worth considering. Have you done any imaging?