Weirdo internal medicine case

Re: Weirdo internal medicine case

ruths — Wed, 05 Mar 2014 07:37:44 GMT

You can get hypercalcaemia in lungworm- I think it is related to granulomatous disease. It's worth a check before calling it neoplasia!

Re: Weirdo internal medicine case

Julie Innes — Fri, 28 Feb 2014 22:11:41 GMT

My friends' dog was diagnosed with multiple myeloma after this sort of high calcium. They were referred to the vet school, but decided they didn't want chemo. The vet school gave her 2wks, but she lasted 3 months with high dose steroids- sadly I euthanased her yesterday :(

Re: Weirdo internal medicine case

Rory Bell — Fri, 28 Feb 2014 20:40:26 GMT

Stigen

A dog with clinical signs and blood results like that is unlikely to get better on its own, so I think your intervention has helped. If the owner won't go for further investigation, then don't let it die without steroids. Prednisolone at a dose of 40mg/square metre body surface area or 2mg/kg once daily would be my suggestion (i.e an immunosuppresive or lymphocytotoxic dose) initially with subsequent tapering according to the dog's response.

cheers

Re: Weirdo internal medicine case

Stigen — Fri, 28 Feb 2014 15:35:40 GMT

[quote user="Martin Atkinson"]

[quote user="Stigen"]I did`nt do an ionised calcium. Have`nt done one of those for many years...seem to remember that they are quite difficult and sensitive tests to get right. [/quote] Not difficult you just have to collect the blood into a plain tube (not gel) taking care to exclude all air, allow to clot, centrifuge and transfer the serum into another plain tube again excluding all air. You can get special low volume tubes from the lab which decreases the amount of blood you need. PTH is trickier and you need special equipment from your lab for that.

[/quote]

thanks, will certainly do that next time I se a great big calcium spike. :)

Re: Weirdo internal medicine case

Stigen — Fri, 28 Feb 2014 15:33:41 GMT

I can`t remember how high dose, but think it was like 1/8 tablet as well.

My case results came back from the lab with no explanation or comments. Cortisol t=0 is 225 nmol and Cortisol T=1 is 705 nmol. I guess that pretty much rules out Addisons.
I told the owner today that it`s most likely cancer. He won`t want to go for chemotherapeutics, and whatever cancer it may be it is certainly systemic, So I guess if the dog gets any worse it`ll be steroids. Thankfully it seems t have perked up and is eating again now. All I did was give it one liter of ringer lactate and an injection of cerenia for nausea...so if it was my efforts helping it or if it just got better on its own I don`t know :)

Re: Weirdo internal medicine case

Martin Atkinson — Fri, 28 Feb 2014 14:04:39 GMT

[quote user="John Flynn"]I tend to use 1/8th of a 15mg mirtazapine tablet and then repeat after an hour if no response.[/quote] You can get 2mg tablets from Summit.

Re: Weirdo internal medicine case

Martin Atkinson — Fri, 28 Feb 2014 14:02:33 GMT

Re: Weirdo internal medicine case

John Flynn — Fri, 28 Feb 2014 13:05:40 GMT

[quote user="Stigen"]I tried Mirtazapide once in a cat, but found it a bit scary as I gave it a tiny dose and after 10 minutes it was bouncing up the wall, eyes dilated looking like a crazed out drug-addict. It went from not eating for 3 days to swallowing down a massive portion of food, and then starting to chew on its bedding and the food trey.. [/quote]

How tiny a dose?

I tend to use 1/8th of a 15mg mirtazapine tablet and then repeat after an hour if no response.

Re: Weirdo internal medicine case

Stigen — Thu, 27 Feb 2014 21:38:33 GMT

Thanks :)
I will certainly check lymph nodes and anal glands. He did seem a bit sensitive caudally.

I`m certain it won`t have leishmannia or erlichia or any other tropical or tick-related disease. IT`s a local farmers dog.
I ll see how the owners want to proceed, further diagnostics would be interesting, but it`s not insured, so don`t know how much they would go for. I would like to do ionised calcium and urine protein electrophoresis if they would agree, but if they don`agree I might resolve to steroids as a last resort if the only other option is euthanasia. I know it is far from ideal, but maybe it could do something towards perking him up a bit and making him eat again.

What apetite stimulants have you used for dogs? I have heard Ondansetron might do something..but never tried.
I tried Mirtazapide once in a cat, but found it a bit scary as I gave it a tiny dose and after 10 minutes it was bouncing up the wall, eyes dilated looking like a crazed out drug-addict. It went from not eating for 3 days to swallowing down a massive portion of food, and then starting to chew on its bedding and the food trey..

Re: Weirdo internal medicine case

Rory Bell — Thu, 27 Feb 2014 14:03:46 GMT

HI Stigen

Looking at the differentials for hypercalcemia and applying them to your case I think neoplasia and possibly protozal infections (leishmania) or rickettsial infections (chronic monocytic ehrlichiosis) - does the dog have a history of travel or tick exposure?- are likely.

Looking at the differentials for hypercalcemia:

Neoplasia: The magnitude of the hyperglobulinemia would indicate that antibodies are probably being produced by a neoplastic clone of plasma cells (myeloma) or chronic immune stimulation (infectious agents as listed above). Runing a serum protein electrophoresis would be helpful as a monoclonal spike would make neoplasia more likely. Other neoplasma associated with hypercalcemia (anal gland adenocarcinoma and lymphoma) are uncommonly associated with hyperglobulinemia

Granulomatous disease: again, looking primarily at chronic infections, and there aren't many of those other then those listed above, and some fungal and algal diseases normally confined to much warmer climates which normally affect skin and kidneys.

Addisons disease: a possibility, but again, does not fit with a hyperglubulinemia or the dermatological changes

Primary hyperparathyroidism: should not cause hyperphosphatemia, hyperglobulinemia or (usually) renal failure

Vit D toxicity: again, does not explain the hyperglobulinemia. Good question to ask the owner though

Renal failure: The calcium x phosphorous product is high enough to cause nephrocalcinosis but without another valid ddx for the hyperphosphatemia (other then possibly osteolytic lesions secondary to neoplasia such as myeloma), I suspect that the hyperphosphatemia is a consequence rather than a cause of renal failure. Beware that a urine specific gravity will not help in differentiating whether the azotemia is pre-renal or renal as PU/PD secondary to hypercalcemia could potentially lower the USG even if the kidneys are functioning normally.

Idiopathic and spurious causes of hypercalcemia are vanishingly unlikely in this case

I would suggest, providing your ACTH stim excludes addison's, which it probably will do:

Checking travel history and considering possibility of Leishmania is travel to an endemic region

If not: running a SPE as mentioned above

ionised calcium will be helpful, as most differentials for hypercalcemia will have a high ionised calcium, apart from renal failure, where <20% of patients will have a high iCa

Imaging chest and abdomen, in particular radiographs of long bones and flat bones looking for multiple 'punched out' lesions suggestive of multiple myeloma.

Depending on what we see with those test results, and what the owners want to do, your next steps might involve obtaining a sample of bone marrow and/or running a urine protein electrophosesis, both of which tests are largely focused on diagnosing multiple myeloma.

Hope this helps, do get in touch if you've any questions!

rory

Re: Weirdo internal medicine case

Rob Davis — Thu, 27 Feb 2014 09:46:33 GMT

[quote user="Suzanne Kelly"]Check the anal glands as well as the lymph nodes. [/quote]

I agree - check anal glands ASAP for neoplasia.

Re: Weirdo internal medicine case

Suzanne Kelly — Thu, 27 Feb 2014 02:31:48 GMT

Check the anal glands as well as the lymph nodes.

Re: Weirdo internal medicine case

Linda Filshie — Wed, 26 Feb 2014 21:29:08 GMT

[quote user="Stigen"]

Thanks Linda :)
I guess D-vitamin deficiency could be a possiblity. I live in Norway,and we did`nt see the sun for a couple of months...I`ve just never heard of a dog suffering from it(except for in textbooks) .
Multiple myeloma...interesting
I found it weird that eosinophils were so high initially, but not on this second blood sample today..those were my main reason for testing for Addisons initially.

[/quote] You're very welcome, hopefully useful. Quick point,it's actually not a lack of vitamin D that can casue hypercalcaemia but a vitamin D toxicosis - usually human skin creams are to blame (dog licking it off the owners hands/eating a tube etc)

Re: Weirdo internal medicine case

Stigen — Wed, 26 Feb 2014 21:12:11 GMT

I did`nt do an ionised calcium. Have`nt done one of those for many years...seem to remember that they are quite difficult and sensitive tests to get right.

some diffuse tumour...that would make sense. I returned to practice 2 days ago after 2 years of travelling and having fun...so I guess my diagnostics skill are a bit rusty these days. Should check the lymph nodes properly next time I see it.

Re: Weirdo internal medicine case

Stigen — Wed, 26 Feb 2014 20:59:08 GMT

Re: Weirdo internal medicine case

Utlendigur — Wed, 26 Feb 2014 20:58:46 GMT

Would definitely be concentrating on getting to the bottom of the hypercalcaemia asap - and trying to get the calcium levels down aswell, otherwise you will have renal problems developing anyway. Is the haematology just a blood count? - if so I'd be getting a pathologist to look at a smear. Urine sample. Hopefully the ACTH stim will r/o addisons, Check lymph nodes, anal glands, mammary glands and survey xrays for tumours. If clear then PTH hormone assay but I'd be expecting neoplasia to be most likely

Re: Weirdo internal medicine case

Claire Fisher — Wed, 26 Feb 2014 20:46:04 GMT

If you haven't already I would check a urine sample, then bloods as others have suggested.

Re: Weirdo internal medicine case

Linda Filshie — Wed, 26 Feb 2014 20:41:18 GMT

[quote user="James Laidlaw"]Ionised calcium? [/quote] Ah - missed that we didn't have that yet.

Re: Weirdo internal medicine case

Julie Innes — Wed, 26 Feb 2014 20:39:38 GMT

Had a similar case a few months ago (unfortunately a friend's dog). high calcium rang the alarm bells ( wasn't addisonian.) Sent to vet school, turned out she was riddled with tumours :(. I am very wary of hypercalcaemia- it's never good news, is it?

Re: Weirdo internal medicine case

James Laidlaw — Wed, 26 Feb 2014 20:34:51 GMT

Ionised calcium? High ca I'd want to clarify, quantify and if high then go on a tumor hunt.

Re: Weirdo internal medicine case

Linda Filshie — Wed, 26 Feb 2014 20:33:38 GMT

Bloods look mildly to moderately azotaemic and you've got a hypercalcaemia. The body is excellent at maintaining its calcium homeostasis unless something's very out of whack. Top ddx include 1ry renal dz (hypercalcaemia can also cause kidney function impairment though), hyperparathyroidism, paraneoplastic syndrome and hypervitaminosis D. Increased globulins - so some kind of immune response. Multiple myeloma is a rare cancer but would be on my differential list.

My next steps would be careful questioning of owner re potential sources of Vit D (psoriasis creams etc), bloods for PTH, PTHrP, urine microscopy and a bloody good feel of the lymph nodes, plus/minus survey rads...