Sudden onset diabetes mellitus or what?

Re: Sudden onset diabetes mellitus or what?

Virginia Campbell — Fri, 18 Apr 2014 22:37:51 GMT

[quote user="Martin Atkinson"]I cannot help but feel that given a bit more time and effort we could have turned things around[/quote]

Well, you probably coulda but then...you would have had to get the non-vet-goer to come in for diabetes montoring very regularly. And get him to pay for and stick to a low fat sensitivity diet to stop the pancreas getting more annoyed. Then talked him into spay +/- dental. Then maybe had to diagnose and deal with EPI developing. Then maybe have to nurse her through another bout or two of pancreatitis despite your best efforts at prevention. For a dog that the non-vet-goer possibly considers record-breakingly old.

Re: Sudden onset diabetes mellitus or what?

Robin Grimmer — Thu, 17 Apr 2014 22:51:45 GMT

[quote user="Martin Atkinson"]

What next? with that high ALP with relatively low ALT its got to be endocrine so Cushings disease and insulin resistance right? Basal cortisol 551 nmol/l >250, yesterday we're getting somewhere now! No Synacthen so performed LDDMS test today: pre dex cortisol 411, 3 hrs post 148. Damn its not Cushings!

[/quote]

No point testing for Cushings in an unstable diabetic in DKA. And the diabetes alone could cause the high ALP. I think the likely cause was the fact that the bitch was unspayed and progesterone causing antagonism of insulin. Spaying is mandatory for DM as will usually become unstable in dioestrus. But there's no way this dog would have been up to spaying, you did everything else right in treating the DKA, think you were on to a loser with this case, nothing else you could have done.

Re: Sudden onset diabetes mellitus or what?

Anthony Todd — Thu, 17 Apr 2014 19:17:38 GMT

[quote user="Martin Atkinson"]Quite frequently - the open ones are easy, but there is always a history of recent or irregular seasons and /or oestrus suppression with drugs. [/quote]

Apart from the oft times when the owner hasn't the faintest idea of what a season is, apart from summer or winter, and thinks "Oestrus" is some celebrity's daughter, let alone timing.

Possibly, but answering the question for myself, I don't think I've ever seen a pyo without some degree of vulval enlargement, with or without discharge.

“It is very unnerving to be proven wrong, particularly when you are really right and the person who is really wrong is proving you wrong and proving himself, wrongly, right.”

Happy to be contradicted but I doubt if I will.

Re: Sudden onset diabetes mellitus or what?

Martin Atkinson — Thu, 17 Apr 2014 16:11:24 GMT

[quote user="Anthony Todd"]Do you ever get a pyo without an enlarged vulva [even slightly] and /or a discharge [even slight]? Would have stopped me going for a pyo [I would say that now, wouldn't I][/quote] Quite frequently - the open ones are easy, but there is always a history of recent or irregular seasons and /or oestrus suppression with drugs.

I recall as if it were yesterday my first week in practice fresh out of college a bitch presented with a bloody vaginal discharge one month post first season. I was all set to spay it when the senior vet stopped me and said no bitches don't get pyos one month after their first season and started looking for odd things like clotting disorders. Anyway the long shot is that they faffed around so much she became seriously ill and the owner ran out of funds so it was PTS. PM examination showed it had had a pyo. Two things I learned from this are that our patients don't always read the textbook and that if I think I'm right, even if everyone tells me I'm wrong, I'm probably still right.

Re: Sudden onset diabetes mellitus or what?

Mark Hedberg — Thu, 17 Apr 2014 14:34:26 GMT

[quote user="Hannah Wynne Richards"]

Wouldn't this job be bliss if it wasn't for the owners.

Wynne

[/quote]

Not really - I've never yet met a dog with a credit card or a bank account!

Re: Sudden onset diabetes mellitus or what?

Hannah Wynne Richards — Thu, 17 Apr 2014 14:18:44 GMT

Wouldn't this job be bliss if it wasn't for the owners.

Wynne

Re: Sudden onset diabetes mellitus or what?

Anthony Todd — Thu, 17 Apr 2014 13:51:12 GMT

[quote user="Martin Atkinson"]At least it didn't turn out to be a pyo[/quote]

Two things to add [which I would have said before the PM, and would have been wrong?]

1. Do you ever get a pyo without an enlarged vulva [even slightly] and /or a discharge [even slight]? Would have stopped me going for a pyo [I would say that now, wouldn't I]

2. I've seen bitches around heat becoming glycosuric etc., and just as we organise diabetic treatment etc. they become unglycosuric and stop polydipsia and coincidentally go off heat....

Re: Sudden onset diabetes mellitus or what?

Martin Atkinson — Thu, 17 Apr 2014 13:39:54 GMT

Final report. After lengthy discussion with owner who was concerned that he would be unable to treat the little dog at home and the ongoing cost of hospitalisation he elected to have her PTS. PM examination revealed a pale fatty liver and very inflammed pancreas, kidneys had miliary white spots, no evidence of adrenal gland tumours and uterus absolutely normal. We are not sending samples for histopath so final diagnosis seems to be: given the normal fructosamine, sudden onset DM probably secondary to pancreatitis and hepatic lipidosis rather than vice-versa.

I cannot help but feel that given a bit more time and effort we could have turned things around but the owner made the decision without pressure from me. I've long given up reproaching myself over these situations and thinking, 'if only I was prepared to hospitalise it for nothing all over Easter things might have turned out OK' etc etc but we can only do what we're allowed to do and move one. At least it didn't turn out to be a pyo after all which would have put me in bad mood!

Re: Sudden onset diabetes mellitus or what?

Eamon McAllister — Wed, 16 Apr 2014 23:30:38 GMT

[quote user="Michael Woodhouse"]

I'd still be thinking pyo...........

(shock horror - ex-lap, check pancreas and uterus?)

[/quote] +1

Re: Sudden onset diabetes mellitus or what?

Michael Woodhouse — Wed, 16 Apr 2014 22:25:26 GMT

I'd still be thinking pyo...........

(shock horror - ex-lap, check pancreas and uterus?)

Re: Sudden onset diabetes mellitus or what?

Martin Atkinson — Wed, 16 Apr 2014 21:48:00 GMT

[quote user="Yantha Smyth"]Perhaps there is progesterone influence that has tipped her over the edge- has there been a season in the last 1-2 months?

[/quote]No, when questioned on this the owner first said she hadn't been in season for a long time then suggested that she might have had one end of last year. I wouldn't have thought a progesterone problem would cause such profound ALP and glucose changes without some suggestion of a pyo but there's no way she's going to get spayed at the moment unless that becomes a major issue.

Re: Sudden onset diabetes mellitus or what?

Yantha Smyth — Wed, 16 Apr 2014 19:48:57 GMT

Perhaps there is progesterone influence that has tipped her over the edge- has there been a season in the last 1-2 months?

Re: Sudden onset diabetes mellitus or what?

Ceri Gruffudd Jones — Wed, 16 Apr 2014 19:35:10 GMT

I would keep treating it as a diabetic with antibiotic cover and symptomatic Tx for vomiting etc and fluids as you are doing. Get the biochemistry stable then see if the USG settles once you don't have a dog full of osmotically active compounds. I once had a Cairn present OOH for seizures while the owners were on hols here which turned out to be massively hyperglycaemic (>35 mmol/l) and presumably hyperosmolar causing the neuro signs. Only after very close repeated questioning did the owners acknowledge that maybe it had drunk a couple more bowls of water over the previous week. They were adamant it had not been 'ill' in any way. Imaging, snap CPL etc all normal. It really did appear to be acute onset Diabetes Mellitus and responded well to treatment. If cost is a concern I'm not sure I would chase the pancreas too much unless you think it will significantly affect your therapeutic plan. You still need to sort the glucose levels, you will probably give it much the same in terms of antiemetics and H2 blockers. The main difficulty is in sorting a low fat / low soluble carb diet to cover both options until it stabilises. Good luck.