5 yo whippet with suspected PLE

Re: 5 yo whippet with suspected PLE

scatty — Mon, 16 Mar 2015 10:10:15 GMT

Seeing the whippet weekly now for B12 and monitoring biochemistry. Today the ascites looked resolved so I couldn't take a sample. However, things are probably still not settled as he still goes through periods of diarrhoea and his appetite can be picky even on lots of steroids. I don't think the steroids are helping his weight either - he is tending to look quite wasted and skeletal. When the ascites goes, he weighs in lower.

I am considering adding in chlorambucil potentially ( a little worried about effect of azathioprine on the liver as his liver enzymes were raised even though BAST was normal).

In answer to your question Christopher, we didn't see a pericardial effusion when we scanned him 5 weeks ago. The owners don't want him to stay in for any more tests due to his stress levels so I feel it is very difficult to make progress in this case. The owners do feel his quality of life is good though.

Such a difficult case!

Re: 5 yo whippet with suspected PLE

Christopher Saul — Sat, 14 Mar 2015 09:25:36 GMT

Hi Anna No I'm not specifically worries about anything in particular. It's just with serum albumin levels as you describe I'd be expecting the ascities to have resolved if it were purely because of the hypoalbuminaemia. Fluid analysis would be useful to further characterise. i take it you're confident it doesn't have a pericardial effusion? Chris 😊

Re: 5 yo whippet with suspected PLE

scatty — Thu, 12 Mar 2015 09:08:29 GMT

Hi Christopher,

I'm sure I would be able to try and take a sample for culture and cytology. Are you worried about neoplasia? I will discuss with the owners.

Many thanks,

Anna

Re: 5 yo whippet with suspected PLE

Christopher Saul — Wed, 11 Mar 2015 21:26:38 GMT

Hi Scatty

Glad to see this case is improving, good job so far.

I'm sorry to be a party pooper though I would echo Andy's concerns that there may be something else going on, perhaps in addition to the PLE; with an albumin of 23.6 g/l one would not normally expect the dog still to be ascitic.

Could you sample the ascitic fluid and send it for cytology culture?

Re: 5 yo whippet with suspected PLE

scatty — Tue, 10 Mar 2015 21:33:19 GMT

Hi everyone, thanks a lot for all your replies,

For Andrew, I have some more recent blood results now:

albumin 23.6 (28-35)

globulin 16.5 (24-40)

total protein 40.1 (50-78)

alkp 268

ALT 226

bilirubin 8.4 (0-7)

calcium 1.98 (2-3)

The rest is fairly unremarkable. The protein has come up higher than it has been so far. The ALT has come up from previous results although it was 115 at the point where I ran the bile acid stim test prior to starting steroids. The bilirubin raise I have not seen previously. He is doing okay clinically - brighter and has even been trying to mount the other dog in the household! Diarrhoea is generally under control. However, he is on a decent dose of diuretic and a bit ascitic.still. He does tend to get a degree of respiratory distress if we try to titrate the diuretic dose down too much.

Re: 5 yo whippet with suspected PLE

Andrew Kent — Sat, 07 Mar 2015 11:23:38 GMT

Hi Scatty,

Have you repeated the bloods again recently? It still doesn't sound like a classic PLE to me so continue to be concerned that there is something else going on.

Andy

Re: 5 yo whippet with suspected PLE

Yantha Smyth — Fri, 06 Mar 2015 18:50:34 GMT

The effusions should be transudates due to hypoprotainaemia, so I would expect the ascites and hydrothorax to improve as the albumin improves rather than require diuretics. I had a greyhound present with hydrothorax once which turned out to be lymphangiectasia, and had hardly any diarrhoea at all!

This was managed very well initially with prednisolone and ultra-low fat diet (rather than a hypoallergenic)- the ultra-low fat reducing the lymphatic loss. The problem we had with our GH ( which you may well see in a whippet too) is the massive muscle loss on high doses of prednisolone, so we introduced azathioprine pretty early on too so we could taper down the steroid. Did very well on a maintenance dose and stayed on the diet long term.

Re: 5 yo whippet with suspected PLE

scatty — Fri, 06 Mar 2015 16:49:53 GMT

Sorrel, he isn't taking the hydrolysed diet properly yet which may be part of the problem. The owners are mixing it with other food to keep his interest up. However, after starting the steroids his appetite has increased and he is feeling much better in himself, playing with the other dogs. I will try and get him on to purina HA when I see him again on monday.

Andrew, we scanned the heart and it looked subjectively a little enlarged but nothing really obvious. The chest had initially lots of effusion but I don't think I could say from the xray if it was cardiogenic or not. Pro BNP was low.

Re: 5 yo whippet with suspected PLE

Andrew Mellor — Fri, 06 Mar 2015 13:19:34 GMT

if you have lymphangectasia caused by right sided heart failure then yes you will need heart meds and diuretics, have you scanned heart or done chest films? often you wont have a murmur just failing musculature and bulging right atrium/auricle.

Re: 5 yo whippet with suspected PLE

Sorrel Proctor — Fri, 06 Mar 2015 13:05:44 GMT

If things area really getting under control I don't think you should need diuretics... but if it is a true PLE with lymphangiectasia etc it may be that you need more immunpsuppressives eg atopica, chlorambucil. Is he taking the hydrolysed diet?

Re: 5 yo whippet with suspected PLE

scatty — Fri, 06 Mar 2015 08:55:11 GMT

Update so far - very positive response to the steroids in terms of the diarrhoea has cleared, he is eating well and better in himself. However, after I tapered the frusemide down (cut the dose down to a 1/3 of what it was), the owners started noticing more ascites so have had to bring the dose back up a bit. I got my boss to have a listen to the heart and he agrees it sounds normal - he can't hear a murmur but we have left the heart meds on as a precaution. Does anyone know if true PLE is responsive to diuretics because I never see this as a recommended therapy - just steroids< b12 , diet etc and unfortunately the steroids in this case (using 2mg/kg/day), don't see be enough to keep the ascites at bay.

Re: 5 yo whippet with suspected PLE

scatty — Sat, 28 Feb 2015 11:24:28 GMT

gosh - that's very interesting you had such a similar case Andrew. Thanks everyone for your replies. Great to hear details of the cases everyone has had - good and bad......I will probably start him on some steroids after the weekend. I have started him on metro and fenbendazole already. I'll let you know how I get on.......

Re: 5 yo whippet with suspected PLE

Andrew Mellor — Fri, 27 Feb 2015 15:45:33 GMT

weird I have in the last 2 weeks had a 5 year old whippet with exactly the same symptoms although he had profuse diarrhoea, massive ascites and hind limb oedema, collapsed , had been doing full faeces exams and dietry trials etc for a few weeks but nothing came up and then over a weekend got really bad when the fluid etc started, bloods and albumen extremely low- sorry cannot remember exact figures . almost in desperation whilst bloods etc away at lab gave steroid and metronidazole for local immunity in gut and dog better in 24 hours , fluid gone , bright and happy, been on for 2 weeks now 10mg pred and all settled , weight increased , faeces well formed , now just at a point that we can do further investigations heart etc.

Re: 5 yo whippet with suspected PLE

Sorrel Proctor — Fri, 27 Feb 2015 15:25:31 GMT

I'm sorry I can't remember values but I remember in the case I was referring to that we were all surprised at the diagnosis because the albumin levels didn't seem low enough to cause such massive effusions, we were thinking neoplasia somewhere even though we couldn't find anything. But I don't have a lot of experience with this I'm afraid. It sounds like if you've done an echo (even in house) and there's no obvious heart pathology cardiac causes have to go lower down the list even with a murmur... You can always just leave a moderate dose of frusemide in place for now to try and keep the effusion at bay and make it easier to auscultate. I assume the dog is fairly 'well'?

Re: 5 yo whippet with suspected PLE

scatty — Fri, 27 Feb 2015 12:01:40 GMT

Hi Andy,

When we first saw the dog the albumin was 21 and the TP was 34. That was in house so assuming the split of alb/glob was accurate. Because of the large level of bicavitary effusions and peripheral limb effusion on initial presentation, I think it has been at times difficult to assess the heart due to fluid. To me at times it has sounded more muffled rather than an obvious murmur. I still think this seems more complicated and that there could be something else going on. Everything you have said makes a lot of sense. At the moment we're on high dose 4 mg/kg tid frusemide plus pimobendan and fortekor and although all the fluid seemed to vanish initially the belly is getting a little ascitic again. I am considering tapering the dose of diuretic and taking away the fortekor. Currently I'm giving 2.5 mg/kg frusemide tid but I wanted to drop the dose back by 2/3. Basically , I'm finding it's difficult to be confident there is no cardiac disease in this case! (however I don't want to affect electrolytes by having too high a diuretic dose with steroids). I have also seen low calcium levels and sl. low cholesterol which looks 'g/I like'.

The owners don't want to refer so I may start the steroids after the wknd but get the metronidazole and parasite treatments underway first as I don't see that could do any harm. I will also treat for lungworm just in case ?!

Re: 5 yo whippet with suspected PLE

Andrew Kent — Thu, 26 Feb 2015 23:00:35 GMT

Hi Scatty,

What were the protein levels when you first saw the dog? And did it already have widespread oedema then? The albumin is only really just low enough to account for that (though the concurrent low globs can contribute) so if this was occurring with much higher albumin levels I might worry that something else is going on.

Otherwise - assuming this is a PLE - yes these can be successfully managed in many cases. They usually do best with a multimodal approach so (assuming that owner definitely declines biopsy) I would use a combination of immunosuppressives (prednisolone plus chlorambucil or ciclosporin), start on a hypoallergenic/hydrolysed diet and give antibiotics (metronidazole). I would also treat for a week with fenbendazole, just to be comprehensive. With your low B12 you will need weekly injections for the next 4 weeks at least.

If you are confident in having excluded cardiac disease then I would stop the heart meds.

Do let us know how you get on,

Andy

Re: 5 yo whippet with suspected PLE

scatty — Thu, 26 Feb 2015 21:17:34 GMT

Sorry I forgot to say I checked the urine and no protein seen. Nothing cultured on faeces and in house faecal Guardia antigen test negative.

Re: 5 yo whippet with suspected PLE

Utlendigur — Thu, 26 Feb 2015 19:11:06 GMT

Given that both albumin and globulin are reduced, plus reduced cobalamin, it does sound like GI loss - but may be worth checking for proteinuria just for completeness. Faeces sample would also probably be worth doing just to rule out things like eg Giardia that might be exacerbating things - or you could just cover with panacur if funds are very tight. Probably worth adding metronidazole in case bacterial overgrowth, plus weekly cobalamin injections. Also a very hypoallergenic diet eg hydrolysed. But at the end of the day it may come down to treating with steroids anyway - the longer things go on as they are, the more debilitated the dog will get, and the harder it will be for it to recover - as long as the owners know that if you go down the route of treating without a firm diagnosis, it will affect/preclude biopsies if they change their minds later. I seem to remember reading that response rates to steroids were something like 25% resolve, 50% improve but need on-going diet and treatement and 25% don't respond and are pts but I can't remember where I got that from or whether it was for all PLE, or PLE due to IBD only.

Re: 5 yo whippet with suspected PLE

Sorrel Proctor — Thu, 26 Feb 2015 19:03:57 GMT

Hi,

I have seen a 3 yo collie cross who was maintained for a couple of months post biopsy diagnosis with a cocktail of chlorambucil, pred, metronidazole and zantac. Although initially his bicavitary effusions resolved, his faeces (never that bad) improved and his protein levels picked up a bit it was a very short term thing (3-4 weeks). After that he just faded really, getting thinner and thinner, ascites returning, going off food etc. Cost was an issue in the end and he was euthansed. Sad and frustrating. Hopefully your whippet does better!