Not a straightforward pancreatitis

Re: Not a straightforward pancreatitis

Rory Bell — Tue, 09 Jun 2015 10:20:17 GMT

Nice one Sir!

Re: Not a straightforward pancreatitis

Anthony Dennison — Tue, 09 Jun 2015 10:13:10 GMT

Just an update on this case: I started the dog on 2mg/kg prednisolone, and saw her back today. She's pretty much back to her normal self! Eating, drinking fine, barking at other dogs (made a right racket in the waiting room) and eager to go for walks.

So, don't know what was wrong with her, but steroids fixed it. Hurrah.

Re: Not a straightforward pancreatitis

Anthony Dennison — Thu, 04 Jun 2015 09:10:45 GMT

[quote user="ruths"]

Oh, I moved on from potassium to Sodium.

. I never got into calcium for some reason, though -)))

[/quote]

I'm obsessed with Sodium:Potassium ratios, always suspicious of Addisons in weird cases after seeing a couple of dogs spend a week having all sorts of tests before we came round to an ACTH stim!

Maybe we should start a support group, electrolytes anonymous?

Re: Not a straightforward pancreatitis

ruths — Wed, 03 Jun 2015 22:46:04 GMT

Oh, I moved on from potassium to Sodium.

. I never got into calcium for some reason, though -)))

Re: Not a straightforward pancreatitis

Kate Richardson — Wed, 03 Jun 2015 21:16:24 GMT

[quote user="ruths"]

lol-

I also enjoy electrolytes - sodium is a particualr favourite of mine..

[/quote] Ha ha- I'm obsessed with potassium!! Interesting case and top input from RB!

Re: Not a straightforward pancreatitis

ruths — Wed, 03 Jun 2015 17:35:47 GMT

Yes- thanks. I forgot the dog had abdo scans. I agree with the pragmatic therapeutic option in this case. I wondered if ou could demonstrate a mass then the next stage is euthanasia without further ado..

Re: Not a straightforward pancreatitis

Rory Bell — Wed, 03 Jun 2015 17:23:54 GMT

We did discuss assessing coagulation times and examining a urine sediment. As far as I know, Anthony is content that the clotting is ok and the urine sediment inactive apart from the presence of red blood cells. The haematocrit is almost normal so I don't think the haemorrhage is all that severe and is a marker if a disease process rather than a problem in its own right. The dog has had one or two ultrasound scans which have not identified any renal lesions so far as I am aware.

If the dog's clotting ability is intact then spontaneous bleeds into the CNS would be unlikely. I agree that without advanced imaging we do not and cannot know what might be going on to cause the seizures, and we cannot exclude a tumour. On the other hand, if the owners cant afford an MRI to detect a tumour, they're probably not going to be able to afford anything beyond steroids (radiation therapy, surgery etc) to treat it and if that tumour is a metatsttic urogenital tumour the prognosis is hopeless anyway. So my reasoning at this stage is that either the haematuria is unconnected, or, if it is connected to the CNS disease, the prognosis is very very poor. Either way, I'm comfortable with the decision to pursue trial steroid therapy, and we can investigate the haematuria (as being less important to the dog at this point in time) depending on what progress we make against the problems that are causing more difficulties to the dog at present.

That's just my reasoning though; other folk may have a different approach that could be equally good or better!

cheers

Re: Not a straightforward pancreatitis

ruths — Wed, 03 Jun 2015 17:00:59 GMT

Hi - thanks for sharing this case - I think we are all getting useful stuff from the discussion.

Rory- are you not worried about the blood in the urine? Would it be ok to ignore this at this stage? For me, it seems to be the next place to look- eg there's a coagulopathy or there's a bleeding lesion that could be a tumour (amongst other things...)

I could connect both a coagulopathy and a tumour with the neuro signs...

Anthony- did you spin down the urine to see if it's haemolysis or whole blood?

Thanks _))

Re: Not a straightforward pancreatitis

Anthony Dennison — Wed, 03 Jun 2015 11:30:38 GMT

Thanks for the quick and detailed reply Rory, really appreciated! I found out this morning as well the dog is regularly treated with advocate too, so lungworm is unlikely (especially as I've never seen it in the North West since graduation (3 yrs), and we have looked for it in the past).

I think I'm going to go along the steroid trial route - just don't think the owner can afford any further investigations, would love to send for an MRI!

Re: Not a straightforward pancreatitis

Rory Bell — Wed, 03 Jun 2015 11:21:19 GMT

Provided that cortisol was measured prior to the dog having colvasone, I'd say Addison's was extremely unlikely (abstract below)

One of the nice things about where I work is that I'm surrounded by folk who know much more about various things than I do. To me, those episodes look like partial seizures; I showed the clips to one of my neurologist colleagues and he agrees.

So, if you exclude coagulopathies / Angio, (and the only other thing that might be useful is measuring the dog's blood pressure to exclude hypertension), you've pretty much excluded all extra cranial causes of seizure activity. You now have two options:

1) Do what Wynne suggested right back at the start of the thread - advanced imaging of the brain +/- CSF taps; which is all well and good, but is this, financially speaking, a realistic option for the owners? I suspect probably not.

2) This dog might have responded on two occasions to steroids. This would imply that whatever is causing the seizures might have an inflammatory component. Perhaps continuing with steroid therapy would be worthwhile? Obviously we don't know precisely what we are treating, and it's possible that steroid therapy might be ineffective, but it would seem that we've got enough evidence of justify using them on a more long term basis. If you had any serum left over from prior to the last dose of steroid (or failing that a fresh sample collected today), it might be worth while measuring acute phase proteins (C-reactive protein). If the pancreatitis is in remission, and there's not any evidence of inflammatory disease elsewhere, an increased CRP will provide further supportive evidence if inflammatory CNS disease and serial monitoring of CRP concentrations might provide a means of objectively measuring a response to therapy. Concentrations of CRP are higher in dogs with SRMA than in dogs with other types of CNS disease

If the dog fails steroid therapy then I'd consider anti-epileptic therapy.

cheers

J Vet Intern Med. 2014 Sep-Oct;28(5):1541-5. doi: 10.1111/jvim.12415. Epub 2014 Jul 28.

Basal serum cortisol concentration as a screening test for hypoadrenocorticism in dogs.

Bovens C1, Tennant K, Reeve J, Murphy KF.

Author information

Abstract

BACKGROUND:

Measurement of basal serum or plasma cortisol concentration is used as a screening test for hypoadrenocorticism in dogs, but is not well characterized.

OBJECTIVES:

To evaluate the sensitivity and specificity of basal serum cortisol to detect hypoadrenocorticism in a population of dogs with a clinical suspicion of hypoadrenocorticism.

ANIMALS:

Four hundred and fifty dogs with nonadrenal gland illness and 14 dogs with naturally occurring hypoadrenocorticism were included.

METHODS:

Retrospective case-control study. The records of all dogs having had an ACTH stimulation test performed between January 2005 and September 2011 at the University of Bristol were reviewed. Dogs were included if the test was performed as a screening for hypoadrenocorticism. The sensitivity and specificity of basal serum cortisol concentration to detect dogs with hypoadrenocorticism were calculated using 2 cut-offs and compared to the gold standard ACTH stimulation test.

RESULTS:

Using a cut-off of ≤2 μg/dL (≤55 nmol/L), the sensitivity and specificity of basal cortisol to detect hypoadrenocorticism were 100% and 63.3%, respectively, whereas for a cut-off of ≤1 μg/dL (≤28 nmol/L), the sensitivity and specificity were 85.7% and 91.8%, respectively.

CONCLUSIONS AND CLINICAL IMPORTANCE:

Measurement of basal serum cortisol is useful as a screening test for hypoadrenocorticism in dogsusing a cut-off of ≤2 μg/dL (≤55 nmol/L), and the disease is unlikely with a basal serum cortisol >2 μg/dL (>55 nmol/L). A basal serum cortisol ≤2 μg/dL (≤55 nmol/L) cannot be used to diagnose hypoadrenocorticism, and an ACTH stimulation test should be performed in these cases

Re: Not a straightforward pancreatitis

Anthony Dennison — Wed, 03 Jun 2015 10:52:48 GMT

Basal Cortisol is 81.4 (ref 25-125). It isn't elevated despite the dog being unwell, but isn't low... any thoughts? Spoke to the owner this morning, apparently she hasn't had any more of these episodes since she had an injection of Colvasone last night.

Money is starting to run out (almost has), so I'm not sure how many more diagnostic tests I can do now. What to prioritise?

Re: Not a straightforward pancreatitis

Anthony Dennison — Wed, 03 Jun 2015 09:44:03 GMT

Hopefully attached is a video of the episodes the dog has - seizure or pain?

www.vetsurgeon.org/.../5488.IMG_5F00_4119.MOV

www.vetsurgeon.org/.../2553.IMG_5F00_4117.MOV

Re: Not a straightforward pancreatitis

Anthony Dennison — Wed, 03 Jun 2015 08:59:25 GMT

I was thinking potentially lungworm last night (after I took the blood unfortunately.. d'oh!). Am awaiting a cortisol to come back this morning, then we'll go from there.

The blood did clot within a minute or so in the serum tube, and that was with me rolling it about for a bit to start to check if there was a coagulopathy. I know that isn't perfect, but there was clotting present.

The dog had an 'episode' whilst in the car as the owner was leaving, so she stopped to let me watch. Lasted about a minute, the right limbs tense up and retract. She seems aware and responsive, has a menace response throughout, then goes a bit wobbly - she does all this lying down. Angio snap test is the next step if cortisol comes back with nowt.

Re: Not a straightforward pancreatitis

ruths — Tue, 02 Jun 2015 18:18:35 GMT

i remember doing those- you also need to amke sure the stopper is repleaced back on the tube if you didn't go through the top to put the blood in.

Clients worry if their vet seems to be haemorrhaging from their armpit all of a sudden -))

Re: Not a straightforward pancreatitis

Rory Bell — Tue, 02 Jun 2015 18:06:31 GMT

You are right in that delays detecting coagulopathies can be dangerous. This might be going off on a tangent a bit (sorry Arlo) but for those who might be reading who have not come across this, performing a whole blood clotting time, while nowhere near as sensitive as assessing APTT / PT, is nonetheless a quick and cheap method of very rapidly figuring out whether your patient is about to bleed due to a defect in secondary haemostats (coagulation factor deficiency).

All you need is a plain glass tube with a stopper/lid and a clock. Add a few ml of your patient's blood, hold the tube in your hand / under your arm (so that it's at about 37 degrees C) and invert is every 30 seconds or so. You are timing how long it takes for the blood not to flow from one end of the tube to the other when you invert it (i.e when it clots). It should be <7minutes in a dog. Longer then this, you've got a real problem, but subclinical / emerging coagulopathies can have a normal whole blood clotting time (it's not a very sensitive test).

Not that I speak from personal experience of course, but here's a top tip. If you do this test, make sure the tube does not contain anticoagulant prior to phoning your boss in a panic at 2am.......

Re: Not a straightforward pancreatitis

ruths — Tue, 02 Jun 2015 18:00:19 GMT

lol-

I also enjoy electrolytes - sodium is a particualr favourite of mine..

Re: Not a straightforward pancreatitis

Hannah Wynne Richards — Tue, 02 Jun 2015 17:44:55 GMT

Ruths I thought I was the one who diagnosed everything as Angiostrongylus until proven otherwise.

Wynne

Re: Not a straightforward pancreatitis

ruths — Tue, 02 Jun 2015 17:40:01 GMT

I love lungworm- it is the most fascinating and perplexing disease!

I was worried that if the dog waited a bit for its coag profile, then got a lungworm test, a more significant hge might occur in the meantime. We had a (sad) but great case of a 2yo staffie with status epilepticus suddenly start to haemorrage from every orifice. It was spectacular to say the least, but very sad as it died very quickly. It didn't know anything after the second it dropped to the floor though.

I'm not sure where you are, and what wormer the dog has had so it might not be a differential at all. calcium is normal- a raised calcium could be due to lungworm too (amongst other things)

Good luck!

Re: Not a straightforward pancreatitis

Rory Bell — Tue, 02 Jun 2015 17:33:08 GMT

agreed - and that was in the back of my mind when I posted about checking for coagulopathies! Case series below from the neuro group (at the time) at the RVC

Vet Rec. 2006 Jun 24;158(25):858-63.

Brain and spinal cord haemorrhages associated with Angiostrongylus vasorum infection in four dogs.

Wessmann A1, Lu D, Lamb CR, Smyth B, Mantis P, Chandler K, Boag A, Cherubini GB, Cappello R.

Author information

Abstract

Multifocal haemorrhages associated with Angiostrongylus vasorum infection were observed in the central nervous system of four dogs with neurological signs including depression, seizures, spinal pain and paresis. In magnetic resonance images the majority of the lesions were isointense or slightly hyperintense in T1-weighted images, hyperintense in T2-weighted images and hypointense in T2*-weighted (gradient echo) images, compatible with haemorrhages more than seven days old. Lesions were found in the brain of three of the dogs and in the spinal cord of two. The cerebrospinal fluid contained high concentrations of protein and evidence of erythrophagia. All the dogs had coagulopathy and pulmonary haemorrhage of varying severity. A vasorum larvae were detected in the faeces of each of the dogs. Neural A vasorum was confirmed at postmortem examination in two dogs.

Re: Not a straightforward pancreatitis

ruths — Tue, 02 Jun 2015 17:22:17 GMT

A real quick answer here - but I've seen angiostrongylus cases having neuro signs, bleeding and non specific abdo signs. It's prob easy to rule out and would be something eminently treatable.

Re: Not a straightforward pancreatitis

Rory Bell — Tue, 02 Jun 2015 16:15:36 GMT

Hi Anthony

If the dog had an anti-inflammatory dose of dex about 72hrs ago then I'd suspect that would not be sufficient to completely suppress adrenocortical function (i.e. a flat line ACTH sim would be diagnostic for addison's). I'm not sure what the lower limit of deception is on your in house cortisol assay so I'm not sure how good it would be for diagnosing addison's disease - if the lower limit of detection is <30nmol / l then it should be fine. The IDEXX SNAP kits will work ok in that regard.

I presume glucose was ok?

If it looks like haematuria then I'd run a coagulation profile. I appreciate that coagulopathies are rare causes of haematuria but I'm trying to se if this dog's clinical signs are due to one disease or several.

cheers!

Re: Not a straightforward pancreatitis

Anthony Dennison — Tue, 02 Jun 2015 15:57:52 GMT

Thanks Rory - liver parameters were within normal limits: GGT was '<0' and TBil '<2'. Calcium was 2.19, Na:K ratio was 40 and there was no azotaemia so Addisons id low down on the list (and it is ALWAYS on my differential list now after an addisonian dog had an ex-lap when no-one had noticed the Na:K ratio, but that's another story). There were no neurological deficits, sorry; cranial nn exam was fine, not ataxic at all.

Using a dipstick, the blood appeared to be whole blood - the reagent strip went blotchy green rather than a diffuse colour, though I will look in to getting a sediment done.

The dog did have an injection of dexamethasone on the day of discharge which corresponded with the improvement... so this is a possibility. We do in house ACTH stims, would this be adequate enough?

Re: Not a straightforward pancreatitis

Rory Bell — Tue, 02 Jun 2015 14:59:04 GMT

Anthony

Just my thoughts:

The haematuria / haemoglobinuria, neck pain and ?seizure episode are all difficult to explain with pancreatitis, but it's not impossible for them to be related.

You don't mention any neurological deficits, other than depressed mentation, so I'm assuming there aren't any.

I would start by excluding extra cranial causes of neurological disease as this is where pancreatitis might be playing a part. I'd run a biochem, particularly looking at calcium, other electrolytes and glucose. Calcium dysregulation, hypoglycaemia and hypokalemia could all cause locomotor disturbance.

I'd also look at a urine sediment; is this haematuria or haemoglobinuria? If it's haematuria and there's otherwise an inactive sediment, in light of the previous thrombocytopenia, maybe this dog has a coagulopathy? Running a coagulation screen would be a very good idea at this stage as intra- or extra- dural haemorrhage could cause neck pain, although one would perhaps expect to find other neurological deficits if that was the case.

Other things worth considering would be measuring creatine kinase in case this dog has a myopathy, and a plain lateral radiograph of the neck might show changes consistent with discospondylitis or neoplasia. A resting cortisol might be useful if you get to this stage, as if it were elevated (which you would expect in an otherwise ill dog) it would exclude Addison's. Warning - anecdote alert, but I have seen some Addisonian dogs which were presented for back pain. Further anecdote - the last dog I saw with pancreatitis and neck pain turned out to have a metastatic pancreatic adenocarcinoma (that one did not end well....)

As Wynne says, you might well end up considering a MRI / CSF tap, but I'd possibly consider looking at some other things first. Apologies if you've already done some / all of the above, but even if a biochem was ok apart from markers of pancreatitis initially, I'd still repeat one now.

Hope this helps

Re: Not a straightforward pancreatitis

Hannah Wynne Richards — Tue, 02 Jun 2015 14:33:07 GMT

I always give fluids at twice normal rates if I suspect pancreatitis. The neck pain in this case would make me suggest referral, as I'd suspect maybe a spinal tap might be useful - and messing about with spines is something I tend to chicken out of.

Wynne