Protein Losing Enteropathy

RE: Protein Losing Enteropathy

Andrew Kent — Tue, 28 Nov 2017 15:37:58 GMT

[quote user="Anthony Dennison"]

[quote user="Robin Grimmer"]

[quote user="Andrew Kent"]

Sorry to hear that Robin - maybe acute thromboembolic disease from the low protein?

Andy

[/quote]I wondered on the exact cause of death. What is the pathogenesis of the thromboembolism?

[/quote]

Some of the proteins lost are molecules like anti-thrombin etc, which puts the dog into a prothrombic state. That's the basic, I'm sure Andy will give a better explanation

[/quote]

Nope its as you said - loss of anticoagulant proteins. Seems relatively uncommon but happens from time to time.

Andy

RE: Protein Losing Enteropathy

Anthony Dennison — Tue, 28 Nov 2017 14:40:24 GMT

[quote user="Robin Grimmer"]

[quote user="Andrew Kent"]

Sorry to hear that Robin - maybe acute thromboembolic disease from the low protein?

Andy

[/quote]I wondered on the exact cause of death. What is the pathogenesis of the thromboembolism?

[/quote]

Some of the proteins lost are molecules like anti-thrombin etc, which puts the dog into a prothrombic state. That's the basic, I'm sure Andy will give a better explanation

RE: Protein Losing Enteropathy

Robin Grimmer — Tue, 28 Nov 2017 14:06:41 GMT

[quote user="Andrew Kent"]

Sorry to hear that Robin - maybe acute thromboembolic disease from the low protein?

Andy

[/quote]I wondered on the exact cause of death. What is the pathogenesis of the thromboembolism?

RE: Protein Losing Enteropathy

Andrew Kent — Tue, 28 Nov 2017 13:52:54 GMT

Sorry to hear that Robin - maybe acute thromboembolic disease from the low protein?

Andy

RE: Protein Losing Enteropathy

Robin Grimmer — Tue, 28 Nov 2017 12:18:34 GMT

Thanks for the advice. Unfortunately the dog died suddenly last night.

RE: Protein Losing Enteropathy

Andrew Kent — Mon, 27 Nov 2017 13:11:21 GMT

Hi Robin,

I think in these circumstances it is reasonable to take the pragmatic approach and treat for the treatable as long as the owner understands that we can't exclude a neoplastic cause in which case the dog may just continue to deteriorate.

I would likely start immunosuppression (pred +/- chlorambucil) plus B12 injections (or oral supplementation) and a novel protein/hydrolysed diet.

Andy

RE: Protein Losing Enteropathy

Anthony Dennison — Mon, 27 Nov 2017 10:05:34 GMT

I've got a PLE case I've been dealing with for about the last 5-6 months (if you search the forum for 'PLE' you'll find the thread).

I had the dog on pred and chlorambucil which did have a positive effect, however the owner wasn't the easiest and kept googling things to add in and what to feed the dog so it's been a struggle!

Dog is now on 1mg/kg prednisolone/day, spironolactone and furosemide when the ascites gets bad. Has a bit of a natural variation, has a few bad days, but generally is doing a lot better. Back in August he was almost euthanased but rebounded so well.

RE: Protein Losing Enteropathy

Robin Grimmer — Mon, 27 Nov 2017 08:23:36 GMT

[quote user="Andrew Kent"]

Hi Kate,

I agree with Gerry's concerns about potential neoplasia in this breed, but in answer to your original question and assuming this was a PLE:

Liverpool published some work recently to show that prednisolone and chlorambucil was a better combination than prednisolone and azathioprine in dogs with PLE in terms of response and survival so I now use that as my preferred immunosuppressive combination.

I would add metronidazole as well - whilst not necessarily supported by evidence anecdotally some dogs are better controlled with this in addition.

I would also use a diet that is both low fat and hydrolysed to cover for both lymphangiectasia and potential food-related disease - Purina HA is really the only diet that ticks both these boxes.

If she is polyphagic have you checked for concurrent EPI?

Hope that helps,

Andy

[/quote]

Found this thread as I have a cass of PLE at the moment. 9yo male JRT, second opinion. Clinical signs are weight loss, diarrhoea. Haematology shows mild non regenerative anaemia, inflammatory leucogram. Biochemistry shows severe hypoproteinaemia. ALB 12, GLOB 17 TP 29, cholesterol low, Ca low due to the low albumin. Pending faeces analysis.

Funds are limited, would like to do tli, fol, b12 but not sure if they can do this. Also ultrasound. How useful would this be and would it change anything? Was thinking of trialling preds and diet, poss chlorambucil as above and poss b12 injections. Any ideas/contributions welcome. Biopsies a no no.

Re: Protein Losing Enteropathy

mariette asselbergs — Tue, 30 Jun 2015 17:25:11 GMT

I wished we could start some sort of coordinated campaign to make post mortems more acceptable to owners and more routine for vets. Isn't it weird that in human medicine any unexplained death will be followed by a PM, and we as vets are not allowed/struggle with owners who don't see the point and refuse it? Not just in small animals, 800 000 cattle are culled every year and only 1% is PM'ed! How do we possibly know what is going on????

Mariette

(having depended most of my life on doing PM's or working on the samples collected by our field staff)

Re: Protein Losing Enteropathy

Kate Richardson — Sun, 28 Jun 2015 14:28:37 GMT

Euthanased on Wednesday, O decided against post mortem sampling, so sadly will never know for certain what the underlying pathology was. I would have liked to give the treatment a bit longer as the dog was still waggy tailed and eating, but the owner had made his mind up, and afterall he is the one who lives with the dog, not me.

Re: Protein Losing Enteropathy

Kate Richardson — Wed, 24 Jun 2015 18:48:34 GMT

Thanks Gerry. I'll post the results if he agrees to the post mortem.

Re: Protein Losing Enteropathy

Gerry Polton — Wed, 24 Jun 2015 18:46:59 GMT

Bone marrow. Probably won't tell us anything but it would be nice to have it and then we wouldn't have to wonder whether it would have told us anything.

Gerry

Re: Protein Losing Enteropathy

Kate Richardson — Wed, 24 Jun 2015 18:21:04 GMT

Update- We discussed the possibility of histiocytosis and he has declined fnas of liver and spleen and has elected to have Megan euthanased as he feels she is slowly deteriorating and doesn't want to prolong things as doesn't want to pursue treatment for histiocytosis if confirmed and isn't responding so far to treatment for PLE, and doesn't want to trial alternative treatments (has only been on azathioprine for 5 days, weight stable, but also has diarrhoea now). So have sent him home with metronidazole to try to improve the diarrhoea until Friday (hoping in vain for a miraculous improvement in 2 days, me not the owner). I have discussed post mortem sampling with him and he is considering it. Other than intestine/any enlarged lymph nodes/liver and spleen, are there any other samples I should consider?

Re: Protein Losing Enteropathy

Kate Richardson — Sun, 21 Jun 2015 20:40:31 GMT

Thanks Andrew. TLI was normal.

Re: Protein Losing Enteropathy

Andrew Kent — Sun, 21 Jun 2015 19:17:26 GMT

Hi Kate,

I agree with Gerry's concerns about potential neoplasia in this breed, but in answer to your original question and assuming this was a PLE:

I would add metronidazole as well - whilst not necessarily supported by evidence anecdotally some dogs are better controlled with this in addition.

I would also use a diet that is both low fat and hydrolysed to cover for both lymphangiectasia and potential food-related disease - Purina HA is really the only diet that ticks both these boxes.

If she is polyphagic have you checked for concurrent EPI?

Hope that helps,

Andy

Re: Protein Losing Enteropathy

Silvia Maldonado — Sun, 21 Jun 2015 03:16:46 GMT

Sure! very intriguing

Re: Protein Losing Enteropathy

Kate Richardson — Fri, 19 Jun 2015 18:38:25 GMT

Absolutely.

No, not leading me up the garden path Gerry, I suspect owners won't elect to try treating histiocytosis so they may decline testing, but equally they may want to know to help them make a decision. Otherwise It will be continue with current regime and wait and see. I guess the polyphagia points me towards PLE, but I was unaware of histiocytosis in this breed, and a very important consideration. If we continue to deteriorate I will see if they would be willing to allow some post mortem sampling.Thanks all.

Re: Protein Losing Enteropathy

Hannah Wynne Richards — Fri, 19 Jun 2015 18:37:34 GMT

Cross reference to thread on CPD. Time spent on vetsurgeon should count towards CPD hours.

Wynne

Re: Protein Losing Enteropathy

Martin Atkinson — Fri, 19 Jun 2015 17:57:37 GMT

This is a supreme example of the value of this forum. Where else would you get such insight and expert opinion so quickly? Keep us posted Kate.

Re: Protein Losing Enteropathy

Gerry Polton — Fri, 19 Jun 2015 17:46:38 GMT

Wow! That's low. I still suspect histiocytic neoplasia but I can totally see why you expected PLE. Prognosis is poor, you are right, even with lomustine chemotherapy. There's another agent, liposomal clodronate but it has to be imported from the US and that usually takes too long to be useful. I hope I am not leading you up the garden path with this one.

Gerry

Re: Protein Losing Enteropathy

Kate Richardson — Fri, 19 Jun 2015 17:43:19 GMT

Thanks Gerry. Very healthy haematology picture approx 4 weeks ago when I first started investigating her. Just hypoproteinaemic and low b12

                          HAEMATOLOGY
RBC                        7.24        x10^12/L       (5.0 -8.5 )
Hb                         17.7        g/dl           (12.0 -18.0 )
HCT                        50.7        %              (37.0 -55.0 )
MCV                        70.0        fl             (60.0 -80.0 )
MCH                        24.4        pg             (19.0 -26.0 )
MCHC                       34.9        g/dl           (30.8 -37.0 )
RDW                        13.8        %              (12.9 -17.8 )
Platelets                  384         x10^9/L        (160 -500 )
WBC                        9.57        x10^9/L        (6.0 -15.0 )
Neutrophils                6.69        x10^9/L        (3.0 -11.5 )
Lymphocytes                1.52        x10^9/L        (1.0 -4.8 )
Monocytes                  0.92        x10^9/L        (0.0 -1.3 )
Eosinophils                0.41        x10^9/L        (0.0 -1.25 )
Basophils                  0.03        x10^9/L        (0.0 -0.2 )
Reticulocyte %             1.4         %
Reticulocyte count         101.36      x10^9/L
Platelet comment           Platelet count appears normal in film
RBC comment                Slight polychromasia
Leukocyte comment          Leukocyte morphology unremarkable

Total protein            * 28          g/L       Low (54.0 -77.0 )
Albumin                  * 12          g/L       Low (26.0 -40.0 )
Globulin                 * 16          g/L       Low (20.0 -47.0 )

B12 164

If it is histiocytosis, poor prognosis? even with chemotherapy? have scanned our books here but limited info.

Re: Protein Losing Enteropathy

Gerry Polton — Fri, 19 Jun 2015 17:34:50 GMT

I would definitely go for the liver and spleen aspirates. I've heard of it hiding in the bone marrow but never found it there when I couldn't also find it elsewhere. Check that with hindsight there aren't any cytopenias on the blood you already have but I wouldn't bother repeating blood evaluations.

Gerry

Re: Protein Losing Enteropathy

Kate Richardson — Fri, 19 Jun 2015 17:20:02 GMT

[quote user="Anthony Dennison"]

[quote user="Kate Richardson"]4yo FN Bernese mountain dog[/quote]

[quote user="Kate Richardson"](weight 28kg)[/quote]

That seems VERY light for a Bernese Mountain Dog!

[/quote]

It is! Sorry, I didn't mention extreme weight loss in the initial post.

Re: Protein Losing Enteropathy

Kate Richardson — Fri, 19 Jun 2015 17:18:31 GMT

Sorry, 20mg pred bid, not 20mg/kg!

That's really interesting Gerry, her owner phoned me after I had posted on here to say he had spoken to the breeder who told him her litter mate died at the age of 4 from histiocytosis apparently. Nothing seen on blood film examination and abdominal organs all normal on ultrasound, but I assume this doesn't rule it out? Should I consider liver/spleen aspirates? repeat blood smear?

Re: Protein Losing Enteropathy

Gerry Polton — Fri, 19 Jun 2015 17:12:56 GMT

Hi Robin

[quote user="Robin Grimmer"]

Out of interest, what's the youngest Bernese MD you've seen with malignant histiocytosis? I guess 4 isn't young for a Bernese MD.

[/quote]I don't honestly know the answer to that one but I suspect it is 2 or 3 years old.

Gerry