Lethargic Boxer with flank alopecia

RE: Lethargic Boxer with flank alopecia

Anthony Dennison — Fri, 31 Jul 2015 14:03:49 GMT

[quote user="robloxley"]

[quote user="Anthony Dennison"]ACTH stim test was also normal[/quote]

There is a fair level of false negatives for an ACTH stim, and with an adrenal nodule and PUPD (what was specific gravity?) I'd reconsider Cushing's. Equally it is a 12yo boxer so a brain tumor would be high on the list :)

[/quote]

Did a urine Cortisol:Creatinine test this week: strong negative for Cushings. Ratio was 13, andything <34 would suggest Cushing's isn't an issue.

RE: Lethargic Boxer with flank alopecia

Rob Loxley — Fri, 31 Jul 2015 13:37:00 GMT

[quote user="Anthony Dennison"]ACTH stim test was also normal[/quote]

RE: Lethargic Boxer with flank alopecia

Anthony Dennison — Fri, 31 Jul 2015 08:55:06 GMT

Just had a thought about this case. One of the main issues is that the dog is massively PU/PD - she weighs 24kg, and drank 6.3l of water in 24 hours. Thats 263ml/kg.

Could this be diabetes insipidus, and everything else is just coincidental?

RE: Lethargic Boxer with flank alopecia

Silvia Maldonado — Fri, 24 Jul 2015 01:03:13 GMT

Do we realize how much do we learn from just reading?

RE: Lethargic Boxer with flank alopecia

Anthony Dennison — Thu, 23 Jul 2015 09:45:53 GMT

Report below:

Re Ruby

Quite a bit to report.

Abdomen: no effusion, liver size, shape, architecture, echogenicity, vasculature all unremarkable. Kidneys have mildly dilted pelvices but oitherwise NAD, Spleen, pancreas, guts, bladder, lymph nodes, R adrenal, major vessels all NAD. L adrenal contains a distinct nodule near the cranial pole -it is not enormous (8mm diameter).

Heart: there is moderate concentric hypertrophy of the left ventricle and septum due to valvular aortic stenosis. The valve leaflets are visibly thick. The pressure gradient across the valve is 72mmHg (=top end of moderate, fit s with degree of hypertrophy). The right heart is unremarkable. There is no evidence of CHF (no pulmonary oedema, no left atrial dilation). During a few minutes of ECG she exhibited no arrhythmias although I did detect some suspected premature beats when auscultating. ECG waveform was unremarkable.

Neck: she has a discrete hypoechoic nodule 5mm (wide) x 10mm (long) in the body of the left thyroid. Both thyroids are hypoechoic compared to the adjacent sterno-hyoideus muscle. They also look small, there are some cystic areas in the left thyroid and the calculated total thyroid volume corrected for body weight was 0.04 ml/Kg^0.75.

Conclusions:

DDx for adrenal nodule include nodular hyperplasia, adrenocortical adenoma or carcinoma or phaeochromocytoma. In the circumstance of one large adrenal and one of normal size there is the possibility of either PDHAC or functional adrenal tumour. Phaeochromocytomas aren't common but worth considering as they can cause PUPD too. If she has Cushing's then my comment would be that it doesn't look advanced -her liver isn't large and her skin isn't particularly thin. It's difficult as the onset can be very insidious.

Heart: moderate aortic stenosis implies some risk of sudden death (due to arrhythmia). However, she's got to 12 and she's not collapsing so I suspect that she'll continue to cope OK. No treatment indicated.

L thyroid/parathyroid nodule: in the circumstances (PUPD) I suspect that this is a parathyroid mass (probably an adenoma). I can't be completely sure that it's not of thyroid origin. Hyperparathyroidism would explain the degree of PUPD if she has an inionised hypercalcaemia.

Thyroids: hypoechoic thyroids with a total thyroid mass < 0.05ml/Kg^0.75 implies a high probability of hypothyroidism -see attached paper.

Recommendations:

Heart leave well alone unless collapsing or sleeping resp rate >30/minute.

Measure ionised calcium. If hight then ideally measure PTH. If confirmed high (primary hyperparathyroidism) then surgical removal of the mass is usually associated with a good prognosis as far as that particular problem goes. I'd be very interested to see any results and discuss them.

L adrenal: my plan would be ask lab to measure 17-OHP on the pre- and post-ACTH samples which they already have. That gives you another shot at getting a diagnosis of HAC. If negative then dex screening test is a further option. Or you could do a urine creatinine:cortisol -if neagtive then definitely not HAC at this point, if positive then suspicious but doesn't prove it. Depends how much you want to throw at that side of things. Alternatively wait and monitor HAC-like signs and repeat ACTH stim at some point in the future depending on how things pan out.

thyroid status: I'm really suspicious she's hypothyroid too. What were fT4 and TT4?

All a bit complex. Feel free to give me a bell if you want to discuss.

Thanks for asking me to scan her.

Ionised Calcium:

Ionised Calcium @ Ph 7.4 1.43 mmol/l 1.25 - 1.45 C

So it is at the higher end of normal - is this still worth chasing or would it normally be sky high if a parathyroid issue?

RE: Lethargic Boxer with flank alopecia

Martin Atkinson — Wed, 22 Jul 2015 18:03:09 GMT

[quote user="John Flynn"]I don't think a nodule on the parathyroid or the adrenal would be causing clinical hypothyroidism.[/quote]True. The parathyroid nodule may be incidental and there is still hypothyroidism. Unless the calcium is sky high then it is probably not an active nodule. The only parathyroid tumour I've seen was in a cat an it was presented PD/PU with hypercalcaemia and big lump in its neck!

RE: Lethargic Boxer with flank alopecia

John Flynn — Tue, 21 Jul 2015 18:42:28 GMT

[quote user="Anthony Dennison"]he found a nodule on the parathyroid and one of the adrenal glands[/quote]

[quote user="Anthony Dennison"]Well done John and Martin who said Thyroid until proven otherwise![/quote]

I don't think a nodule on the parathyroid or the adrenal would be causing clinical hypothyroidism.

[quote user="Anthony Dennison"]Apparently the dog will need surgery to remove them[/quote]

The full report should clarify things for you I suspect if there are nodules identified on those organs requiring surgical excision present.

RE: Lethargic Boxer with flank alopecia

Anthony Dennison — Tue, 21 Jul 2015 16:53:52 GMT

So an interim update on this case:

Ruby was scanned by someone who is much better at scanning (a mobile ultrasound guy called Roger Wilkinson, would highly recommend him!) and he found a nodule on the parathyroid and one of the adrenal glands - this is what my nurse has told me, I'm awaiting the report from Roger. She also has some mild aortic stenosis. Apparently the dog will need surgery to remove them, so I pass on the report when I get it!

Well done John and Martin who said Thyroid until proven otherwise!

RE: Lethargic Boxer with flank alopecia

John Flynn — Thu, 16 Jul 2015 18:13:52 GMT

[quote user="Anthony Dennison"]

*Thyroxine 16.9 nmol/L 13.0 - 51.0
(Microgenics)
*Canine Serum TSH 0.66 High ng/mL 0.00 - 0.50
*Free T4 (Immulite) 23.2 pmol/L 7.7 - 47.

*Anti-thyroglobulin NEGATIVE
antibodies

[/quote]

I'm no endocrinologist, but as a GP, I'm with Martin that I haven't ruled out hypothyroidism yet based on these.

I might be barking up the wrong tree though given all the other testing, repeating the thyroid testing might do no harm if it's 4 weeks later now or someting?

Also, I'm not sure that is a free T4 by equilibrium dialysis? Check with the lab and if not then do that next maybe. In fact, just phone the hormone lab (now http://www.nwlabs.co.uk/our-services/tests-and-profiles/thyroid/?submit=view), give them your case summary and ask them if they recommend further testing for hypothyroidism.

[quote user="Anthony Dennison"]I'm suspicious of DCM as the heart sounds quieter than I would expect[/quote]

When I've thought the heart sounds unusually quiet in the past it has surprisingly often been due to a mass. I guess if you are getting the adrenals scanned then would make sense to have the heart looked at at same time?

[quote user="Anthony Dennison"]I'm trialling her on Pardale for now[/quote]

I wouldn't expect much of a response, i'd be tempted to try a different NSAID instead if meloxicam doesn't agree rather than tramadol or paracetamol - neither of which I rate very highly as musculoskeletal analgesics.

DISCLAIMER: All the opinions of an isolated, crazy GP, so don't pay too much attention!

RE: Lethargic Boxer with flank alopecia

Anthony Dennison — Thu, 16 Jul 2015 17:22:55 GMT

I must apologise - Biochemistry wasn't unremarkable: Her Creatinine was 180, amylase and lipase were also rasied (the latter around 2200).

I've look over this dog's record so much in the past week I just skipped over the bloods without thinking!

RE: Lethargic Boxer with flank alopecia

Martin Atkinson — Thu, 16 Jul 2015 13:17:31 GMT

Despite your normal fT4, the high TSH and low normal TT4 are very suspicious. For my money this would still be hypothyroid until proven otherwise. Although it is not relevant to the clinical condition other than the lethargy. the heart needs investigation as does the need to rule in or out the possibility of an adrenal tumour,

RE: Lethargic Boxer with flank alopecia

Anthony Dennison — Thu, 16 Jul 2015 12:44:15 GMT

Sorry John Flynn, didn't want to write more of an essay than I already had:

*Thyroxine 16.9 nmol/L 13.0 - 51.0
(Microgenics)
*Canine Serum TSH 0.66 High ng/mL 0.00 - 0.50
*Free T4 (Immulite) 23.2 pmol/L 7.7 - 47.

*Anti-thyroglobulin NEGATIVE
antibodies

Increased TSH with normal T4 and Free T4 may be seen in
animals recovering from systemic diseases, following
administration of certain drugs (steroids, sulphonamides,
anticonvulsants).

I'm suspicious of DCM as the heart sounds quieter than I would expect (though she is a deep chested boxer), murmur seems to be more at the apex. She has a bad behavioural reaction to both loxicom and tramadol, so I'm trialling her on Pardale for now.

RE: Lethargic Boxer with flank alopecia

John Flynn — Thu, 16 Jul 2015 11:45:55 GMT

[quote user="Anthony Dennison"]What could be causing the flank alopecia if thyroid and adrenal function is normal?[/quote]

Cyclical flank alopecia very common in Boxers

[quote user="Anthony Dennison"]grade 4/6 systolic murmur[/quote]

Apex or base? Heart rate?

[quote user="Anthony Dennison"]is showing no other signs of CHF[/quote]

[quote user="Anthony Dennison"]is gaining weight[/quote]

[quote user="Anthony Dennison"]I am awaiting a pro-BNP level[/quote]

I wouldn't bother. Owner checking resting resp rate (+ heart rate if apex beat easy to see) at home would suffice for me here.

[quote user="Anthony Dennison"]a raised TSH but normal fT4[/quote]

Numbers please on all thyroid function testing!

[quote user="Anthony Dennison"]Ruby is a 12 year old FN Boxer, who over the past 6-8 weeks has been lethargic, is gaining weight despite being on Hills r/d.[/quote]

Any stiff / sore joints? Meloxicam trial could be a consideration but I'd like to know more about the thyroid testing first.

You'll know how suspicious you're adrenal finding is or how likely to be artifact, but certainly as Gerry says getting expert to scan would be good, both to assess adrenals as disease here certianly possible and as learning feedback for your own scanning.

RE: Lethargic Boxer with flank alopecia

Gerry Polton — Thu, 16 Jul 2015 11:21:33 GMT

Hi Anthony

I would not ignore the possible sighting of an adrenal tumour. It could be producing a gonadal hormone. I would therefore vote for the further abdominal ultrasound scan.

Gerry