Advice needed - hypokalaemia in a beagle

RE: Advice needed - hypokalaemia in a beagle

David Mills — Mon, 04 Jun 2018 23:32:43 GMT

Keep us posted!

RE: Advice needed - hypokalaemia in a beagle

Gillian Mostyn — Mon, 04 Jun 2018 23:21:07 GMT

Just NSAIDS. We have decided if she relapses again we'll probably reach for the preds.

RE: Advice needed - hypokalaemia in a beagle

David Mills — Mon, 04 Jun 2018 23:07:19 GMT

[quote user="Gillian Mostyn"]

She was referred on Tuesday, after improving a little on NSAIDS, but despite further investigations, she remains stubbornly 'normal' on all tests.

I'll let you know if we ever do get to the bottom of this frustrating PUO! She continues to gradually improve!

[/quote]

What is she on now, out of interest? I wonder whether preds are now in the offing?

RE: Advice needed - hypokalaemia in a beagle

Liz Barton — Mon, 04 Jun 2018 22:30:53 GMT

[quote user="Gillian Mostyn"]I'll let you know if we ever do get to the bottom of this frustrating PUO![/quote]

Yes - please do! I referred a dog once because of intermittent, severe abdominal pain, which persisted despite all our in house efforts and an ex lap. He came back after every test under the sun with the 'diagnosis' of 'intermittent abdominal pain syndrome'... He belonged to one of our VNs and for the rest of his long, happy life he had occasional intermittent tramadol-responsive colic!

Just when we thought we knew it all there are still these cases which defy diagnosis and end up with a syndromic descriptor instead! Yours is obviously a very different case, and i hope you collectively get to the bottom of it with your Beagle.

RE: Advice needed - hypokalaemia in a beagle

Gillian Mostyn — Mon, 04 Jun 2018 22:19:09 GMT

She was referred on Tuesday, after improving a little on NSAIDS, but despite further investigations, she remains stubbornly 'normal' on all tests.

I'll let you know if we ever do get to the bottom of this frustrating PUO! She continues to gradually improve!

RE: Advice needed - hypokalaemia in a beagle

Anthony Todd — Mon, 28 May 2018 23:38:54 GMT

[quote user="Liz Barton"]What a frustrating case! Looking at the persistent leucocytosis and neutrophilic/monocytic inflammation I just wonder if there's a migrating FB somewhere in this dog - one of those annoying ones that bursts out months after initially entering the body.[/quote]

Yes that's the way it looks to me too, [and reading the stories in the lollipop stick, and worse, thread]..........

If it was mine, I'd try and find some signs of a painful abdomen and do a quick ex lap, having a look at the uterine stump etc. as well as everything else. At least you can then completely eliminate anything abdominal and/or even take a biopsy of anything suspicious, might even find a cocktail stick.....

Even with a penetrating ingested cocktail stick etc you'd probably get an temporary improvement with corticosteroids, even given alone.

I don't think the urine SG is anything abnormal as the dog probably is just drinking more than usual??

RE: Advice needed - hypokalaemia in a beagle

Liz Barton — Mon, 28 May 2018 23:02:02 GMT

[quote user="Gillian Mostyn"]Because this dog is only 2 years old. You may, indeed, be correct and this dog may need corticosteroids for the rest of its life[/quote]

What a frustrating case! Looking at the persistent leucocytosis and neutrophilic/monocytic inflammation I just wonder if there's a migrating FB somewhere in this dog - one of those annoying ones that bursts out months after initially entering the body.

Did the referrals rule out any UTI/renal pathology? SDMA test perhaps - SG does seem low despite sick dog.

RE: Advice needed - hypokalaemia in a beagle

Gillian Mostyn — Mon, 28 May 2018 11:27:55 GMT

OK Anthony. Thanks for your advice.

RE: Advice needed - hypokalaemia in a beagle

Anthony Todd — Mon, 28 May 2018 11:18:09 GMT

[quote user="Gillian Mostyn"]We know antibiotics and corticosteroids 'cure' this dog for a short period of time. What we don't know is why.[/quote]

As far as I understand these are given either together or with concurrent pain relief so the response is therefore difficult to assess.

Given singly with pain relief only if necessary may help decide which way the treatment should go and help with a possible diagnosis, while you wait.

PS and try a B/S antibiotic that hasn't been tried before??

RE: Advice needed - hypokalaemia in a beagle

Gillian Mostyn — Mon, 28 May 2018 10:45:10 GMT

[quote user="Anthony Todd"]as, the diagnostician is away[/quote]

They aren't. I spoke to her on Saturday and she is on call all weekend. She is more than happy to see the dog, but can't get the labs run until Tuesday, so the dog is likely to be happier at home until then.

[quote user="Anthony Todd"]all you can do as far as diagnosis or treatment is concerned is to try various drugs[/quote]

The problem is that this dog has received all these 'various drugs' and does indeed get better, but presumably by masking the symptoms...not finding the underlying condition.

[quote user="Anthony Todd"]Even with advanced accurate and specific diagnosis [except surgery?] you are still limited to the same therapeutic drugs that are available before the promised diagnosis, so why not try them logically and sequentially while you are waiting, [/quote]

Because this dog is only 2 years old. You may, indeed, be correct and this dog may need corticosteroids for the rest of its life. But, equally, it may not. I think that rather than just guesswork, if possible the owners want a diagnosis. If I were the owner, I would also want to know.

[quote user="Anthony Todd"]using pain relief only as and when needed as an diagnostic or, better, therapeutic indicator.[/quote]

Indicator of what though? We know antibiotics and corticosteroids 'cure' this dog for a short period of time. What we don't know is why.

Anthony...if you got ill every 2 months, but the doctor just kept giving you symptomatic treatment, wouldn't you expect, at some point, to be admitted for further investigation?

RE: Advice needed - hypokalaemia in a beagle

Anthony Todd — Sun, 27 May 2018 23:51:21 GMT

[quote user="Gillian Mostyn"]I don't understand what you mean.[/quote]

Sorry, not trying to be a smart-arse, but as, the diagnostician is away, all you can do as far as diagnosis or treatment is concerned is to try various drugs.

Even with advanced accurate and specific diagnosis [except surgery?] you are still limited to the same therapeutic drugs that are available before the promised diagnosis, so why not try them logically and sequentially while you are waiting, using pain relief only as and when needed as an diagnostic or, better, therapeutic indicator.

RE: Advice needed - hypokalaemia in a beagle

Gillian Mostyn — Sun, 27 May 2018 21:33:41 GMT

[quote user="Anthony Todd"]Why not just give the ABs[/quote]

Because she's just finished a long course of antibiotics....and she's still ill.

[quote user="Anthony Todd"] and add the pain relief only if she is uncomfortable or and/taper the analgesics off after 12 hrs say?[/quote]

She is uncomfortable. She will receive analgesics only as long as they're needed.

[quote user="Anthony Todd"]You may get even better "diagnostics"even before the referral surgeon comes back which gives you a better indication than some change in blood value.[/quote]

I don't understand what you mean. This dog has been ill on and off since last year. (As my original post documents). She has had lots of symptomatic treatment, but keeps deteriorating again. Like you suggest, sometimes treating the symptoms is enough, and is what most vets do most of the time. But even the nicest client is going to get cheesed off if I keep just giving her meds and it keeps happening again and again...

[quote user="Anthony Todd"]

I am, again, reminded of the Modern Veterinary Practice cartoon of the day with the client's saying,

"I just want my dog to get better doc., so skip the blood tests" which I think most clients would still agree with today, if they had a choice.

[/quote]

I know you're just trying to be helpful Anthony, but please remember that I am an experienced vet and am only posting about it here because this case is unusual.

RE: Advice needed - hypokalaemia in a beagle

Anthony Todd — Sun, 27 May 2018 16:54:34 GMT

[quote user="Utlendigur"]You were quite lucky that "extreme flexion" of your disc lesion didn't result in paralysis - if it was a disc lesion[/quote]

I should have said "unless pain at which point I obviously stopped". Normal dogs tolerate it well, even to extreme.

[quote user="Utlendigur"]Just because symptom A can be seen caused by condition B does not make a diagnosis[/quote]

I just always got them better and within 24 hours which seemed good enough for me way back then.

If they weren't I/we thought again and sometimes GA and Xray but I can't remember too many failures.

I am, again, reminded of the Modern Veterinary Practice cartoon of the day with the client's saying,

"I just want my dog to get better doc., so skip the blood tests" which I think most clients would still agree with today, if they had a choice.

RE: Advice needed - hypokalaemia in a beagle

Utlendigur — Sun, 27 May 2018 13:41:40 GMT

[quote user="Anthony Todd"]phenylbutazone [you won't know it][/quote]

Actually I do remember bute does that make me a dinovet?

[quote user="Anthony Todd"]

Easy to diagnose [so I thought] with extreme neck flexion or extension and obvious pain.

I just called them "disc lesions"

[/quote]

You were quite lucky that "extreme flexion" of your disc lesion didn't result in paralysis - if it was a disc lesion

Just because symptom A can be seen caused by condition B does not make a diagnosis

RE: Advice needed - hypokalaemia in a beagle

Anthony Todd — Sun, 27 May 2018 13:25:36 GMT

[quote user="Utlendigur"]Any neurological signs or neck pain[/quote]

Sorry just read up on this and recall I used to see many dogs with "simple" but very painful on neck hyperflexion or extension...... Often as second opinions.

Easy to diagnose [so I thought] with extreme neck flexion or extension and obvious pain.

I just called them "disc lesions" and they always resolved with steroids, phenylbutazone [you won't know it] and no jumping off sofas???

How do modvets differentially diagnose these acute symptoms these days??

RE: Advice needed - hypokalaemia in a beagle

Anthony Todd — Sun, 27 May 2018 12:35:00 GMT

[quote user="Gillian Mostyn"]We are just keeping her comfy until she has her diagnostics. [/quote]

Why not just give the ABs and add the pain relief only if she is uncomfortable or and/taper the analgesics off after 12 hrs say?

You may get even better "diagnostics"even before the referral surgeon comes back which gives you a better indication than some change in blood value.

Also it's obvious and free....

Easy to do, even on a bank holiday?

RE: Advice needed - hypokalaemia in a beagle

Gillian Mostyn — Sun, 27 May 2018 12:01:54 GMT

[quote user="Beats"]young beagle and i think steroid-responsive meningitis-arteritis first.[/quote]

Absolutely.

[quote user="Beats"]cisternal magnum tap when not on steroids [/quote]

Was normal (but had received steroids) ... plan is to repeat on Tuesday.

[quote user="Beats"] baseline CRP,[/quote]

Was the only abnormal result from previous investigation...high.

[quote user="Beats"]agree decent course of antibiotcs and NSAID first as a diagnostic trial sounds sensible[/quote]

Yes...but has come back.

It is just the bank holiday slowing things down.

[quote user="Anthony Todd"]Just to be clear [to me] has a stumpuloma/pyo been positively ruled out and not just "not confirmed".....?[/quote]

Yes.

[quote user="Anthony Todd"]Surely NSAIDs just mask any signs so don't help diagnosis?[/quote]

Absolutely. We are just keeping her comfy until she has her diagnostics. (The referral surgeon is available, but lab back-up isn't.)

RE: Advice needed - hypokalaemia in a beagle

Anthony Todd — Sun, 27 May 2018 11:26:56 GMT

Just to be clear [to me] has a stumpuloma/pyo been positively ruled out and not just "not confirmed".....?

Surely NSAIDs just mask any signs so don't help diagnosis?

RE: Advice needed - hypokalaemia in a beagle

Beats — Sun, 27 May 2018 10:43:52 GMT

young beagle and i think steroid-responsive meningitis-arteritis first.

cisternal magnum tap when not on steroids before restarting and baseline CRP, then monitor response to steroids if restarting (won't be affected by steroids same way as wbcs will) to see if inflammation resolving or not at doses used?

agree decent course of antibiotcs and NSAID first as a diagnostic trial sounds sensible

RE: Advice needed - hypokalaemia in a beagle

Gillian Mostyn — Sat, 26 May 2018 14:14:17 GMT

[quote user="Kate Richardson"]Thanks for the update. Out of interest, how do the owners feel about this- are they happy to have ruled out something sinister, or miffed to have gone through all of that and not have a diagnosis. Not criticising, genuinely interested.[/quote]

Sorry for delay...I hadn't spoken to the owners....until today!

They are fine. They were made fully aware from the beginning that this could be as frustrating for the vets as much as it is them, and they are grateful for all the attempts at finding the answer!

The patient had been doing well, and had been off the antibiotics for a few days, but started deteriorating again yesterday. She is now pyrexic and very unhappy again, but possibly is showing some back and neck pain. The referral centre is keen to have her back for more scans, cardiac echo and blood cultures, but her timing (bank holiday weekend ) is awful! We're hoping to keep her stable on NSAIDS over the weekend and she's booked in for everything on Tuesday.

Will keep you posted...

RE: Advice needed - hypokalaemia in a beagle

Liz Barton — Sun, 13 May 2018 01:07:24 GMT

[quote user="Gillian Mostyn"]Just a quick update for those who were kind enough to offer advice:[/quote]

Thanks for this - just read the whole thread and was wracking my brains.... some things remain a glorious mystery even with all the modern diagnostics. I really hope this little dog recover from it's PUO and never looks back!

RE: Advice needed - hypokalaemia in a beagle

Anthony Todd — Fri, 11 May 2018 09:59:51 GMT

Just interested as I've seen a few stump granulomas and would have thought they'd be visible on ultrasound, even if vague on X-ray.

Some of them were asymptomatic too.

Some of them we've even been able to palpate, I seem to recall, and I think some of them were actually removed??

Would fit this history, IMHO, and some turned out to be a sort of pyo in the remaining uterine horn remnant.

RE: Advice needed - hypokalaemia in a beagle

Kate Richardson — Thu, 10 May 2018 21:47:02 GMT

Thanks for the update. Out of interest, how do the owners feel about this- are they happy to have ruled out something sinister, or miffed to have gone through all of that and not have a diagnosis. Not criticising, genuinely interested.

RE: Advice needed - hypokalaemia in a beagle

Gillian Mostyn — Thu, 10 May 2018 19:52:48 GMT

Just a quick update for those who were kind enough to offer advice:

The beagle was rechecked by my colleague at the weekend with no reduction in the pyrexia, but still with no other symptoms beyond general malaise. The vet who saw her felt a referral was needed and she was seen by a large referral centre on Tuesday. She had very many diagnostics, including lumbar puncture, and all came back normal!

She has therefore come back to us with a diagnosis of PUO .... and a long course of synulox.

It is great that nothing nasty has been found....and I'm very happy that I hadn't actually missed anything! But we'll have to see how she goes.. there has just been a small improvement so far.

RE: Advice needed - hypokalaemia in a beagle

Gillian Mostyn — Fri, 04 May 2018 07:17:19 GMT

Thanks David.

[quote user="David Mills"]I think it was Ian Ramsey who said if in doubt give a decent course of Vitamin S (synulox) and wait and see.[/quote]

Fingers crossed!

[quote user="David Mills"]Personally wouldn't go hunting for anything just yet.[/quote]

Oh good. With no specific symptoms at all, it is hard to know where to start!

[quote user="David Mills"]Discospondylitis is apparently a fairly common cause of puo.[/quote]

Interesting. Excuse my ignorance, but would you not normally expect some signs of pain with this?

I know that as a young beagle, this is likely to just be coincidental illnesses. I was just concerned about seeing the same puo issue a few times in 6 months and missing something....