Case Discussion - 8year Miniature Schnauzer with lethargy

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Joyce Whitehead — Thu, 18 Jun 2020 17:50:10 GMT

That was one of my initial thoughts so I would definitely supplement the thyroid too at this stage. The liver enzymes have normalised nicely, so I’m not sure I’d be rushing to surgery. I think most of the owner’s supplementary questions would be better answered by a specialist (she said, ducking out of answering ;) )

Nice case, thanks.

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Beats — Thu, 18 Jun 2020 13:02:12 GMT

OK Julian, that's a great post to bring back up at this point.

You'd originally put that low total T4 (below the lower measurable limit at the lab) down to sick euthyroid syndrome initially (i.e. it was low because there was something else wrong with the dog in respect of cholestatic biliary disease or the like.

But remembering that as many as a third of hypothyroid dogs don't have an elevation in TSH, and that while not classic, it does have a scurfy skin coat that has not improved and is lethargic, you decided to retest the thryroid including free T4 by equilibrium dialysis

[there is an argument that doing TT4/fT4d instead of TT4/TSH in the first place if not doing all 3 bits might have been better idea]

You now have a dog whose bile acids and liver values are broadly normal, had a low normal PCV on initial sampling, has been persistently hypercholesterolemic on fasting samples even now that has respectable bile acids and liver enzymes and is fed a white fish and vegetable diet, and has fT4d and TT4 below the level that your lab can detect.

You start the dog on 50mcg Thyforon twice daily.

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Julian Earl — Thu, 18 Jun 2020 10:05:41 GMT

The elevated Alkaline phosphatase is not as sky-high as some [many!] cases go bit I would want to do an ACTH-stimulation lest for Cushing's. So I would like to know the results when you have them thanks!

Apologies just spotted this post"! Oops!

Pre-ACTH Cortisol 90.2nmol/L (50-250)

Post-ACTH Cortisol 370nmol/L (150-550)

Bile Acids 142.9 umol/L (0-10)

Total Bilirubin 5.3umol/L (0-16)

Total T4 <3.9nmol/L (10-55)

TSH 0.12ng/ml (0.01-0.6)

What happened next? Thank you.

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Beats — Thu, 18 Jun 2020 09:36:41 GMT

Sorry, Joyce, I missed your post.

You discuss the possibility of surgery with the owner and he has just a few questions, and then once he's done his due diligence on your suggestion via the internet:

https://www.youtube.com/watch?v=6sg655qsJQw

https://www.youtube.com/watch?v=HZ8X5tY3FBQ

https://www.youtube.com/watch?v=VDXQ1fo2IpU

https://www.youtube.com/watch?v=4ayNsH7XhBw

a few more questions...

While he can see the logic of a gall bladder specialist surgeon performing such a procedure if to be performed, he has questions about the case selection procedure. He would like to know what factors would lead to a decision to remove the gall bladder, and would like to know what estimate of mortality would be given for an overtly healthy dog getting this procedure done. He prioritises current life over future health and would like to know, specifically, how post-operative hypotension will be avoided as he has concerns regarding his dog's long-standing loud heart murmur.

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Beats — Thu, 18 Jun 2020 08:07:50 GMT

You schedule another fasted blood sample for a month's time. Here are your results:

ALKP 271 U/L@37C (12-83)

ALT 59 U/L@37C(13-78)

AST 37 U/L@37C (14-53)

GGT 4 U/L@37C(0.1-9.0)

GLDH 6 U/L@37C (0-6)

Total Protein 67.2 g/L (50.0-72.0)

Albumin 30.4 g/L (26.0-40.0)

Urea 11.3 mmol/L (1.7-7.4)

Cholesterol 9.8 mmol/L (2.8-8.3)

Total T4 <3.9 nmol/L (10.0-55.0)

FT4d <3.0 pmol/L (6.6-40.0)

TSH 0.09 ng/ml (0.01-0.60)

Bile acids 2.1 unol/L (0.0-10.0)

Total bilirubin 2.9 umol/L (0.0-16.0)

Triglycerides 1.83 mmol/L (0.34-1.97)

Anything else you'd like to know?

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Beats — Wed, 17 Jun 2020 22:05:31 GMT

Well your bag of Royal Canin Gastrointestinal Low Fat sits at reception uncollected and all goes quiet for 2 months.

Then we're back weighing in at 6.1kg (and looking good at this weight) having been on a white fish and vegetable diet for the last 2 months, supplemented with half a 150mg ursodeoxycholic acid tablet daily.

The coat however is still a bit dry and lacking lustre, with some thinning of the hair perhaps and a fine dry white scale still present. Humilac has been discontinued and the owner would like your advice on improving the skin /hair-coat.

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Beats — Wed, 17 Jun 2020 21:42:55 GMT

So half a 150mg ursodeoxyholic acid tablet daily and 2 weeks later you decided to bleed the dog again (fasted 16+ hours). The owner thinks the dog is a bit better already. You get these results from Idexx:

What are you thinking now?

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Joyce Whitehead — Wed, 17 Jun 2020 21:36:32 GMT

I think that as Schnauzers are prone to hyperlipidaemia, which can then lead to pancreatitis and liver disease (I think they are therefore more likely to get gall bladder mucocoeles) I’d be thinking of referring for the possibility of gall bladder surgery if thought appropriate. I think from my knowledge that these can deteriorate pretty quickly. I have border terriers and they have a high incidence so I’ve read quite a few case reports.

All depends on owner finances, choices etc of course. Possibly might be worth checking a PLI?

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Beats — Wed, 17 Jun 2020 21:06:52 GMT

That's not very fair to anyone better skilled equipped than me, but thankfully agreed to get another local practitioner with considerably more skill and experience in the field of abdominal ultrasound to take a look.

So the next Tuesday get this:

"Observations included, a dilated gall bladder with copious hyperechoic material. The liver parenchyma had a generally
homogenous appearance. Hyperechogenicity was noted aorund the common bile duct. The pancreas had a slightly
altered, corrugated appearance also."

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Beats — Wed, 17 Jun 2020 21:02:04 GMT

It's Friday now and really must phone owners, even though did say results can take a week...

Suggest a liver scan and agree to 1pm on Tuesday, fasted, with owner holding.

Always worth a look, don't know what you might find (gall bladder mucocele would be a great suggestion relevant to this case), but you're not a great ultrasonographer, sorry, I mean your ultrasound machine is not great; with a little imagination, you add the following to your clinical notes:

Basic scan only of liver area. Gall bladder has much echogenic material - probably sludge, but doesn't move much when pushed probe in and out (did not scan in few different positions to see if moved with gravity). Bile duct possibly a little distended as well but think can follow to duodenum OK without obvious obstruction. Unable to image pancreas.

Are you getting any further on in helping the dog keep up with walks with the rest of the pack?

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Tom Ward — Wed, 17 Jun 2020 20:53:18 GMT

Bile acids could be elevated with lipaemia, but seem quite high for that... I worry this dog could be a bit cholestatic and would want to rule out a gall bladder mucocele so...

Abdominal ultrasound as next step, poss LDDST depending on how the adrenals and liver look!

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Beats — Wed, 17 Jun 2020 20:13:25 GMT

It's Wednesday, results are in:

No triglycerides on this occasion to report I'm afraid, Tom, but yes I think that would have been worthwhile.

I've never personally diagnosed a case of cushings with a SG of 1.044, but I think maybe cases can rarely occur that aren't PUPD? Might be a controversial topic - I'll leave it up to anyone more knowledgeable to take this point any further.

Pre-ACTH Cortisol 90.2nmol/L (50-250)

Post-ACTH Cortisol 370nmol/L (150-550)

Bile Acids 142.9 umol/L (0-10)

Total Bilirubin 5.3umol/L (0-16)

Total T4 <3.9nmol/L (10-55)

TSH 0.12ng/ml (0.01-0.6)

Time to phone owner to report those results. Any recommendations on next steps?

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Tom Ward — Wed, 17 Jun 2020 20:08:28 GMT

Worth checking serum triglycerides too? SG of 1.044 seems weird with Cushings but a lot of other things pointing that way!

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Beats — Wed, 17 Jun 2020 19:19:36 GMT

So had a chat and came back on Tuesday morning for an ACTH stim test (fasted from 6pm Monday evening)

10.10am blood sample taken and 2ml tetracosactide injected IM

11.10am blood sample taken

Some extra blood taken on the 10.10am sample, and not noted to be grossly lipemic, but the cholesterol level still elevated on the VetTest (one nice thing about VetTest is always have plenty of spare cholesterol slides!)

Any other tests on that you want to request from the lab on that fasted pre-ACTH sample at this point?

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Beats — Wed, 17 Jun 2020 17:54:20 GMT

Not sure what features made owner think cushings most likely, probably the poor quality hair coat and lethargy.

The missing ALKP on a VetTest is a great spot, Claire - almost always means is too high to read (I think uses up all the substrate before the reaction completes? or something like that). I often just assume is very high, but in this instance I did a dilution:

ALKP = 2662 U/L

Sample is indeed quite lipemic as you suspect, Rob, but well-centrifuged, run promptly and not hemolysed.

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Rob Davis — Wed, 17 Jun 2020 16:53:20 GMT

Is the sample lipaemic?

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Claire Fisher — Wed, 17 Jun 2020 16:43:53 GMT

What makes the owner think the dog has Cushings?

Is the missing ALKP a machine error or is it too high to read? Run a dilution?

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Beats — Wed, 17 Jun 2020 16:27:21 GMT

OK. You've taken a "general screening" blood sample and promised to phone with results at end of clinic:

any further thoughts or questions before we continue?

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Beats — Wed, 17 Jun 2020 15:16:22 GMT

So you've got a urine sample (obtained while chatting to owner before examining dog):

SG (refractometer): 1.044

Dipstick (Kruuse): pH5, protein-trace, bilirubin+

Sediment: some debris present

Brief exam doesn't reveal anything obviously different from last vet's notes, the heart murmur is perhaps loudest at left heart base with stethoscope tucked up under triceps, but it radiates loud enough to left heart apex and right also, no thrill noted; is holosystolic and perhaps slightly high in pitch. No improvement noted in last 2 weeks on pimobendan. Isn't a big eater, home cooked diet with lots of tasty meat and things. Review of notes confirm murmur has been there at least 6 years. Coat condition bit poor with dry white scale dorsally and on flanks and relative hypotrichosis ventrally. No obvious back pain or abdominal pain noted; trotted out unremarkably while getting urine sample. Barks incessantly in waiting room with other dogs in it on return on way back to consult room.

RE: Case Discussion - 8year Miniature Schnauzer with lethargy

Gillian Mostyn — Wed, 17 Jun 2020 12:42:39 GMT

Full history from owner

Full clinical exam.

Act on any specific findings of history and clinical exam.

If no new findings, tell them to bring a urine sample in tomorrow for dipstick and specific gravity, and go from there.