A Case A Week for Veterinarians
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Monday, November 3, 2008
Case 1
A 9-year old neutured male Wirehaired Dachsund was presented to AcaseAweek Clinic with history of lethargy, generalized bilateral symmetrical alopecia of increasing severity, potbellied appearance and complaint of polyuria/polydipsia for one month duration. The patient is current on vaccinations, heartworm preventative, de-worming, and flea and tick control.

Physical Exam:
T: 102.8
P: 100
R: 32
MM: pink/moist
CRT <2

Bilateral symmetrical alopecia, rat-tail, comedones over ventrum, bruising on left lateral thorax. Potbellied abdomen, weakness, muscle wasting (esp. semitendinous, semimembranous muscles).

CBC and Biochemistry: all values within reference range

Urinalysis:
Color : pale yellow
pH : 8.0
SG (refractometer): 1.015, SG (dipstick): 1.010 [1.015-1.060]
Protein (dipstick): 2 + (100-300 mg/dL) [negative-trace]
Blood (Dip stick): Moderate
Sediment exam: small number of cocci


What will be your tentative and differential diagnosis?
What further diagnostic test(s) you will perform to confirm your diagnosis?
What will be your treatment plan(s)?

Post your answers in the comments section of this site.

posted by Dr Banga's Websites @ 12:00 AM  
4 Comments:
  • At November 3, 2008 at 6:25 AM, Blogger Irene Arboleda said…

    Hyperadrenocorticism aka Cushing's Disease

    Differentials: SLE, Hyperparathyroidism, Nephrogenic Diabetes, Hypoparathyroidism

    Diagnostic Tests:

    UCCR – Urine Cortisol/Creatinine ratio
    a. Sensitive – can give false positive results
    b. Normal results: rules out
    Cushings
    c. Incr results: requires LDDS test to confirm

    2. ACTH Stimulation
    a. Identifies 80-85% dogs w/ Cushings
    b. Get exaggerated response to ACTH if dog has Cushings
    i. Like UCCR: some dogs w/ severe, NON adrenal disease can also have an exaggerated response to ACTH
    ii. 15-20% Cushings dogs have a normal response (& need LDDS)

    3. TEST of CHOICE
    LDDS – Low-dose dexamethasone suppression test
    a. Give Dexamethasone
    i. Normal dogs: suppress cortisol levels for 8 hrs
    ii. Cushing dogs: No decrease in cortisol levels

    i. DDX Pituitary Dependent Hyperadrenocorticism (PDH)
    ii. TEST: HDDS – High-dose dexamethasone suppression

    ii. Desmopressin Test - new, to differentiate pituitary from adrenal dependent

    Treatment:

    i. If an adrenal tumor is identified, surgical removal may be a viable option esp. that 80% of Cushing's is of pituitary type

    ii. Lysodren (Mitotane) is a treatment for pituitary dependent Cushing's

    iii. Trilostane - newer, more expensive but doesn't have the side effects of Mitotane.
    References: Merck, Zuku Notes

     
  • At February 24, 2013 at 8:39 PM, Anonymous Daniel Vesselinov said…

    Well,...
    I concur fully with Irene Arboleda in regards Tentative Diagnosis and Tests etc . SLE can hardly be a Differential in this case though!!! Some people would consider it differential in nearly any canine skin disease :-)... but the most common signs of SLE are a non-erosive POLYARTHRITIS (an arthritis that affects several joints !),LAMENESS and PROTEINURIA! This patient is with hematology in normal range / SLE often comes with decreased platelet and white blood cell count too, immune mediated hemolytic anemia (IMHA)/. No mention of any lameness or any other signs ...
    And I may add on Tumors and Hepatic Failure as differentials

     
  • At March 5, 2014 at 6:31 PM, Blogger Dr Mack said…

    tentative diagnosis: hyperadrenocorticism

    other differentials:
    -Nefrogenic/central diabetes insipidus
    -psychigenic diabetes insipidus
    -UTI
    -Urolithiasis
    - SLE-
    -Paraneoplastic syndromes/or neoplasia
    -Infectious (rickettsial and fungal)
    Less likely:
    -glomerular dz
    - Hypothyroidism (not PU/PD)
    -Hypoadrenocorticism (not PU/PD)

    Further diagnostics in chronologic order:

    -ACTH stem
    -UCCR
    -Low dose Dex
    -High dose Dex
    -AbdominaL RADS AND US
    -URINE CULTURE( CONCURRENT UTI COMMON)

    You would only proceed if not Cushing's

    -Snap 4 DX
    -UPCR
    -Water deprivation test + ADH
    - T4
    -serology infectious dz
    - Thoracic rads (look for neoplasia)
    -Skin biopsies
    ANA titers

    RX Cushings:
    -Mitotane or
    -Trylostane

    Adrenalectomy (for FAD)

    Comments: Good case showing that not every cushioned dog has changes in bloodworm( hypercholesterolemia, low BUN, the infamous STRESS LEUKOGRAM, and elevated ALP. which are classical changes mentioned in many references and seen in many cases.

    Daniel I partially agree with you. However I would still listed SLE not only because of skin issue but also because of the proteinuria.
    A classic SLE will have lameness as clinical sign. As far as for WBC, may be increased or decreased, PLT may be decreased or normal. I would think in this case SLE is unlikely, but I wouldn't rule it out until you have rull out all other differentials. This case is a typical example that things just don't always read the book.

     
  • At March 5, 2014 at 6:42 PM, Blogger Dr Mack said…

    Just to add to final comments:
    Daniel I think you could list hepatic failure

    However I think this more even than SLE would be a very unlikely scenario:

    Liver DZ with normal BUN, albumin, bilirubin, and liver enzymes, and no other changes in PLT, WBC, RBC showing some king inflammatory process going on (like an hepatitis)???

    So that would be in the very bottom of list of differentials.

    -Bile acids/liver panel could be performed to rull that out in any case.

     
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