Signalment and History: "Louie," an 8-year-old, 28 kg (62 lb) male neutered Standard Poodle, is presented for evaluation of intermittent, episodic neurologic events that have been occurring for the past three months.
The owner reports that the "spells" are becoming more frequent and severe. They typically occur in the early morning before breakfast or after a long walk. During an episode, Louie becomes acutely weak, disoriented, and stumbles as if drunk (ataxia). He will sometimes stare blankly into space, and his muscles will twitch (fasciculations). Last night, he had his first generalized seizure, which lasted about 45 seconds.
The owner provides a crucial piece of history: during the first few episodes of weakness, she panicked and rubbed some honey on his gums, and he seemed to improve dramatically within minutes. His appetite, thirst, and urination have all been normal between these events.
Physical Exam:
T: 101.5°F
P: 88 bpm
R: 20 bpm
BCS: 5/9
Louie is bright, alert, and responsive at the time of presentation. The physical examination, including a detailed neurologic exam, is completely unremarkable. He has a normal heart rate and rhythm, clear lungs, and no abnormalities on abdominal palpation. This normal presentation between episodes is a key feature of the history.
Initial Diagnostic Workup: Given the episodic nature of the signs and the owner's report of a response to sugar, Louie was admitted to the hospital for a monitored fast.
Four hours into the fast: Louie became quiet, weak, and started to tremble.
Point-of-Care Blood Glucose (AlphaTrak): A blood glucose reading was immediately taken from his ear, which registered 36 mg/dL (Profound Hypoglycemia).
Blood Sample Collection: As soon as the hypoglycemia was documented, a blood sample was drawn from the cephalic vein for a full CBC, serum chemistry panel, and a paired insulin-glucose concentration test before any treatment was administered.
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)?
Solution to Case 35 will be posted on Oct 10
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