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Paws and Consider...

The online blog of Westside Animal Hospital — important healthcare information to help you take the best care of your pet!

Frankie's Interesting Diagnosis

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Poor Frankie was sick.  He presented to us after a three-day history of a poor appetite, diarrhea, and lethargy.  Frankie was a very nice two-year-old neutered male Mastiff (although not very happy on the day of presentation due to his illness).  Although Frankie was able to walk, he would soon flop down on the floor from weakness after just a few steps.  What could be wrong with such a young dog?  Frankie looked terrible!

frankie1On further questioning, his owner stated that Frankie was prone to dietary indiscretion (eating things he shouldn't) on occasion, although nothing specific had turned up missing from his surroundings.  He had not vomited, but he wasn't eating much either.  On physical exam, Frankie was very weak.  His gums were dry and tacky instead of moist — a clear sign of dehydration.  Nothing else noteworthy was apparent from his examination.  Because of Frankie's severe weakness, dehydration, and tendency toward dietary indiscretion, full bloodwork, abdominal X-rays, and hospitalization for IV fluid therapy were recommended.  Unfortunately, due to financial constraints Frankie's owner asked if we could just start with basic bloodwork to see where that might lead us.  The results are shown below:

 

 

Test Result Normal Range Evaluates
Glucose 48  ↓ 74 - 143 Blood sugar
Blood Urea Nitrogen
(BUN)
71  ↑ 7 - 27 Kidney function
Creatinine 2.1  ↑ 0.5 - 1.8 Kidney function
Phosphorus 12.1  ↑ 2.5 - 6.8 Kidney function
Calcium 11.9 7.9 - 12.0  
Sodium (Na) 139  ↓ 144 - 160  
Potassium (K) 6.5  ↑ 3.5 - 5.8  
Sodium:Potassium Ratio
(Na:K)
21  ↓ 27 - 40  
Chloride 109 109 - 122  
Total Protein 6.6 5.2 - 8.2  
Albumin 3.3 2.3 - 4.0  
Globulin 3.3 2.5 - 4.5  
ALT 33 10 - 100 Liver
Alkaline Phosphatase 22  ↓ 23 - 212 Liver
GGT 0 0 - 7 Liver
Total Bilirubin 0.4 0 - 0.9 Liver
Cholesterol 88  ↓ 110 - 320  
Amylase 1134 500 - 1500 Pancreas
Lipase 1104 200 - 1800 Pancreas
Packed Cell Volume
(PCV)
73%  ↑ 35 - 55 Red Blood Cell count

 The most noteworthy findings on Frankie's bloodwork were the following:

  • Hypoglycemia (low blood sugar) - Frankie's value of 48 was very low
  • Azotemia (elevated kidney values) - the BUN is disproportionately higher than the creatinine; this is often seen with dehydration.  Renal failure typically causes a proportional increase in both BUN and creatinine.  Renal failure was still possible, however.
  • Electrolyte imbalance - Frankie's potassium was high, and his sodium was low, yielding a very low Na:K ratio of 21.
  • Frankie's Packed Cell Volume of 73% was markedly elevated; this is likely reflective of dehydration.

Although this basic work-up was far from comprehensive, his history, physical exam, and bloodwork abnormalities were suggestive of a disease called Addison's Disease.

Addison's Disease (also called hypoadrenocorticism) is the condition that results when the body's adrenal glands produce inadequate amounts of cortisone.  As discussed in the previous blog post ("Cortisone"), the adrenal glands are responsible for producing continuous amounts of cortisone; the body is highly dependent on this.  When the levels of cortisone in the body are not in the correct amount and balance (either too high or too low), serious disease results.

The most suggestive abnormality on Frankie's bloodwork was his abnormal Na:K ratio.  Because adrenal hormones are responsible for keeping sodium and potassium in proper balance, the abnormal sodium/potassium levels and ratio were very suggestive that Frankie's adrenal glands were not functioning properly.  Severe dehydration, while not specific to Addison's Disease, is also a common finding.  Frankie's elevated kidney values and very high packed cell volume (along with his physical exam) were all supportive of dehydration.  Low blood sugar is also a common finding with Addison's Disease.  Many patients with Addison's Disease have a high calcium level; while Frankie's was in the normal range, you can see it was at the high end of normal.

The gold standard test for Addison's Disease is a special blood test called an ACTH Stimulation test, which was our next step with Frankie.  We started by drawing a blood sample.  We then administered an injection of Cortrosyn®— a synthetic hormone designed to stimulate the adrenal glands.  One hour later, a second vial of blood was drawn.  Both tubes of blood (the 'pre' and '1-hour post') were sent to the lab for cortisol level analysis.

Because Frankie's diagnosis was so likely to be Addison's Disease (although at this point still unproven), it was appropriate to begin treatment for it.  The ACTH Stimulation test results wouldn't be back for about 24 hours, so waiting wasn't an option.  We gave Frankie 1 liter of sodium chloride (saline) subcutaneously (under the skin).  Although the best treatment would have been hospitalization for intravenous fluid therapy, the subcutaneous option was much more affordable for Frankie's owner, and I thought it still would do Frankie a lot of good.  In addition, we gave Frankie an injection of dexamethasone — a type of cortisone.  The fluid therapy would help correct the dehydration and low sodium levels, and the dexamethasone injection would provide the much-needed cortisone that his own adrenal glands were likely not producing (and would do no harm even if it turned out he did not have Addison's Disease). 

Frankie's owner brought him back in the next morning.  He was stronger, feeling better, drinking water, and was eating canned dog food.  We repeated his dexamethasone injection.  Later that day, we received Frankie's ACTH Stimulation test results from the lab:

 
Time Result Normal Range
Pre less than 0.2 2 - 6
1-hour Post less than 0.2 6 - 18

Frankie's cortisol levels were below the lowest detectable range, and the Cortrosyn injection failed to stimulate his adrenal glands — diagnostic for Addison's Disease. 

frankie2Although Addison's Disease is quite serious (fatal if untreated), it is a highly treatable disease.  We started Frankie on an oral medication called fludrocortisone acetate — a special type of cortisone that is highly effective at regulating the sodium and potassium levels in the body.  While other cortisones such as dexamethasone or prednisone can help in the short-term, they are not the best choices long-term and have more side effects.  Addison's Disease can also be managed with monthly injections.

One week later, Frankie was the picture of health!  He was eating, active, and his bloodwork results were all back to normal.  Frankie's owners are to be commended for their loving care and commitment to him.

Even after 17 years of small animal practice, I still get excited making diagnoses such as Frankie's.  Medicine is often like detective work:  gathering all available evidence, using reasoning, eliminating certain leads, and finally catching the "bad guy."  In this case, the "bad guy" (Frankie's disease) was treatable.  Not a bad few days' work!

Comments

  • Guest
    Frankie's mom Saturday, 17 October 2015

    Almost 3 years later and Frankie is still doing great because of Dr. Fox. Earlier this year Dr. Fox diagnosed him with an enlarged heart with an abnormal heart beat. Again, because of Dr. Fox and his expertise, Frankie is doing great. His energy levels are not what they use to be, but he is a mastiff that is 5 years old with major health problem.

    The team at Westside Animal Hospital is awesome. They are always calm, cool, and collected. If I call or come in in a panick about Frankie's condition or running out of his medicine, they help me out and calm me down. Dr. Fox and his team are the best. They are the best animal hospital that I have ever been to. I cannot say enough good thing about them.

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Guest
Guest Monday, 17 December 2018

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