History
A 2-year-old, spayed female Alaskan malamute weighing 68 pounds was presented on an emergency basis for evaluation of vomiting, lethargy, and ataxia. The night prior to presentation the dog vomited multiple times and appeared uncoordinated and ataxic. The morning of presentation she had not eaten and was unable to rise. The dog had been treated by another veterinarian a week prior for presumptive gastroenteritis, with clinical signs of lethargy, hematochezia, inappetence, and restlessness. In-hospital therapy had included metronidazole, a single dose of carprofen, maropitant, intravenous fluids, and a bland diet. Blood analysis from the primary veterinarian revealed elevated liver values, azotemia, electrolyte abnormalities, and hypoglycemia:
- Total protein: 7.8 g/dL (range, 5.0–7.4)
- Globulin: 4.2 g/dL (range, 1.6–3.6)
- Aspartate aminotransferase: 864 U/L (range,15–66)
- Alanine aminotransferase: 177 U/L (range,12–118)
- Alkaline phosphatase: 3 U/L (range, 5–131)
- Blood urea nitrogen: 63 mg/dL (range, 6–31)
- Creatinine: 3.2 mg/dL (range, 0.5–1.6)
- Phosphorus: 10.2 mg/dL (range, 2.5–6.0)
- Glucose: 66 mg/dL (range, 70–138)
- Calcium: 12.6 mg/dL (range, 8.9–11.4)
- Potassium: 7.7 mEq/L (range, 3.6–5.5)
- Sodium: 135 mmol/L (range, 139–150)
- Amylase: 1467 U/L (range, 290–1125)
- Lipase: 936 U/L (range, 77–695)
- Creatine phosphokinase: 23,682 U/L (range, 59–895)
Imaging
- Abdominal radiography: unremarkable
- Skull radiography: unremarkable (Dog had vocalized when her mouth was touched and had been reluctant to play with toys.)
- Abdominal ultrasonography: unremarkable
PRESENTATION 1
Physical Examination
The dog was quiet but alert/responsive and had tacky gingivae with a capillary refill time of about 2.5 seconds. No heart murmur was noted, but bradycardia (68 bpm) was present; pulses were moderate and synchronous. She was ambulatory but exhibited weakness when rising and fell when walking. Stools were normal with no melena or hematochezia. The rectum was dilated and dry. Findings of the examination were otherwise unremarkable.
Diagnostics
- Blood analysis
- Glucose: 66 mg/dL (range, 60–115)
- Sodium: 127 mmol/L (range, 139–150)
- Potassium: 9.0 mmol/L (range, 3.4–4.9)
- Ionized calcium: 1.47 mmol/L (range, 1.12–1.40)
- Hematocrit: 62% (range, 35–50)
- pH: 7.173, metabolic acidosis
- ACTH stimulation test: prestimulation <0.7 μg/dL (range, 1.0–5.0), poststimulation <0.7 μg/dL (range, 8.0–17.0)
- Urinalysis (abnormal value): specific gravity 1.007 (range, 1.015–1.050)
Treatment
- Fluids
- 1 L 0.9% sodium chloride, followed by 3.2 g calcium gluconate (for cardioprotection against hyperkalemia) IV boluses
- Insulin (regular): 16 U with dextrose 50% (100 mL bolus), followed by 5% dextrose CRI in 0.9% sodium chloride (160 mL/hr)
Repeat blood analysis after treatment revealed improvement in hyperkalemia and hyponatremia (sodium 131, potassium 6.5, glucose 138). The patient appeared brighter after treatment as well. The ACTH stimulation test confirmed the suspected diagnosis of hypoadrenocortocism.
- Prednisone (10 mg q12h PO)
- Desoxycorticosterone pivalate (70 mg IM)
Another blood recheck showed resolution of azotemia. The dog was bright, active, and eating well, with no additional vomiting or diarrhea noted during the 2-day hospitalization. Her electrolytes were evaluated shortly prior to discharge and were normal (sodium 145 mmol/L [range, 144–160], potassium 5.6 mmol/L [range, 3.5–5.8]).
At-Home Treatment
- Prednisone (10 mg q12h PO)
Initial Outcome
Shortly after discharge, the dog was noted to vomit a single time. A streak of frank blood was noted in the vomitus. She was otherwise behaving normally at home. Gastroprotectants (famotidine [30 mg q24h PO], sucralfate slurry [1 g q8h PO]) were then prescribed.
PRESENTATION 2
Four days after discharge, the patient was re-presented. The dog’s appetite had decreased (~ 30% of normal, eating only chicken and beef). The night prior to presentation, she vomited 5 times; the first vomitus contained abnormal material resembling "black spaghetti." Two days prior to presentation, the dog also developed diarrhea (liquidy, with frank blood); her stools were initially normal after discharge. On the day of presentation she was very lethargic. She had last received her medications that morning.
Physical Examination
- Quiet, alert, responsive
- Mild dehydration, eyes sunken in orbits bilaterally, slightly tacky mucous membranes, CRT <2 sec
- BCS 4/9 with marked temporal and epaxial muscle wasting
- Minimal aural debris bilaterally
- No cardiac murmur, normal sinus rhythm. Moderate femoral pulse quality
- Eupneic. Appropriate bronchovesicular sounds over all fields
- Full palpation of abdomen performed without discomfort. Uncomfortable and vocalizing during ultrasound examination.
- Ambulatory × 4, coordinated gait but tired easily
- Liquid stool in colon. Defecated after examination: moderate amount of mucus with tinge of frank blood
Diagnostics
- Blood analysis
- White blood cells: 18.6/μL (range, 6–7,000)
- Glucose: 185 mg/dL (range, 74–143)
- Blood urea nitrogen: 31 mg/dL (range, 7–27)
- Alanine aminotransferase: 588 U/L (range, 10–100)
- Sodium: 138 mmol/L (range, 144–160)
- Potassium: 4.0 mmol/L (range, 3.5–5.8)
- Chloride: 106 mmol/L (range, 109–122)
- FAST*: Poor ultrasound detail, somewhat concerned about free gas; small amount of free fluid noted
- Abdominal fluid: turbid and serosanguineous; in-house cytology: predominant degenerative neutrophils with intracellular bacteria (rods). Culture & sensitivity: Escherichia coli
- Blood pressure: 90 mmHg
Based on all available diagnostics, septic peritonitis was highly suspected. Potential causes as discussed with her owner included gastrointestinal perforation secondary to ulceration caused by hypoadrenocorticism or previous use of NSAIDs or steroids. A surgical estimate was given, and her owners consented to surgery that day.
Treatment
- 500 mL Plasma-lyte† bolus
- Exploratory laparotomy: duodenal perforation identified and repaired; Jackson-Pratt drain placed
- Abdominal drain fluid collection/analysis postoperatively
Postoperative Course
Day 1
- Abdominal fluid from drain: occasional red blood cells, very few inflammatory cells, no bacteria
- Packed cell volume: 35% (range, 37-55)
- Total solids: 4.0 g/dL (5.0–7.4)
- Blood analysis
- pH: 7.37 (range, 5.5–7.0)
- Sodium: 144 mEq/L (range, 139–154)
- Potassium: 4.4 mEq/L (range, 3.6–5.5)
- Chloride: 105 mEq/L (range, 102–120)
Day 2
- Abdominal fluid from drain: moderate number of neutrophils; no toxic changes/bacteria
- Blood analysis with liver panel
- Packed cell volume: 35% (range, 37–55)
- Total solids: 4.2 g/dL (range, 5.0–7.4)
- Blood urea nitogen: 4 mg/dL (range, 6–31)
- Albumin: 1.4 g/dL (range, 2.7–4.4)
- Alanine aminotransferase: 116 U/L (range, 10–100)
- Alkaline phosphatase: 245 U/L (range, 5–131)
- Cholesterol: 75 mg/dL (range, 92–324)
- Blood Smear: Adequate number of platelets, few neutrophils
Day 3
- Abdominal fluid from drain: moderate number of neutrophils without toxic changes/bacteria; low number of lymphocytes
- Packed cell volume: 38% (range, 37–55)
- Total solids: 4.8 g/dL (range, 5.0–7.4)
Day 4
- Blood analysis: albumin 2.6 g/dL (range, 2.7–4.4), otherwise unremarkable
- Drain removed
Postoperative Treatment
- Amoxicillin/clavulanate: 375 mg q12h × 14 days PO, based on culture & sensitivity results
- Metronidazole: 250 mg q12h × 14 days PO with food
- Famotidine: 20 mg q24h × 14 days PO
- Sucralfate: 1 g in slurry q8h × 14 days PO
- Misoprostol: 100 μg q12h × 14 days PO
- Prednisone: 5 mg (1/2 10-mg tablet) q12h × 3 days; then q24h thereafter
Based on the patient’s weight, the "physiologic" prednisone dosage was estimated between 3 and 6 mg per day with the possibility of it being lowered in future based on control of signs of Addison's disease and presence of signs of steroid excess, such as excessive thirst and urination. The clients were advised that mineralocorticoids and glucocorticoids would be required for the rest of the dog’s life.
Outcome
Response to desoxycorticosterone pivalate was evaluated after 14 days of treatment via blood analysis. Electrolytes were within normal range, indicating the dose was appropriate at that time. The incision healed well and the sutures were removed on postoperative day 16. The dog was bright, alert, and responsive and had a healthy appetite, with no vomiting, diarrhea, melena, hematochezia, or hematemesis noted.
*FAST = fast abdominal ultrasonography for trauma; †Plasma-lyte is a multiple electrolyte solution.