Presentation
- 10-year-old, spayed female mixed-breed dog is presented for progressive polyuria/polydipsia of 2 weeks’ duration. Side/belly are often wet with urine after reclining. No stranguria/pollakiuria described.
- Client recounts recent significant weight loss (formerly 80 lb)
- New client, so limited history to this point. Vaccination and heartworm preventive are up to date.
Physical Examination
- Vital Signs
- Temperature: 101.2⁰F
- Pulse: 100 bpm
- Respiration: 60 bpm (Excessive panting but normal bronchovesicular sounds in all lung fields)
- Bright, alert, responsive; mucous membranes pink/moist; CRT: <2 sec (estimated hydration adequate)
- Obese: BCS 9/9 (58 lb)
- Grade 2 periodontal disease
- Abdominal palpation: abdomen distended/round, soft/pain free; moderate hepatomegaly
- Integument: Flaky/dry skin with hyperpigmentation of ventral abdomen
Diagnostic Procedures
- Serum biochemical profile
- ALP: 1724 U/L (range, 10–150)
- Glucose: 447 mg/dL (range, 60–125)
- Anion gap: 32 mEq/L (range, 12–24)
- Bicarbonate: 10 mEq/L (range, 17–24)
- CBC
- Platelets: 538 × 103/μL) (range, 164–510)
- WBCs: 25.0 × 103/μL (range, 5.7–16.3)
- Absolute monocytes: 1500/μL (range, 150–1350)
- Absolute neutrophils: 21.25 × 103/μL) (range, 3–11.5); neutrophils slightly toxic
- Urinalysis (urine collected free-catch)
- Glucose: 3+
- Ketones: 3+
- Specific gravity: 1.021
- pH: 5.0
- ACTH Stimulation Test (Performed day after blood analysis at request of owner)
- Pre-ACTH resting cortisol: 9.9 μg/dL (range, 2–6)
- Post-ACTH: 27.2 μg/dL (>22 consistent with hyperadrenocorticism)
Treatment
- Continue high-fiber diet (Already feeding a dry commercial weight-management food)
- Initiated NPH insulin (6 U q12h) with instructions to check blood glucose curve in 1 week
- Client scheduled glucose curve 4 days after starting insulin. Client checked blood glucose with in-home glucometer; administered 6 U NPH insulin prior to presentation:
- Initial value: 563
- Hour 2: 371
- Hour 4: 621
- Hour 6: 654
- Hour 8: 596
- Recalculated starting dose of insulin; recommended 12 U q12h
- Discussed with client concurrent Cushing’s disease/challenge of adequately controlling diabetes mellitus. Because dog was clinically stable/not showing clinical signs of diabetic ketoacidosis, recommended increasing dose of insulin; then initiating treatment for Cushing’s disease after several days. Due to cost of trilostane, client opted for mitotane. Strict instructions were given to client on multiple occasions during visit to wait several days (until after the weekend) to initiate treatment for Cushing’s disease to enable daily communication regarding the dog’s status.
- Mitotane (750 mg q24h; divided into 500 mg AM/250 mg PM) for induction phase
- Prednisolone (5 mg) also prescribed for use in case of emergency. Client instructed about signs to monitor, when to give prednisolone if unable to reach anyone at the hospital, and to continue giving insulin if, and only if, the dog is eating.
Presentation 2
Patient was presented on Monday AM (when mitotane should have been started) recumbent/unable to stand. For last 2 days, patient had not been eating; was dribbling urine, trembling in rear legs, breathing heavily/panting excessively, lethargic/acting drunk, drinking excessively. Vomited this morning. Currently on 9 U NPH insulin; owners gave “a few doses” of aspirin at some point over the weekend and had elected against medical advice to start mitotane (250 mg in first dose) 4 days ago “to get a jump-start on Cushing’s.” Aforementioned clinical signs appeared on days 3 and 4 after initiating mitotane. Owners then proceeded to give prednisolone, insulin, and mitotane (250 mg in AM/500 mg in PM) q12h through the weekend.
Physical Examination
- Patient in lateral recumbency/minimally responsive/nonambulatory
- Blood glucose (by glucometer): 640
- Hydration: severely tacky, pink mucous membrances; CRT 3 sec (estimated 10% to 12% dehydration)
- Tachycardic (HR: 145)/tachypneic (RR: 42) at rest; panting when manipulated
- Temperature: 103.1⁰F
- Weight: 51 lb
Diagnostic Procedures
- Serum biochemistry panel
- ALP: >2000 U/L (range, 23–212)
- Glucose: 630 mg/dL (range, 70–143)
- BUN: 49 mg/dL (range, 7–27)
- Lipase: 5670 U/L (range, 200–1800)
- Electrolytes
- K: 5.7 mmol/L (range, 3.5–5.8)
- HCO3: 6.3 mmol/L (range, 20–29)
- pCO2: 20 mmHg (range, 32–49)
- pH: 7.14 (range, 7.31–7.42)
- tCO2: 7 mmol/L (range, 21–31)
- CBC
- HCT: 28.3%
- RBCs: 4.85 × 103/μL (range, 5.5–8.5)
- HGB: 8.9 g/dL (range, 12–18)
- MCV: 58.4 fL (range, 60–77),
- Reticulocytes: 0.8%
- WBCs: 55.29 × 103/μL (range, 5.5–16.9)
- Neutrophils: 44.67 × 103/μL (range, 2–12)
- Monocytes: 8.43 × 103/μL (range, 0.3–2)
- PLTs: 564 × 103/μL (range, 175–500)
- Urinalysis
- Glucose: 100 mg/dL
- Ketones: 15 mg/dL
- Protein: 30 mg/dL
- Erythrocytes: 250/μL
- pH: 7.0
Treatment/Progress
- 0.9% NaCL bolus (400 mL over 90 minutes IV)
- For diabetic ketoacidosis: 0.9% NaCl + 20 mEq/L KCl + 29 mEq HCO3 (in 600 mL) over next 6 hr at 100–150 mL/hr
- Glucose measurements by glucometer:
- Initial value: 607; administered 5 U regular insulin IM
- Hour 1: 538; administered 2.5 U regular insulin IM. Blood pressure: 165; Temperature: 102.8⁰F
- Hour 2: 448, administered 2.5 U regular insulin IM. Dog more responsive when stimulated, wagging tail, breathing more easily and steadily. Rectal exam: darker, possibly tarry stools. Administered cefazolin (500 mg IV)
- Hour 3: 354; no additional insulin
- Hour 4: 304; no additional insulin
- Hour 5: 311; administered 9 U NPH insulin SC
- Abdominal ultrasound: homogenous, hyperechoic region noted in area of pancreas; consistent with pancreatitis. Both adrenal glands enlarged but normal in shape; caudal pole of left = 0.7 cm; caudal pole of right = 0.8 cm. No other abnormalities noted.
- Electrolytes 6 hours after starting treatment: HCO3 improved but still low.
- Administered maropitant IV, sucralfate (1 gm slurry PO), famotidine (10 mg IV)
- Hour 6: Respirations increased/dog less responsive. Continued IV fluids with KCl additive only (75 mL/hr)
Outcome
During the day, owners were advised of severity of diabetic ketoacidosis. Recommended continued treatment/hospitalization overnight at Emergency Clinic for continued close observation. Owners could not afford financially; patient remained in-house on IV fluid pump overnight. Late in the day, owners had been informed that pet appeared to be declining despite treatment; prognosis now guarded to poor. Patient died overnight.