- 12 year old mn Basset Hound that twice became Addisonian after Lysodren tx for Cushing’s disease-tx w/ Lysodren once a year ago and again last week. The patient is now on prednisone.
- Clinical signs include chronic PU/PD that never resolved on Lysodren, and a serious vomiting episode after recent Lysodren tx
- Chemistry profile shows Na:K=23 (Na=148, K=6.3), ALKP=350, negative urine culture. ACTH stim done post Lysodren tx supports Addison’s disease.
- 12 year old mn Basset Hound that twice became Addisonian after Lysodren tx for Cushing’s disease-tx w/ Lysodren once a year ago and again last week. The patient is now on prednisone.
- Clinical signs include chronic PU/PD that never resolved on Lysodren, and a serious vomiting episode after recent Lysodren tx
- Chemistry profile shows Na:K=23 (Na=148, K=6.3), ALKP=350, negative urine culture. ACTH stim done post Lysodren tx supports Addison’s disease.
- Abdominal US shows normal size adrenal glands, marked mass-like left liver enlargement with retention of hepatic internal architecture, and bilaterally dilated renal pelvises with decreased corticomedullary definition
- My R/O’s for the liver mass include benign nodular hyperplasia, hepatic carcinoma, other neoplasia, and or steroid hepatopathy/reactive vacuolar hepatopathy
- My R/O’s for the kidneys include current or past episodes of pyelonephritis. Is the diminished corticomedullary definition as sign of age, inflammation, or is there a possibility of metastases here?
The patient needs a needs a liver biopsy, but I am wondering about the significance of the renal pathology and the etiology of the chronic PU/PD : hepatic carcinoma? pyelonephritis? unsuccessfully treated Cushing’s disease or prednisone administration?
Comments
Hi Melissa,
As a non-expert
Hi Melissa,
As a non-expert opinion, pyelocentesis may be the only way to confirm the absence of pyelonephritis as urine cultures can be negative. Don’t know if I would stick this one though-could be challenging!
Although this pyelectasia is a little more prominent in your case than when I have seen it, I am starting to convince myself that patients with pu/pd often have a mild degree of pyelectasia simply due to diuresis (and I also think u/s machines are much better these days in picking it up)
Jacquie
Hi Melissa,
As a non-expert
Hi Melissa,
As a non-expert opinion, pyelocentesis may be the only way to confirm the absence of pyelonephritis as urine cultures can be negative. Don’t know if I would stick this one though-could be challenging!
Although this pyelectasia is a little more prominent in your case than when I have seen it, I am starting to convince myself that patients with pu/pd often have a mild degree of pyelectasia simply due to diuresis (and I also think u/s machines are much better these days in picking it up)
Jacquie
Thanks Jacquie. I appreciate
Thanks Jacquie. I appreciate your input.
Thanks Jacquie. I appreciate
Thanks Jacquie. I appreciate your input.
I would have to agree with
I would have to agree with Jaquie but those kidneys look like chronic intertsitial nephrosis. Any chance this dog was never cushingoid in the first place and had pupd for another reason? I see false + lddst and acth stim all the time and lysodren to addisons…. what about medullary washout, psychogenic, early rf, di, occult uti, dietary salt……Is there hypertension? Chronic lepto?
yes i agree on the pyelctasia … the us machine resolution is ahead of the literature curve on pyelectasia….Im running into this issue currently finishing the uro chapter of the book and how to address it. You can usually get a little urine if the pyelectasia is > 0.3 cm wide with a 25g needle. IR cases usually want 0.5 cm to place a stent but if you are good with a needle 0.2-0.3 cm should be enough..
i am more concerned with pyelo if the pelvic fat is ill defined that suggests inflammation and less concerned if the urine is inactive and there is a slight clean pyelectasia like you get with any animal on fluid tx.
Regardless I like to run the pyelkectasia/pupd cases on baytril for 10 days and then check the usg and see what it does just in case there is occult infection. Many of the pupd cases just respond to this and if so I carry it out for a month. I never trust cultures as its way too imperfect a procedure but if you get a bug then great we have something to shoot at but the industry needs to improve on the SE and Sp of urine cultures that’s for sure. If that doesnt work then i go to partial water dep and see what the concentrating ability is… then iohexal would be ideal or di testing.
You could go on an on but much also depends on urine sediment too and we could post for weeks discussing just that
I would have to agree with
I would have to agree with Jaquie but those kidneys look like chronic intertsitial nephrosis. Any chance this dog was never cushingoid in the first place and had pupd for another reason? I see false + lddst and acth stim all the time and lysodren to addisons…. what about medullary washout, psychogenic, early rf, di, occult uti, dietary salt……Is there hypertension? Chronic lepto?
yes i agree on the pyelctasia … the us machine resolution is ahead of the literature curve on pyelectasia….Im running into this issue currently finishing the uro chapter of the book and how to address it. You can usually get a little urine if the pyelectasia is > 0.3 cm wide with a 25g needle. IR cases usually want 0.5 cm to place a stent but if you are good with a needle 0.2-0.3 cm should be enough..
i am more concerned with pyelo if the pelvic fat is ill defined that suggests inflammation and less concerned if the urine is inactive and there is a slight clean pyelectasia like you get with any animal on fluid tx.
Regardless I like to run the pyelkectasia/pupd cases on baytril for 10 days and then check the usg and see what it does just in case there is occult infection. Many of the pupd cases just respond to this and if so I carry it out for a month. I never trust cultures as its way too imperfect a procedure but if you get a bug then great we have something to shoot at but the industry needs to improve on the SE and Sp of urine cultures that’s for sure. If that doesnt work then i go to partial water dep and see what the concentrating ability is… then iohexal would be ideal or di testing.
You could go on an on but much also depends on urine sediment too and we could post for weeks discussing just that
Thanks Eric. I will pass on
Thanks Eric. I will pass on your input to the client. An ACTH stim was performed on this dog on 7-11-12 and the results were as follows:
Base-Line Cortisol=3.8mcg/dL
4 Hour post cortisol=2.3 mcg/dL
8 Hour post cortisol= 3.1 mcg/dL
Subsequent ACTH stims have shown basline and 1 hour posts <1.0mcg/dl. The adrenal glands appear small to normal on US with some mildly echogenic adjacent fat. This dog does not look Cushingoid other than a ventral abdominal dermatitis. He is not obese, there is no muscle wasting, and he is not pot bellied. The main complaint is PU/PD.
Thanks Eric. I will pass on
Thanks Eric. I will pass on your input to the client. An ACTH stim was performed on this dog on 7-11-12 and the results were as follows:
Base-Line Cortisol=3.8mcg/dL
4 Hour post cortisol=2.3 mcg/dL
8 Hour post cortisol= 3.1 mcg/dL
Subsequent ACTH stims have shown basline and 1 hour posts <1.0mcg/dl. The adrenal glands appear small to normal on US with some mildly echogenic adjacent fat. This dog does not look Cushingoid other than a ventral abdominal dermatitis. He is not obese, there is no muscle wasting, and he is not pot bellied. The main complaint is PU/PD.
if usg < 1.020 then true
if usg < 1.020 then true pupd is present and may be from other causes. Is this and acth stim or lddst?
if usg < 1.020 then true
if usg < 1.020 then true pupd is present and may be from other causes. Is this and acth stim or lddst?
Sorry, it was a low dose
Sorry, it was a low dose dexamethasone test.
Sorry, it was a low dose
Sorry, it was a low dose dexamethasone test.