see attached typical

see attached typical yorkie with ple and stippling/striations on the microconvex and a typical PLE on linear.

Search the basic search for PLE and there will be many of them as well.

http://sonopath.com/members/case-studies/search

I Like plasma transusion to help keep the albumin > 2.0 as bad things happen when its under 1.5 like thromboembolic disease and if there is a need for sx then they won’t heal well. Plasma gets a jump start and buys time. Purina HA or Royal canine HP, cover for parasites, metronidazole and plasma expanders as needed and of course prednisone. PLE can occur as paraneoplastic so ensure no LSA. You can get fancy and do a corn oil test and scope for duodenal bx to confirm the dx.

See this unedited partial excerpt for the curbside guide coming out in the next couple of months on PLE:

Diagnosis: Typical diagnostics for protein losing enteropathy (PLE) include the clinical profile of hypoalbuminemia (but may also be within normal serum levels), a sonogram with suggestive intestinal wall prominence and mucosal striations noted, and clinical signs of vomiting, weight loss, diarrhea. Be warned some cases can have a lack of GI signs altogether and no weight loss. PLE is preferably definitively diagnosed by full thickness or endoscopy guided biopsies after feeding a fatty meal the night before in order to dilate lacteals to adequately diagnose lymphangiectasia. PLE can be associated with:

1. Inflammatory bowel disease (IBD)
2. Granulomatous disease
3. Neoplasia
4. Immunoproliferative enteropathy

Often GI blood loss may occur potentially caused by lymphosarcoma, ulcerative disease, or intussusception. A dynamic sonogram testing procedure feeding corn oil (0.5-1 cc/kg) 45 minutes prior to the sonogram of an NPO patient will enhance the presence of mucosal striations in the small intestine during the sonogram. This is a reliable test founded by Marks et al. at UC Davis (NAVC 2011).

Endoscopy both anterior and posterior approaches are ideal in order to access the stomach/duodenum in the former case and colon/ileum in the latter in order to maximize the biopsy information. However, this will not detect transmural disease such as lymphoma affecting the muscularis and submucosa that are not typically obtained readily via endoscopy. Ultrasound evaluation of the GI tract can help decide whether the pathology is luminal, and available for sampling through endoscopy, or mural and necessitating US-guided FNA or core biopsy or surgical biopsy ideally guided by intra-operative ultrasound. More information regarding intra-operative ultrasound may be found in “resources” at http://www.sonopath.com.

B12, Folate, Ionized calcium, ionized magnesium and antithrombin levels should all be measured in the clinical PLE patient and levels should be corrected with Calcium gluconate (50-150 mg/kg Iv over 12-24 hours) or 1 tablet extra strength Tums (300 mg calcium) PO SID to TID as needed to maintain normal calcium levels over 3-4 weeks. Mg sulphate (1mEq/kg/day IV) or MgOxide 10-20 mg/kg PO BID (Milk of magnesia) may be utilized for magnesium supplementation but milk of magnesia may cause diarrhea.

Yorkshire Terriers are 10X more likely to develop IBD and 9X more likely to suffer hypocalcemia and hypomagnesemia with IBD. Therefore magnesium and calcium supplementation may be in order.

Other differentials for Hypoalbuminemia include:

1. PLE
2. Liver failure
3. Glomerulonephritis/amyloidosis/protein losing nephropathy (PLN) (typically with elevated serum globulins)
4. Vasculitis
5. Exocrine pancreatic insufficiency (EPI)
6. Addison’s disease (typical or atypical).

Hypocalcemia may be present owing to albumen loss (carrier proteins). If depressed cholesterol is also present with hypoalbuminemia then either liver failure or PLE should be suspected. Hypocalcemia may also be an issue with PLE and general causes of Hypoalbuminemia.

Hypocalcemia differentials include:

1. Hypoalbuminemia
2. Hypovitaminosis D
3. Hypomagnesemia
4. Hypoparathyroidism
5. Pancreatitis
6. Spurious/idiopathic

Treatment:  Given that a significant fraction of PLE cases are caused by a food allergy causing IBD, then lymphangiectasia and leading to PLE, Purina HA diet should be fed.  This diet is low (not restricted in fat) in fat; low enough to use for lymphangiectasia cases.  Plus, it is hydrolyzed, meaning there is nothing in which the body can respond antigenically.  No other hydrolyzed or novel protein diets are as low in fat.  (Z/D, RC, HP, and IVD diets are moderately high in fat).

It is a good idea to rule out parasitism and/or utilizing empirical treatment with Fenbendazole 50 mg/kg SID for 5 days & repeat in 2 weeks combined with Metronidazole 15mg/kg BID for 10 days. Also ruling out neoplasia with FNA or biopsy, if a target is available or full thickness may be performed. Occasionally GI lymphoma or mast cell disease may be emerging in these cases.

Feeding normal levels of fat with lymphangiectasia patients causes further dilation of the lacteals with rupture, exacerbating protein losses.  Many recommend a low fat diet with lymphangiectasia, however, if the primary cause was a food allergy, this recommendation could be counterproductive. 

Feed Purina HA for a few weeks and monitor total protein and albumin.  If the levels are still low, I would transition to a novel protein diet that is ultra restricted in fat  (ostrich, kangaroo, crab).  Since none exist commercially, the diet would have to be homemade, which can be expensive for the owner to make.  This largest challenge is to make the diet balanced.  Homemade diet formulations created through a nutritional consultation is recommended.

Low dose lasix (1-2 mg/kg BID) and/or spironolactone (2-4 mg/kg BID) may be utilized for ascites until oncotic pressures are restored with a colloid or plasma therapy. Abdominocentesis should be utilized only to keep the patient comfortable owing to excessive abdominal distention. Excessive drainage will cause further depletion of the protein supply that we are trying to restore.

B12 supplementation of 250-1,000 ug (cat/small dog lower end, Large breed higher end dose or 1/4cc-1cc) SC weekly x 6 weeks would be recommended owing to loss of B12 in the ileum regardless of serum levels.

Aspirin therapy is suggested (1 mg/kg sid) to assist in potential thromboembolic episodes that are the often the source of sudden death in these cases owing to antithrombin III loss. This dose will not cause side effects in GI tract or elsewhere.

Azothiaprine or cyclosporine may also be considered for refractory cases.

In a last ditch effort if this doesn’t work and biopsies are still not possible then a prednisone trial would be in order.  I always prefer utilizing cortisones in these patients based on biopsy results but realize that this is not feasible in many cases.

It makes sense and leukeran

It makes sense and leukeran is quite tolerable… dont know if its necessary but maybe for refractive cases..