Date post: | 06-May-2015 |
Category: |
Health & Medicine |
Upload: | sarah-reynolds |
View: | 303 times |
Download: | 0 times |
HypercalcaemiaHypercalcaemiaHypercalcaemiaHypercalcaemia
The Hunt for the TumourThe Hunt for the TumourThe Hunt for the TumourThe Hunt for the Tumour
10 year old MN Labrador Cross
Presented at the SAH on 23/09/13 for further investigation of PU/PD
Past 3 months showing signs of:
PU/PD
Lethargy
Weight loss
Anorexia
Weakness
10 year old MN Labrador Cross
Presented at the SAH on 23/09/13 for further investigation of PU/PD
Past 3 months showing signs of:
PU/PD
Lethargy
Weight loss
Anorexia
Weakness
Yellow DogYellow DogYellow DogYellow Dog
HistoryHistoryHistoryHistoryFirst visit to vets on 09/08/13
Biochemistry:
Calcium 3.83 mmol/l
No other abnormalities
Urinalysis:
USG 1.010 (Isosthenuric)
pH 7
No other abnormalities
Second visit to vets on 19/08/13
Water deprivation test:
7am: USG 1.0095, weight 33.4kg
12pm: USG 1.009, weight 33.15kg
2pm: USG 1.012, weight 32.8kg
4pm: USG unable to get urine, weight 31.7kg
First visit to vets on 09/08/13
Biochemistry:
Calcium 3.83 mmol/l
No other abnormalities
Urinalysis:
USG 1.010 (Isosthenuric)
pH 7
No other abnormalities
Second visit to vets on 19/08/13
Water deprivation test:
7am: USG 1.0095, weight 33.4kg
12pm: USG 1.009, weight 33.15kg
2pm: USG 1.012, weight 32.8kg
4pm: USG unable to get urine, weight 31.7kg
History History History History • Results of the water deprivation test indicative of Diabetes
Insipidus.• Started on Desmopressin 0.1mg 1.5 tablets SID• Retested urine on 27/08/13
• USG 1.010• Drinking less, urinating the same but doing “bit poorly” per
owner• Changed Desmopressin to 2 tablets SID
• Retested urine on 09/09/13• USG 1.011• Drinking less, urinating the same, not interested in food, very
thin, lethargic• Retested urine on 16/09/13
• USG 1.010• Still unable to concentrate urine, not eating, lethargic, muscle
weakness
• Results of the water deprivation test indicative of Diabetes Insipidus.
• Started on Desmopressin 0.1mg 1.5 tablets SID• Retested urine on 27/08/13
• USG 1.010• Drinking less, urinating the same but doing “bit poorly” per
owner• Changed Desmopressin to 2 tablets SID
• Retested urine on 09/09/13• USG 1.011• Drinking less, urinating the same, not interested in food, very
thin, lethargic• Retested urine on 16/09/13
• USG 1.010• Still unable to concentrate urine, not eating, lethargic, muscle
weakness
Physical ExaminationPhysical ExaminationPhysical ExaminationPhysical ExaminationQuiet, alert and responsive
Thoracic auscultation and abdominal palpation were unremarkable
No evidence of any anal gland masses on rectal exam
Peripheral lymph nodes were unremarkable
BCS 2/5 and weighed 30.2kg
Quiet, alert and responsive
Thoracic auscultation and abdominal palpation were unremarkable
No evidence of any anal gland masses on rectal exam
Peripheral lymph nodes were unremarkable
BCS 2/5 and weighed 30.2kg
HaematologyHaematologyHaematologyHaematology
Mild Leukocytosis and left shiftMild Leukocytosis and left shift
BiochemistryBiochemistryBiochemistryBiochemistry
Marked Total Hypercalcaemia (4.24 mmol/l)
Hypophosphataemia
Hypercholesterolaemia
Ionised Calcium: 2.17 mmol/l consistent with HYPERCALCAEMIA!!
Marked Total Hypercalcaemia (4.24 mmol/l)
Hypophosphataemia
Hypercholesterolaemia
Ionised Calcium: 2.17 mmol/l consistent with HYPERCALCAEMIA!!
UrinalysisUrinalysisUrinalysisUrinalysis
USG 1.014
pH 6
Normal UPC ratio 0.04
USG 1.014
pH 6
Normal UPC ratio 0.04
HypercalcaemiaHypercalcaemiaHypercalcaemiaHypercalcaemiaH: hyperparathyroidism
A: addison’s disease; vitamin A toxicosis
R: renal disease
D: vitamin D toxicosis, dehydration
I: idiopathic
O: osteolytic (multiple myeloma)
N: neoplasia (anal sac adenocarcinoma, lymphoma)
S: spurious (lab error, lipemic sample causing false elevation of calcium)
H: hyperparathyroidism
A: addison’s disease; vitamin A toxicosis
R: renal disease
D: vitamin D toxicosis, dehydration
I: idiopathic
O: osteolytic (multiple myeloma)
N: neoplasia (anal sac adenocarcinoma, lymphoma)
S: spurious (lab error, lipemic sample causing false elevation of calcium)
Thoracic RadiographsThoracic RadiographsThoracic RadiographsThoracic RadiographsIncreased soft tissue opacity in cranial thorax, with splaying of the cranial lung lobes and elevation of the trachea
Loss of clarity of cranial cardiac silhouette
Cranial Mediastinal Mass (ie. LSA, thymic lymphoma)
Possible bony lesions affecting sternebrae 4 & 5 and the dorsal spinous processes of T4 and T9
Increased soft tissue opacity in cranial thorax, with splaying of the cranial lung lobes and elevation of the trachea
Loss of clarity of cranial cardiac silhouette
Cranial Mediastinal Mass (ie. LSA, thymic lymphoma)
Possible bony lesions affecting sternebrae 4 & 5 and the dorsal spinous processes of T4 and T9
Mediastinal Mass
Abdominal UltrasoundAbdominal UltrasoundAbdominal UltrasoundAbdominal UltrasoundSpleen diffusely mildly mottled (consistent of nodular hyperplasia, extramedullary haematopoises, reactive splenitis, congestion or infiltrative neoplasia).
Gall bladder mild wall thickening (consistent with previous or chronic cholecystitis).
Both kidneys cortices were diffusely bright and pelvis deverticuli were associated with mineralisations (consistent with age related changes or chronic renal disease).
Spleen diffusely mildly mottled (consistent of nodular hyperplasia, extramedullary haematopoises, reactive splenitis, congestion or infiltrative neoplasia).
Gall bladder mild wall thickening (consistent with previous or chronic cholecystitis).
Both kidneys cortices were diffusely bright and pelvis deverticuli were associated with mineralisations (consistent with age related changes or chronic renal disease).
Thoracic UltrasoundThoracic UltrasoundThoracic UltrasoundThoracic UltrasoundIn the cranial thoracic cavity cranial to the heart, there was a large heterogeneous mass.
Two round large hypoechoic slightly heterogeneous masses were identified as enlarged cranial mediastinal lymph nodes.
Ultrasound guided FNA of both mediastinal mass and lymph node: sadly non-diagnostic.
In the cranial thoracic cavity cranial to the heart, there was a large heterogeneous mass.
Two round large hypoechoic slightly heterogeneous masses were identified as enlarged cranial mediastinal lymph nodes.
Ultrasound guided FNA of both mediastinal mass and lymph node: sadly non-diagnostic.
PCRPCRPCRPCR
• FNA was submitted for PCR to enable us to see if a monoclonal population of lymphoid cells are present which would be consistent with lymphoma.
• Results:
• Polyclonal distribution suggesting presence of a mixed population of T-Cells.
• FNA was submitted for PCR to enable us to see if a monoclonal population of lymphoid cells are present which would be consistent with lymphoma.
• Results:
• Polyclonal distribution suggesting presence of a mixed population of T-Cells.
DiagnosisDiagnosisDiagnosisDiagnosis
Suspect T-cell Mediastinal Lymphoma
• Stage V substage b Lymphoma
Suspect T-cell Mediastinal Lymphoma
• Stage V substage b Lymphoma
Hypercalcaemia of Hypercalcaemia of MalignancyMalignancy
Hypercalcaemia of Hypercalcaemia of MalignancyMalignancy• Hypercalcaemia is a paraneoplastic syndrome in domestic animals and is
a great tumour marker.
• The 2 most common non-parathyroid neoplasms that cause persistent hypercalcaemia in dogs:
• Lymphoma (Lymphosarcoma)
• Adenocarcinoma of the apocrine glands of the anal sac
• Hypercalcemia of malignancy manifests as a result of three underlying pathological processes associated with neoplasia:
• interference with 1 alpha-hydroxylase activity, leading to unregulated conversion of calcidiol to active calcitriol and enhanced intestinal absorption of calcium
• hypersecretion of parathyroid releasing protein (PTHrP), a polypeptide structurally similar to intact parathyroid hormone
• heightened activity of interleukin-1, interleukin-6 and tumor necrosis factor. The production and secretion of these humoral mediators lead to pathologic increases in osteoclastic resorption, often without visible radiographic bone lesions.
• Hypercalcaemia is a paraneoplastic syndrome in domestic animals and is a great tumour marker.
• The 2 most common non-parathyroid neoplasms that cause persistent hypercalcaemia in dogs:
• Lymphoma (Lymphosarcoma)
• Adenocarcinoma of the apocrine glands of the anal sac
• Hypercalcemia of malignancy manifests as a result of three underlying pathological processes associated with neoplasia:
• interference with 1 alpha-hydroxylase activity, leading to unregulated conversion of calcidiol to active calcitriol and enhanced intestinal absorption of calcium
• hypersecretion of parathyroid releasing protein (PTHrP), a polypeptide structurally similar to intact parathyroid hormone
• heightened activity of interleukin-1, interleukin-6 and tumor necrosis factor. The production and secretion of these humoral mediators lead to pathologic increases in osteoclastic resorption, often without visible radiographic bone lesions.
TreatmentTreatmentTreatmentTreatmentFluid therapy with 0.9% NaCl
• providing additional sodium to renal tubules will diminish calcium reabsorption and increase calciuresis
Diuretics following rehydration
• furosemide will increase calcium excretion by the kidneys
Glucocorticoids
• dexamethasone reduce bone resorption of calcium, reduce intestinal calcium absorption, and increase renal calcium excretion
Calcitonin
• rapid calcium-lowering effect due to inhibitory effects on osteoclastic activity and renal tubular reabsorption of calcium.
Bisphosphonates
• act to lower serum calcium by reducing the number and action of osteoclasts
Fluid therapy with 0.9% NaCl
• providing additional sodium to renal tubules will diminish calcium reabsorption and increase calciuresis
Diuretics following rehydration
• furosemide will increase calcium excretion by the kidneys
Glucocorticoids
• dexamethasone reduce bone resorption of calcium, reduce intestinal calcium absorption, and increase renal calcium excretion
Calcitonin
• rapid calcium-lowering effect due to inhibitory effects on osteoclastic activity and renal tubular reabsorption of calcium.
Bisphosphonates
• act to lower serum calcium by reducing the number and action of osteoclasts
PlanPlanPlanPlanFurther investigation was discussed with the owner to be able to obtain a definitive diagnosis but this was declined.
Owners would like to trial palliative steroids. This will help reduce his hypercalcaemia and improve his appetite.
Prednisolone 25mg tablets and Zantac 150mg tablets.
Owners want to take him home for a few days and then euthanise.
Further investigation was discussed with the owner to be able to obtain a definitive diagnosis but this was declined.
Owners would like to trial palliative steroids. This will help reduce his hypercalcaemia and improve his appetite.
Prednisolone 25mg tablets and Zantac 150mg tablets.
Owners want to take him home for a few days and then euthanise.
The EndThe EndThe EndThe End