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PacPacific Tide March 2012
Volume 3, Issue 1
Pacific Veterinary Specialists & Emergency Service ~ 1980 41st Avenue, Capitola, CA 95010
Specialty 831-476-2584 ~Emergency 831-476-0667
Pacific Veterinary Specialists Monterey, 2 Harris Court Suite A-1, Monterey, CA 93940 Monterey Office 831-717-4834 or Capitola 831-476-2584
Panhypoproteinemia
Author of the month:
Michelle Pressel,
DVM, DACVIM
Dr. Pressel received her
Doctorate in Veterinary
Medicine from Colorado State
University in 2000. Her
internship at Veterinary Care
Animal Hospital in
Albuquerque followed, and
was completed in 2001. She
remained in Albuquerque in
general practice for one year
before pursuing her residency
training in internal medicine
at Iowa State University
which she completed in 2005.
She became board certified
that same year. She has
published several articles and
participated in a number of
presentations and lecture
series. Dr. Pressel's special
interests include
gastroenterology, oncology,
and hematology. She is active
in regional and national
veterinary societies, as well as
a participant, on the local
level, in agility, obedience, and
tracking. She joined PVSES in
June 2007, and shares her life
with her kitties Nutmeg,
Spice & Sage, and her Golden
Retrievers, Cedar & Safari.
An informational monthly newsletter
Panhypoproteinemia is a fairly common problem seen in dogs with chronic diarrhea. The history is usually of prolonged diarrhea but can occur on a more acute basis. Panhypoproteinemia is defined by low albumin and low globulin and therefore also low total protein. When a patient has a combination of all 3, it is almost always related to intestinal loss. Other causes of hypoalbuminemia alone include liver disease and proteinuria which are rarely associated with concurrent hypoglobulinemia. There are other much less common instances where panhypoproteinemia can be seen such as significant gastrointestinal hemorrhage and severe sepsis. However, a dog with a more chronic history of illness is much more likely to have intestinal loss. Therefore, when panhypoproteinemia is noted, a focused approach on the gastrointestinal tract should be undertaken. The following is a case example of a dog with panhypoproteinemia describing a general diagnostic workup, treatment options and prognosis. Case example: Charlie is a 4 year old MN Yorkie that the owner brought in because one of his littermates just died of diarrhea. The owner is worried because Charlie has been having intermittent diarrhea over the last 3-4 months. Treatment with a diet change (Iams Low Residue) and metronidazole have not resulted in any significant improvement. Charlie has a distended abdomen and possible fluid wave. The owner notes this has been present for about 3 weeks. Lab work shows an albumin of 1.4, globulin of 1.6 and total protein of 3.0 and low cholesterol of 89. Charlie has a classic presentation of panhypoproteinemia, a condition that is especially common in Yorkies. Clinical signs: A patient with panhypoproteinemia usually presents with diarrhea which can be chronic or acute. In most cases, the history is more chronic with weeks to months of diarrhea. There can also be associated vomiting, decreased appetite and weight loss. Diarrhea is rarely responsive to routine therapy with metronidazole or diet change. There are certain breeds of dog that are prone to panhypoproteinemia, specifically Wheaten terriers and Yorkies as well as Norwegian Lundehunds and Basenjis. Physical exam: Findings in these patients are nonspecific and often limited to signs of weight loss. Due to the hypoalbuminemia, these patients can develop ascites if their albumin is less than 1.5.
Differentials: Possible causes of panhypoproteinemia are inflammatory bowel disease, lymphoma, small cell lymphoma (much more common in cats than dogs) and lymphangitis / lymphangectasia. Dogs can have a combination of both IBD and lymphangectasia or lymphangectasia could be a primary problem. The latter is often more difficult to treat. Diagnostics:
1. Establish a minimum database including a CBC, chemistry panel, urinalysis +/- thyroid level depending on age and breed. Also consider cobalamin level and fecal exam.
a. Liver disease should not result in a decrease in globulins and neither should proteinuria due to kidney disease. However, a urinalysis should still be performed to complete the minimum database and bile acids might be warranted if the history supports a liver component to the disease process.
b. Dogs with panhypoproteinemia may also have low cholesterol due to loss through the intestinal tract and low calcium directly related to decreased albumin.
2. Abdominal ultrasound is often a good logical next step. Ultrasound is used to rule out an intestinal mass and other abnormalities not necessarily associated with the biochemical change. Incidental findings could include a liver or splenic mass which might change how a client wants to proceed and how the diagnostic plan should proceed. There are no consistent changes seen on ultrasound that can confirm a diagnosis. However, hyperechoic mucosal striations secondary to lacteal dilation can be seen at times which suggests lymphangectasia. Enlarged lymph nodes can be aspirated, especially if their echogenicity suggests more than inflammation. A boarded radiologist often can tell if the changes to the lymph nodes are more consistent with inflammation or neoplasia which will help determine if aspirates are warranted.
3. Biopsies of the intestines are often needed to make a definitive diagnosis of many causes of panhypoproteinemia. However, if lymphoma is expected, a diagnosis can at times be made via fine needle aspiration of an enlarged lymph node. Small cell lymphoma, on the other hand, is much more difficult to diagnose via aspirates. The diagnosis of small cell lymphoma is made through the identification of architectural changes found within the mucosal layer of the intestines and therefore, biopsies are recommended. Lymph node aspirates of these patients often show evidence of hyperplasia and reactivity and are rarely diagnostic for small cell lymphoma. Biopsies can be collected via endoscopy or surgery. Care must be taken with surgical biopsies as a patient with low proteins is at risk for poor healing from surgery making endoscopy often the better diagnostic choice.
Treatment: The mainstay of therapy is immunosuppressive doses of prednisone at 2.2mg/kg once daily or divided BID. Many patients will show a significant response to therapy in 2-3 weeks. Resolution of diarrhea is followed by improvement in protein blood levels. The dose of prednisone should not be tapered until all changes have resolved. If improvement is not appreciated in this time period, additional medications can be added including metronidazole, chlorambucil, azathioprine and/or cyclosporine. Diets can sometimes be helpful by feeding a low fat diet such as Iams Low Residue, Royal Canin gastrointestinal or Hill’s ID or a hydrolyzed diet such as Hill’s ZD or Purina HA. Supplementation with vitamin B12 injections should be given weekly in cases with hypocobalamenemia. Ancillary treatment with a combination of Lasix and spironolactone can be used in the initial stages of treatment to help control the related ascites. Prognosis: Fair to guarded depending on the severity and response to therapy. If a patient does not improve within the first few weeks, the long term prognosis becomes more worrisome. Many patients can eventually be tapered off all medications but some will require lifelong therapy. The goal is to find the lowest possible dose that maintains the signs and normal protein levels.
3
Our Team
Mark Saphir, DVM Emergency
Tom Lahue, DVM, DACVS Surgery Mandi Kleman, DVM, DACVIM
(Cardiology)
Theresa Arteaga, DVM, DACVIM (Oncology) Kim Delkener, DVM
Emergency
Jessica Kurek, DVM Emergency
Lisa Metelman, DVM, DACVS Surgery
Chris Robison, DVM Emergency
Colleen Brady, DVM, DACVECC Criticalist Lillian Good, DVM, DACVECC
Criticalist
Kelly Akol, DVM, DACVIM Internist
Merrianne Burtch, DVM, DACVIM Internist Michelle Pressel DVM, DACVIM
Internist
Specialty Services and Our Doctors
About Our Organization
PVSES was founded to
provide high quality,
specialized medical
care to companion
animal patients. Our
practice is dedicated to
serving the veterinary
community as a
partner in total patient
care. We offer
comprehensive
specialized services
including endoscopy,
Doppler ultrasound,
surgery, 24-hour ICU
care, and emergency
and critical care. Our
staff is committed to
providing
compassionate and
thorough medical care
that meets the needs
of the patient, client,
and referring veterinarian.
Internal Medicine
Kelly Akol, DVM, DACVIM
Merrianne Burtch, DVM,
DACVIM
Michelle Pressel, DVM,
DACVIM
Surgery
Lisa Metelman, MS, DVM,
DACVS
Tom LaHue, DVM, DACVS
Critical Care
Colleen Brady, DVM,
DACVECC
Lillian Good, DVM, DACVECC
Oncology
Theresa Arteaga, DVM,
DACVIM(Oncology)
Cardiology
Mandi Kleman, DVM,
DACVIM(Cardiology)
Radiology
Larry Kerr, DVM, DACVR
Mark Lee, DVM, DACVR
Michelle Laurensen, DVM,
DACVR
Emergency
Chris Robison, DVM
Kim Delkener, DVM
Mark Saphir, DVM
Jessica Kurek, DVM
Behavior
Jan Brennan, DVM
Alternative Therapies
Darren Hawks, DVM
Pacific Veterinary
Specialists & Emergency
Service
1980 41st Avenue
Capitola, CA 95010
Phone
(831) 476-2584
Emergency
(831) 476-0667
Fax
(831) 476-8499
pvses@pacbell.net
Pacific Veterinary
Specialists Monterey
2 Harris Court Suite A-1
Monterey, CA 93940
Phone
(831) 717-4834
Fax
(831) 717-4837
Emergency (Capitola)
(831) 476-0667
pvsmonterey@pacbell.net
Pacific Veterinary Specialists &
Emergency Service
1980 41st Avenue
Capitola, CA 95010
We’re on the Web!
See us at:
www.pvses.com
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