Early Summer 2016

We all do it. The minute we see a high calcium value on an older pet’s lab work, we immediately think the worst: there is cancer in there somewhere, right? If you are like me, you grab your physical exam and review the visit in your mind. Did I find any suspicious masses or prominent lymph nodes; were the anal glands normal on rectal exam?

After that review, it is time to think about the possible differentials. Slow down and go through the mnemonic HARDIONS:

H Hyperparathyroidism

A Addison’s disease

R Renal

D Vitamin D toxicosis

I Idiopathic (mostly in cats, very rare in dogs)

O Diseases causing osteolysis

N Neoplasia

S Spurious

Where do you begin after getting a high total calcium? I recommend that you start with taking those causes off the list that really do not fit your patient. Then consider measurement of parathyroid hormone levels, ionized calcium levels, and parathyroid hormone-related protein levels, most commonly sent to Michigan State University. This can help you sort out many of the remaining causes. It is critical to remember that the body controls ionized calcium levels closely, thus when that value is high, the parathyroid should be zero or extremely low. This is one of those cases in which normal, especially high normal, is NOT normal!

Meet Antoine, an adorable 8-year-old male neutered Shih Tzu. He presented for further evaluation of a total calcium of 15.1 mg/dL. He had originally presented to his primary care veterinarian for increased thirst and urination and muscle stiffness. An ionized calcium and a parathyroid hormone level were also submitted. His ionized calcium was 2.08 mmol/L (normal 1.25-1.45), and his PTH was 3.0 pmol/L (normal 0.5-5.80). Chest x-rays had been done and were normal. Antoine was also mildly azotemic with a creatinine of 1.8 mg/dL (normal 0.5–1.5) and a BUN of 38 (normal 7–35).

Hypercalcemia: It’s Not Just Cancer – By Melissa Riensche, DVM, DACVIM

(continued on page 2)

P 1- Internal Medicine Article: Hypercalcemia: It’s Not Just Cancer

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P 2- IM Article (cont’d)

- Did You Know?

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P 3- Continuing Education: Specialist Symposium

- Team Member Highlight: Dr. Riensche

- Technician Tip: Exceptional Hospitalized Patient Care Starts With The Basics

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P 4- Testimonial: Caida

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dvmspecialists.com

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Hypercalcemia: It’s Not Just Cancer (continued from page 1).

No enlarged lymph nodes were detected on exam, and his anal glands were normal. An abdominal ultrasound to further rule out cancer and better evaluate his kidneys was performed, along with an ultrasound of his parathyroid glands. His abdominal ultrasound revealed mild pylectasia in both kidneys but no other significant findings. A urine culture was negative. His right cranial parathyroid was mildly enlarged, measuring 0.18–0.22 cm, with 0.20 cm being the cutoff for normal.

Because Antoine’s total calcium was over 14.0 mg/dL at the time of surgery, Antoine was started on calcitriol and Tums the day prior to surgery. Antoine underwent surgical removal of the right cranial parathyroid gland and was monitored in the hospital for 24 hours. His ionized calcium was measured every 8 hours to make sure it was not dropping too rapidly, and at discharge it had decreased to 1.50 mmol/L. For the first week, Antoine returned once daily to have his ionized calcium measured and his calcitriol and Tums doses adjusted. The goal is to keep the ionized calcium at the low end of normal to stimulate the remaining parathyroid glands to resume functioning. This is typically signaled by a modest rise in the ionized calcium. Once the ionized calcium is stable in the low normal to just below normal range, monitoring occurs weekly. For Antoine, it took 9 weeks for his parathyroid glands to start functioning again. Calcitriol and Tums are slowly discontinued while the ionized calcium is monitored, typically every 2 weeks at that point. Antoine has done great since his surgery.

Histopathology should always be performed; however, the majority of these tumors are benign. Those that are malignant tend to be slow to spread, and surgery is often curative if the margins are clean. Since his surgery a year ago, Antoine’s azotemia normalized within 2 weeks after surgery, his values remain normal with good urine concentration, and his owners report that he is like a puppy again! The muscle stiffness is gone. Often, with primary hyperparathyroidism, the clinical signs are subtle, and you may find it on routine lab screening. However, slow changes such as increasing muscle stiffness and mild changes to thirst and urination (that the owners are unable to notice) may improve after treatment, leading to a better quality of life. The most important part of helping owners navigate primary hyperparathyroidism is to help them understand that the follow up and medical management after this surgery is more intense, but the outcome can be extremely rewarding!

Contact Melissa Riensche, DVM, DACVIM, at Desert Veterinary Medical Specialists to discuss a perplexing case of hypercalcemia or any other internal medicine cases.

DID YOU KNOW... WE HAVE TELERADIOLOGY SERVICES?

First time users: call 888.669.8090 or email support@dvminsight.net to sign up for this service Digital images may be submitted online at dvmspecialists.com (Click on “For Veterinarians” tab) All images are interpreted by our radiologist, Vicki Heffelman, DVM, DACVR Analog film radiographs are also accepted by mail Detailed reports are sent within 24 hours

For more information, please call 480.635.1110 x7 and we’ll be glad to show you how to submit images through our website.

In our high-tech world, it is often easy to forget how critical some foundational steps are to take to ensure that patient care goes smoothly.

Exceptional hospitalized patient care begins with having generic information. For example, we need to know the pet’s history, why they are being hospitalized, and the best contact information for the family. Make sure all paperwork is filled out completely. All patients should be tagged with their name and all pertinent information should be readily available.

All patients deserve a clean kennel with appropriate bedding. Very ill or injured patients should be kept where they can be closely monitored for any changes in behavior or vital signs. Keep patients warm throughout their stay, and if they are allowed, give them access to fresh water and food. Make sure cats have a clean litter tray and someplace to hide (a plastic container turned upside down with a hole cut out works well as a hideaway box). At DVMS, we also label patient kennels as DNR or CPR so the pet can be treated according to the family’s wishes, if necessary.

To keep all associates up to date on the hospitalized patients, notes should be taken when any procedure is done to that patient and/or if there is any fluid loss. Lastly, try to keep the pets’ stress levels as low as possible. There are many different options available, some as simple as providing pheromones such as Feliway to help reduce stress in patients.

TECHNICIAN TIP

EXCEPTIONAL HOSPITALIZED PATIENT CARE STARTS WITH THE BASICS – BY AMBER CARLSON, CVT

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Dr. Riensche received her Doctor of Veterinary Medicine degree from Iowa State University in 2004. After graduation she completed a one-year rotating internship at VCA Animal Referral and Emergency Center of Arizona. Dr. Riensche then continued her training in internal medicine with a residency at the University of Illinois in Champaign-Urbana. Following her residency, Dr. Riensche relocated to Phoenix to join the staff of Arizona Veterinary Internal Medicine, now Desert Veterinary Medical Specialists. She has particular interests in nephrology, gastroenterology, infectious disease, respiratory medicine, and endocrine diseases.

She shares her home with her husband, 2 dogs named Hunter and Barrett Jackson, and 1 cat named Shelby. In her spare time, she enjoys sharing a comfy spot with her pets while reading, hiking and biking, interior decorating, and art projects.

TEAM MEMBERHIGHLIGHT

MELISSA RIENSCHE, DVM, DACVIM

SAVE THE DATE

UPCOMING CE EVENTS

Join us for the Scottsdale Specialist Symposium

WHEN: NOVEMBER 12, 2016 12:30 pm – 8:00 pm (Registration begins at 12:00 pm)

WHERE: Marriott Courtyard Salt River Conference Center 5201 N. Pima Road • Scottsdale • 480.745.8200

INFO: scottsdalevetspecialists.com/continuing-education

Dr. Riensche,

Thank you so much for taking care of our sweet dog Caida. I thought we were about to lose her.

So happy that she is back with us, she is doing great. Caida also thanks the staff who cared for her night and day. Great job.

– Diane and Chris Hanes

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