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

E-mail

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

E-mail

pvsmonterey@pacbell.net

Pacific Veterinary Specialists &

Emergency Service

1980 41st Avenue

Capitola, CA 95010

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See us at:

www.pvses.com