““Dillinger” DuckworthDillinger” Duckworth

11yo MN Siberian Husky

MR# 12957

Dillinger 11yo MN Siberian Dillinger 11yo MN Siberian HuskyHusky Presenting complaint: PU/PD and urinary

incontinence History: 1-year history of slight

incontinence. Over the past few months, the owner observed increased thirst and increased frequency of drinking. Consequently, he has been urinating more and appears to be more incontinent. Otherwise, there are no other clinical signs.

HistoryHistory

• Medical history – 12/03: Hpercalcemia = 12.5; USpG = 1.007

• No previous surgery besides neuter• Travel history – Texas and California• Medications – Rimadyl PRN;

Cephalexin for hot spots

Physical ExamPhysical Exam

P.E.: BAR, vitals WNL, reluctant to allow palpation of the caudal abdomen, normal rectal exam.

Problem ListProblem List

PU/PDIncontinence?Hypercalcemia– Intact PTH – 134.5 (20-130)– Ionized Calcium – 2.16 (1.24-1.43)– Calcium – 12.8 (8.9-11.4)

Primary HyperPTHPrimary HyperPTH

Working diagnosis of primary hyperparathyroidism

Additional diagnostics:– Cervical ultrasound – Thoracic radiographs– Abdominal ultrasound

SEE RADIOLOGY/US REPORT

Adrenal Mass?Adrenal Mass?

FNAC– Neuroendocrine/Adrenal tumor

High-dose Dexamethasone suppression test– Cortisol, 0hr – 5.2 (0.0-10.0)– Cortisol, 4hr – 0.4 – Cortisol, 8hr – <0.3 (0.0-1.4)

Suspect Pheochromocytoma

PlanPlan

BP = 105 systolicParathyroidectomy 1st

– PU/PD– ↑ Ca2+

+/- Adrenalectomy (Pheo.)?– Incidental finding? (approx 30%)– PU/PD (25%)

Other possible diagnostics?Other possible diagnostics?

Diagnostic Imaging– CT/MRI• Rosenstien (MSU) Vet Rad/US 2000

– P-[18F] fluorobenzylguanidine (PET)• Berry et. al. (NCSU) Vet Rad/US 2002

Other possible diagnostics?Other possible diagnostics?

Hormonal testing– Plasma catecholamines– Clonidine supression test– Urinary catecholamies/metabolites• Metanephrine, Normetanephrine, VMA

– Pentolamine test

PlanPlan

Initiate Phenoxybenzamine– Alpha-adrenergic blocking agent–Minimize hypertensive reactions and

cardiac arrhythmias+/- beta blocker– If hypertension present despite

phenoxybenzamine– If arrhythmias or tachycardia present

Surgery (10/27/04)Surgery (10/27/04)

CBC, Chem, UASaline diuresisParathryoidectomy– Intra-operative PVCs– Blood pressure• Systolic 70-90• Mean 50-70

– Responded to Lidocaine

Surgery (10/27/04)Surgery (10/27/04)

Recovered well post-op– Fluids– ECG, BP– Calcium checks– Analgesia

Hypocalcemia (expected) - stabilizedDischarged 10/30/04Parathryoid adenoma

Follow-up 11/14/04Follow-up 11/14/04

NormocalcemicNo improvement in the PU/PDPlan Adrenalectomy

Surgery (11/17/04)Surgery (11/17/04)

Anesthetic considerations– Alpha-blocking agent– +/- Lidocaine before induction– Avoid Ketamine – sympathetic stim.– Isoflourane– +/- non-depolarizing NM blocking agent– Fentanyl CRI intra-op– Direct BP– Central line

Surgery (11/17/04)Surgery (11/17/04)

Intra-op– Large adrenal mass engulfing the left

kidney• Nephrectomy and Adrenalectomy

– No arrhythmias– BP (60-120 systolic)– HR ↑ 200 in one reading

Surgery (11/17/04)Surgery (11/17/04)

Intra-op– Blood loss hypotension• ↑ fluids• Hetastarch• Whole blood transfusion

Surgery (11/17/04)Surgery (11/17/04)

Immediately post-op– Sudden arrest in prep-room as central

line being placed– CPR no response

Surgery (11/17/04)Surgery (11/17/04)

Possible causes?– Blood loss– Rapid hypotension post-pheo. removal– Cardiac arrhythmia– Hemorrhage– Thromboembolic episode

HistopathologyHistopathology

Adrenal carcinoma?– Cushing’s?– Thromboembolic episode?

HistopathologyHistopathology

Requested special stains– Churukian-Schenk silver stain– Pheochromocytoma

DiscussionDiscussion

What could have been done differently?– Lidocaine pre-med?– LMWH?– Direct BP?– Beta blocker?