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
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
Requested special stains– Churukian-Schenk silver stain– Pheochromocytoma
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