Wednesday, November 7, 2012

Insulinoma? Hypoclycaemia in a female Miniature Schnauzer

"The 5-year-old spayed Miniature Schnauzer has 3 problems," the lady owner told me as I noted the lumps and scabs crusting the upper surface of the spinal area. "Skin infections in this backbone area, ear infections and urinary tract infections."
The dog had been to Vet 1 who had diagnosed UTI and had found one calcium oxalate crystal. He advised ultrasound at another practice and the report dated Sep 3, 2012 stated that the liver was enlarged, gall bladder had sediments 20%, stomach distended, intestines thick-walled, bladder had echogenic materials, kidneys inflamed.

I palpated and got a slight pain from anterior abdomen which appeared swollen. Onset of recurring UTI started a few months ago, vulval licking around one year ago. Anal sac expressed - thick oil +++
No steroid inj as the owner was not in favour of it and Vet 1 had already injected on Jun 29, 2012 for the "hot spots on dorsal back region" which was what had happened again in this consultation.

dipstick pH 6.0, SG 1.040, Pn 3+, no blood, no white cells.

Commercial Lab Test -   pH 7.0, SG 1.048, Pn +, no blood,  white cells present, bacteria +, nitrites +,
ketones trace, crystals nil

1. Total cholesterol 11.28, HDL 5.7, LDL not able to estimated due to interference from elevated triglycerides level of 14.30

2. Glucose 1.4  (3.9 - 6.0).   Hb 20.9 (12-18) but other values are normal. Kidney and liver are normal.

So, what is the main problem? UTI.
What's the solution?
Nov 7, 2012 7.30 pm I phoned the owner. On Nov 5, 2012, Dr Daniel had used his GPS and drove me to the Bishan apartment. I delivered the blood test and urine test results in her post-box as Dr Daniel was going to Bishan. Today, I asked her. She did not go to the letter box yet.

Q1. How's the right ear?
Scaly. No pus.

Q2. Urine.
A. No blood. No dribbling or incontinent.

Q3. Does the dog drink a lot?
A. Drinks little. This explains why the UTI recurs. There is insufficient urine production to flush off the bladder's sediments which I presumed included calcium oxalate from the dry dog food. This explained the high USG of over  1.040

Q4. Still feeding the dry dog food? The owner bought expensive organic dry dog food of different brands.
A. Yes.

1. June 29, 2012   Hotspots on dorsal back region. Antibiotic and shincort injection.
2. Jul 30, 2012      Haematuria & dysuria. No stones palpated inbladder. Cystitis. Advised to review with urine analysis and ultrasound if recur

3. Aug 18, 2012   Vaccination
4. Aug 28, 2012  Haematuria. Appointment for ultrasound at another practice.
5. Sep 3, 2012     Owner showed ultrasound report indicating "cystitis" and renal inflammatory condition". No stones, mass, polyps in ultrasound. Urine analysis - leucocytosis, glucose -ve, blood -ve, one calcium oxalate crystal seen.
6. Sep 25, 2012. Otitis externa right ear. pus.

This case is a challenging case and the whole history and situation has to be reviewed regularly. The main problem is the recurring UTI. According to the owner, onset of dysuria, haematuria, polyuria started a few months ago. The vulval licking was around one year.

How to solve this problem economically?
1. Increase water intake. The dog drinks little. Therefore canned food. No dry food. What brand?
2. As one calcium oxalate crystal was found by Vet 1 and the pH was NOT stated in his two urine test on Jul 30 and Sep 3, 2012, it is hard to know whether the urine was alkaline or acidic.
Based on my urine test on Nov 3, it was pH 7.0 (neutral) but bacteria was present. No urinary crystals. Why was there positive nitrite?
3. For the next 4 weeks, strictly on U/D diet and re-check the urine again for infection. If no recurring UTI, the dog should be on U/D diet for some months.

Low glucose. The dog did not faint or go into fits any time as the owner did not complain about this. So the low glucose on Nov 3, 2012 was a puzzle. The beginning of insulinoma since ketones (trace) was present in the urine? High lipid in the blood - gluconeogenesis, starting ketosis?

More reviews will be needed.



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