Central DI in Dog

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Central Diabetes Insipidus in aDog

Brian CasertoCornell College of Veterinary MedicineClass of 2007May 9, 2007

Advisor: Dr Ken Simpson


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Signalment

Princess, a 12 year old FS mixed breed dog

2 month history of PU/PD and right side nasaldischarge , lethargy . Hypercalcemia, hyperproteinemia, and

hyperglobulinemia (from referring vet) Baseline T4 mild low (1.43 mcg/dL) Cortisol slightly elevated (9.24 mcg/dL) History of dehydration


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Physical Exam

QAR normal TPR

Significant findings Right side mucopurulent nasal discharge Purulent discharge OD


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Problem List

Purulent ocular discharge (right eye)Right side mucopurulent nasaldischarge

PU/PD


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Problem List continued

Hypercalcemia

HyperproteinemiaHyperglobulinemiaHypothyroid

Hyperadrenocorticism


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PROBLEMS


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Purulent ocular

discharge (righteye)Right sidemucopurulentnasal dischargePU/PD

Differential Diagnosis


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Purulent ocular


KeratoconjunctivitissiccaKeratitisConjunctivitisNeoplasia



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Purulent ocular


KeratoconjunctivitisBacterial rhinitisFungal rhinitis

Neoplasia



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Purulent ocular


HypercalcemiaDiabetes MellitusHyperadrenocorticismPyelonephritis

Liver diseaseRenal disease



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PROBLEMS

ocular discharge PU/PD

NasalDischarge

Lethargy

KCS


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Diagnostic Plan

Schirmer tear test Ophthalmology consult

CBCSerum chemistryIonized calciumUrinalysisAbdominal ultrasoundThoracic radiographs


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ResultsBelow normal tear production OU Ophthalmology consult

Bilateral KCSNeutrophilia 10.5 thou/uL Mild/ stress relatedHyperproteinemia 8.1 g/dL Mild/ hydration)Hypernatremia 154 mEq/L (142-151)Hyperchloremia 119 mEq/L (107-117)

Hypercalcemia (iCa) 1.38 mmol/l Mild/hydrationElevated Alk Phos 123 U/L Mild/hydration/stressHyposthenuria (1.003)Normal chest radiographs


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ResultsBelow normal tear production OU Ophthalmology consult

Bilateral KCSNeutrophilia 10.5 thou/uLHyperproteinemia 8.1 g/dLHypernatremia 154 mEq/L (142-151)Hyperchloremia 119 mEq/L (107-117)

Hypercalcemia 1.38 mmol/lElevated Alk Phos 123 U/LHyposthenuria (1.003)Normal chest radiographs


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US

Liver

Hypoechoic nodule(right)

Spleen Nodule deforming

the capsule


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Conclusions from Lab Work

Hyposthenuria (1.003)

No evidence of systemic infectionMild HypercalcemiaMild Hypernatremia


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Additional Problem List

Hyposthenuria

HypercalcemiaHypernatremiaKCS


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Additional DDX List

Central Diabetes

InsipidusNephrogenic DiabetesinsipidusDiabetes MellitusPsychogenic polydipsia

Hyposthenuria



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Additional DDX List

Hyperparathyroidism

Vitamin D toxicityHypercalcemia of Malignancy

HemoconcentrationSpurious

Hyposthenuria



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Additional DDX List

Hypercalcemia

HyposthenuriaHypernatremiaKCS

Auto immune

dacryoadenitisDistemper Systemic sulfonamidetreatmentTraumaNeurogenic


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Additional DDX List

Hypercalcemia

HyposthenuriaHypernatremiaKCS

Auto immunedacryoadenitisNeurogenic


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Simplify


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PU/PD

Hypercalcemia

HyperadrenocorticismHypoadrenocorticismRenal FailureDiabetes InsipidusPsychogenic Polydipsia

Repeat ionized calcium

ACTH stimulation

Baseline Cortisol

Technecium GFR

NORMAL

NORMAL

NORMAL

NORMAL


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PU/PD

Diabetes Insipidus

Nephrogenic CentralPsychogenic Polydipsia

Desmopressin Response Test


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Diabetes Insipidus

What is it?

AnatomyPhysiologyClinical aspects


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Pitutary Gland

Evans and DeLahunta, 2000


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MammillaryBodies

Infundibulum


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Boron and Boulpaep, 2003


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ADH is alsoknown as

AVP

Or

Vasopressin



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Renal Collecting Ducts

WATER



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Central Vs Nephrogenic



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PU/PD

Central Diabetes Insipidus

Nephrogenic Diabetes InsipidusPsychogenic Polydipsia


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PU/PD

Central Diabetes Insipidus Neoplasia

Primary pituitaryCraniopharyngiomaMeningiomaMetastatic tumor

Inflammatory disease TraumaNephrogenic Diabetes InsipidusPsychogenic Polydipsia


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PU/PDCentral Diabetes InsipidusNephrogenic DiabetesInsipidus Primary- Huskies Hypercalcemia Diabetes Mellitus Hyperadrenocorticism HypoadrenocorticismPsychogenic Polydipsia

Pyometra Pyelonephritis Liver disease Renal disease

Hyperthyroidism Medullary washout


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PU/PD


Nephrogenic Diabetes InsipidusPsychogenic Polydipsia Young dogs that are kept alone for long

periods of time


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Clinical signs of DI

PU/PD

HyposthenuriaHypernatremia Water Deprived


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PU/PD Reduced water reabsorption in the kidney

HyposthenuriaHypernatremia


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PU/PD

Hyposthenuria Salt reabsorption and lack of water reabsorptionPU/PD

Hypernatremia


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PU/PD

HyposthenuriaHypernatremia Result of severe dehydration due to water

loss Occurs in animals without access to free water


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Back to Princess


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PU/PD

Diabetes Insipidus

Nephrogenic CentralPsychogenic Polydipsia



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DDAVP Decreased water intake over 24 hrs Urine SG increased from 1.003- 1.029

Water intake

Time

U r i n e S G

Desmopressin


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Diagnosis


KCS (OU)Possible rhinitis


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Treatment

Treatment DDAVP (Desmopressin) Synthetic vasopressin

used to treat the symptoms, concentrate urine,stop PU/PD

Optimmune (cyclosporine) and NeoPolyDex

ointment, and paralube


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Follow up

Princess returned 11/4/06 with increasedlethargy and increased respiratory rateExam Severe Depression Masseter muscle atrophy No Cranial nerve deficits Bloodwork unremarkable


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Follow Up

Treated with fluids overnight

Urine SG low desmopressin was increased to 2 drops in theevening.

Chest radiographs (11/6/06)- normal

MRI- Severe Progressive DepressionCTEndoscopy- no abnormality in nasal cavity


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MRI T1

T1Contrast


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MRI

DeLahunta, 1983

PituitaryPrincess Normal

T1


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MRI

Princess Normal

T1 T1


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MRI

Princess Normal

T1 T1


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MRI

Polyostotic aggressive bone lesion

Otitis media (right side worse)


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CT


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CT Pterygoid

NormalPrincess


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Normal

CT

Princess

Sphenoid

Complex


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CT Basisphenoid

NormalPrincess

Bone Lysis


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CT

Polyostotic aggressive bone lesion

Otitis Media (right)


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Follow Up

Endoscopy- no abnormality in nasal cavity

?Princesses depression and lethargy continues and euthanasia waselected


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Necropsy findingsGross findings

Skull- locally extensive basioccipital bone densityirregularityLiver- multifocal hepatoma (presumptive)Kidney (R)- multifocal chronic infarctsSpleen- focal nodular hyperplasiaMasseter muscle- moderate chronic diffuse muscleatrophyRight AV valve- focal hematocyst


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Necropsy Findings

Histopathology

Liver- vacuolar hepatopathy spleen- Focal leiomyoma Basioccipital bone

Thinning focal medullary cavity

fibroplasiaEvans and DeLahunta, 2000

Pituitary


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Histopathology 4X

Cementing Lining

Normal Bone Affected Bone


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Histopathology 4X

Spindle Cells

Blood Vessels

Normal Bone Affected Bone


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Histopathology 40X

Cementing Lining Spindle Cells

4X4X

Bone Remodeling Fibroplasia


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Conclusions

No cause for the changes in the bone weredeterminedThe cause of the pituitary disorder was notfound


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SpeculationsInflammatory process or infection causinglocally extensive bone destruction andsecondarily affecting the pituitary and other parts of the brain.An unidentified pituitary neoplasm


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REFERENCES1. Authement JM, Boudrieau RJ, Kaplan PM. Transient, traumatically induced, central diabetes insipidus in a dog.J Am Vet Med Assoc . 1989;194:683-685.2. Barr SC. Pituitary tumour causing multiple endocrinopathies in a dog. Aust Vet J . 1985;62:127-129.3. Bolger WE, Leonard D, Dick EJ,Jr, Stierna P. Gram negative sinusitis: A bacteriologic and histologic study inrabbits. Am J Rhinol . 1997;11:15-25.4. Boron WF, Boulpaep EL, eds. Medical Physiology: A Cellular and Molecular Approach. 1st ed. Philadelphia,Pennsylvania: Saunders; 2003.5. DeLahunta A. Veterinary Neuroanatomy and Clinical Neurology . 2 nd ed. Saunders; 1983.6. Evans HE, DeLahunta A. Guide to Dissection of the Dog. 5 th ed. Saunders, 2000.7. Feldman EC. Central diabetes insipidus in a dog. Mod Vet Pract . 1979;60:615-619.8. Feldman EC, Nelson RW. Diagnostic approach to polydipsia and polyuria. Vet Clin North Am Small Anim Pract .1989;19:327-341.9. Goossens MM, Rijnberk A, Mol JA, Wolfswinkel J, Voorhout G. Central diabetes insipidus in a dog with a pro-opiomelanocortin-producing pituitary tumor not causing hyperadrenocorticism. J Vet Intern Med . 1995;9:361-365.

10. Harb MF, Nelson RW, Feldman EC, Scott-Moncrieff JC, Griffey SM. Central diabetes insipidus in dogs: 20cases (1986-1995). J Am Vet Med Assoc . 1996;209:1884-1888.11. Neer TM, Reavis DU. Craniopharyngioma and associated central diabetes insipidus and hypothyroidism in adog. J Am Vet Med Assoc . 1983;182:519-520.12. Nichols R. Polyuria and polydipsia. problems associated with patient evaluation. Probl Vet Med . 1990;2:610-616.13. Ramsey IK, Dennis R, Herrtage ME. Concurrent central diabetes insipidus and panhypopituitarism in agerman shepherd dog. J Small Anim Pract . 1999;40:271-274.

Thanks


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Thanks

Dr SimpsonDr DykesDr Arauz

LisiaThe class of 2007


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QUESTIONS ?

Central DI in Dog

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