Signalment: Canine, Boston Terrier, Male, 10 years old
	History: Referred for treatment of a corneal ulcer in left eye that developed 2 days ago. Dog is scratching at eye. One month ago a similar problem developed in the right eye which would not heal.  A staphyloma and panophthalmitis developed requiring enucleation.  Polyphagia and diffuse truncal alopecia have developed in the last 6 months.  PU/PD has developed in the last 3 weeks but is not severe.  There are no problems noted by the owner.
	Physical Examination: T 100.8, P 80, R 16, and WT 13 lbs.  Generalized truncal alopecia (see slide 1 and slide 2) with no hyperpigmentation noted.   The skin is thin and follicular plugs are noted on the abdominal skin. Left eye: corneal ulcer with a moderate anterior uveitis.  Right eye is missing.
	Diagnostic Plan:Using the POVMR format, identify the problems and formulate a diagnostic plan for this case.

No.	Problem
1.	corneal ulcer with anterior uveitis
2.	diffuse truncal alopecia with thin skin
3.
4.
5.
6.
7.
8.
9.
10.

B. Of the problems you have identified, which is (are) the most important to manage?

A. DX: List ruleouts for the problems you identified in Step 2.

Problem No.	Ruleout(s)
1.	bacterial keratitis, trauma, keratoconjunctivitis sicca, (is there a cause and effect relationship with the ruleouts in problem #2)
2.	Hyperadrenocorticism, hypothyroidism, Sertoli cell tumor
3.
4.
5.
6.
7.
8.
9.
10.

B. List those diagnostic procedures that will be most cost-effective.

1.  2.

3.  4.

5.  6.

7.  8.

9.  10.

Analyze the initial database results.

Hematology:

RBC Morphology:

Test	Value	Unit	Point your mouse here to view Hematology Norms	Test	Value
WBC	9550	x 103 /mm3		Normal
RBC		x 106 /mm3		Rouleaux
HGB		gr/dl		Polychrome
PCV	37	%		Aniso
MCV		fl		Poik
MCV		pg		Crenation
MCHC		g/dL		Target
PLT		x 103 /mm3		Hypochrome
TP	7	g/dL		BasoStrip
FIB		mg/dL		Sphero
Retic		%		NRBC/100 WBC
PUNT
AGGR
SED RATE		x 103 /mm3

Differentials:

Assessment: What is your assessment of the hematology data?

Test	%	Absolute	Point your mouse here to view Hematology Norms	The hemogram is suggestive of glucocorticoid effects (lymphopenia and eosinopenia are present).
SEG		8069
Band
Lymph		334
Eosin		47
Mono		1098
Baso		0
Other
PLTest
Toxic change

Biochemical profile:

Test	Value	Unit	Point your mouse here to view Chemistry Norms	Test	Value	Unit
Sodium	152	m mol/L		T. Bili		mg/dl
Potassium	4.5	m mol/L		ALKP	327	u/l
Chloride	101	m mol/L		ALT	41	u/l
TCO2		m mol/L		AST		u/l
Urea	9	mg/dl		LDH		u/l
Creatinine		mg/dl		CK		u/l
Calcium	10.6	mg/dl		GGT		u/l
Phosphorus		mg/dl		Magnesium		mg/dl
Glucose	123	mg/dl		Osmolality		mosm/L
T. Protein	7.6	g/dl		Anion Gap		mosm/L
Albumin	3.5	g/dl
Globulin		g/dl
A/G ratio

What is your assessment of the biochemical profile ?

The ALKP is increased. There are 2 mechanisms in dogs, cholestasis and enzyme induction. There is no evidence of cholestasis (see UA) so enzyme induction (glucocorticoids) should be suspected.

Urinalysis:

Microscopic Sediment Exam:

Test	Value	Unit		Test	Value	Unit
Volume		ml		WBC	many	ml
Color	yellow			RBC	2-3/hpf
Transparency	Clear			Bacteria	4 plus
Specific Gravity	1.018			Epitheliel	0
Phosphorus				Fat	0
Protein	1 plus	mg/dl		Sperm	0
Ketones	0	mg/dl		CaOxalate	0
Bilirubin	0			CaCarbonate	0
Blood	trace			TriplePhos	0
Urobili	trace			Bilirubin	0	mg/dl
				Amorph	0	mg/dl
				Casts	0

What is your assessment of the urinalysis data?

If urine has been collected by cystocentesis, a urinary tract infection is present. The urine should be cultured.

Identify the major ruleout(s) supported by this data.

The primary ruleout supported by initial data base is hyperadrenocorticism. All of the findings can be associated with this disease.

Have you identified any new problems?	No Yes	If so, what are they?
urinary tract infection

List the diagnostic tests or procedures that should be performed next.

1. Urine culture; 2. Screening test for hyperadrenocorticism

RX:

What immediate therapy would you prescribe for problems identified in Section 2?

The corneal ulcer and anterior uveitis should be treated aggressively. Topical antibiotics, pupilary dilation, and corneal protection (third eyelid or conjunctival flap) should be given. The eye should be kept moist (artifical tears). Corticosteroid therapy may be indicated once the cornea begins to heal. Urinary antibiotics are indicated after urine is submitted for culture.

Learning Issues:

	UTI is very common in dogs with CCS. Why?
	Review the advantages and disadvantages of urine cortisol/creatinine, ACTH stimulation and LDDS tests in screening dogs for hyperadrenocorticism.

Continue with Expanded Case Evaluation

Problems? Content: Dr. Michael D. Lorenz; Web page operation: Betty Handlin
Copyright^© 1999 Oklahoma State University College of Veterinary Medicine
This page was last updated 10/19/07 09:51:09 AM