An 11-year-old female spayed Domestic Shorthair cat, showing symptoms of diabetes mellitus (DM), presented to Dr. Leah Goodman at Stoneledge Animal Hospital. Karen Ebersole, DVM, DABVP, from Scanvet was called in to perform an abdominal ultrasound due to the patient being non-responsive to medical management of DM. This case highlights how SonoPath works with the sonographer as well as the referring DVM to pursue a diagnosis as well as determine appropriate management of the patient’s disease. Remo Lobetti, BVSc, MMedVet, PhD, DECVIM, provided an internal medicine consult to aid in the diagnosis and management of the patient’s condition.
HISTORY:
Polyuria/polydipsia (Pu/PD); polyphagia, weight loss, mild to moderate hyperglycemia (200-300) with no response to Senvelgo®
Clinical Exam: poor condition, distended abdomen, thin abdominal skin.
CBC: WNL (persistent lipemia)
Serum Biochemistry
- Persistent Lipemia
- Persistently elevated albumin
- Progressive elevation in AST from 47-175
- Persistent hyperglycemia
Endocrinology
T4 – WNL
ULTRASONOGRAPHIC FINDINGS:
Urinary bladder: Over-distended with anechoic contents. Normal thickness and layering of bladder wall. Visible pelvic urethra was normal.
Adrenal Glands: Both adrenal glands were increased in size, with smooth capsular contour. There was a hyperechoic clearly demarcated nodule in the cranial pole of the left adrenal gland. Aside from the hyperechoic nodule, the remainder of the parenchyma was hypoechoic and homogeneous.
- LADR – 7.1 mm width at cranial pole, 6.1 mm at caudal pole, 1.5 cm in length
- RADR – 7.3 mm width at cranial pole, 1.4 cm in length
Liver: Increased in size with a smooth but rounded capsular contour. The parenchyma was subjectively hyperechoic with mild coarse echotexture. The hepatic and portal veins were normal in size and structure, with no visible congestion. There were no overt nodules or masses.
Pancreas: Mild to moderately enlarged in size. Mildly asymmetric capsular contour. Hypoechoic to heterogenous parenchyma with mildly bright adjacent mesentery.
ULTRASONOGRAPHIC INTERPRETATION:
- Low-grade active pancreatitis
- Diffuse, mild mucosal thickening in small intestine
- Mesenteric inflammation adjacent to pancreas and small intestine
- Bilaterally enlarged adrenal glands with mild asymmetry
- Hepatomegaly with diffusely bright parenchyma – Ddx hepatic lipidosis, vacuolar hepatopathy, vs endocrine related hepatopathy
INTERNAL MEDICINE CONSULT WITH DR. REMO LOBETTI
- Although the PU/PD, polyphagia, weight loss, and persistent lipemia are all hallmarks of diabetes mellitus, the degree of hyperglycemia with no response to Senvelgo® tends to make it less likely.
- There is no report of the fPL result but active pancreatitis tends to result in anorexia rather than polyphagia; thus this cat is far more likely to have a low grade chronic pancreatitis, which may be contributing to the persistent hyperglycemia.
- The two most likely etiologies for the bilateral adrenomegaly would be disease stress and pituitary-dependent Cushing’s disease.
- The reported enteropathy on the ultrasound can be considered an incidental finding.
- The persistently elevated serum albumin can be ascribed to mild dehydration.
- The glucosuria is secondary to the hyperglycemia.
What is Hyperadrenocorticism?
Hyperadrenocorticism (HAC) is a rare finding in the cat. Like the dog, 85% of feline patients have pituitary-dependent HAC. The remaining 15% will have either an adrenal adenoma or carcinoma. Tumors of the adrenal gland are generally unilateral. Bilateral enlargement is more consistent with pituitary disease. Clinical signs are generally seen in middle-aged to older cats with no breed predilection; however, there is a mild predilection in female patients. Clinical signs include PU/PD, polyphagia, pendulous abdomen, and thin skin/skin tears. Unlike dogs, the development of PU/PD may be delayed in the clinical course of the disease until the patient becomes hyperglycemic with glycosuria. As such, the PU/PD is secondary to an osmotic diuresis. Many patients will also have a history of weight loss, which is more commonly attributed to poorly controlled diabetes mellitus in 90% of patients. Testing for HAC is most reliably performed using a low dose dexamethasone suppression test (LDDST). The ACTH stimulation test is useful for differentiation of iatrogenic HAC but shows a poor sensitivity with naturally occurring HAC. A urine cortisol creatinine ratio may be used as a screening tool for potential HAC; however, if the results are positive, a second test such as the LDDST may be used to confirm the diagnosis. The LDDST has almost 100% sensitivity and is the preferred test for HAC. The treatment of choice for adrenal tumor causing HAC is surgical removal. For patients with pituitary-dependent HAC, the treatment of choice is trilostane. The prognosis of HAC is guarded to grave. With no treatment, most cats will succumb to complications of the disease, including cardiovascular effects from chronically elevated cortisol, skin tears secondary to glucocorticoids, and secondary infections.
Peterson ME, Baral RM Adrenal gland disorders in: Little S: The Cat, 2nd ed., Elsevier, Philadelphia 2012 pp.774-783
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