By Dr. Warren Riggle
Lily, a 4 year 4 month German Shorthaired Pointer, came to us as an emergency on November 16, 2011 around 2:30 P.M. after being seen by another veterinary hospital two weeks prior for undiagnosed pain. At that hospital, she was prescribed a pain medication called tramadol, and she seemed to be doing better.
The evening before Lily came to our clinic she had gotten into the trash and started vomiting. The following morning, Lily continued vomiting and was not eating or drinking but was able to walk. Early in the afternoon, Lily had suddenly gotten much worse and was not able to walk or even get up before she was presented to us.
When Lily came in to our hospital, she was non- responsive. She couldn't raise her head and it was immediately apparent that Lily was critically ill. Her temperature was extremely low at 96.6 (normal is 101.0 – 102.5) and her heart rate was 40 (the average dog’s heart rate is 80-160). It is extremely concerning and unusual to see a dog with a temperature of 96.6 and a heart rate of 40. These vital signs told us Lily was dying and needed an immediate diagnosis.
Fortunately, we have lab equipment in our hospital that gave us very quick blood test results, which allowed us to have a better understanding of what was causing Lily’s problems. We did a series of tests and had the results back about 2 minutes after drawing the blood sample. Her potassium was extremely high at 8.1 (normal 3.4 – 4.9) and sodium was very low at 126 (normal 139 – 150). The BUN, a kidney test was 114 (normal is 10-26) and the glucose was quite low at 41 (normal 60-115). The hematocrit was 68 (normal is 35-55) showing she was extremely dehydrated. The results of these tests were very consistent with a disease called Addison’s Disease. Addison’s Disease is a common name for hypoadrenocorticism, a condition where there is a diminished production of hormones from the adrenal gland.
A potassium of 8.1 is extremely life threatening and was responsible for causing Lily’s heart rate to be so slow. The emergency goals were to decrease the potassium, start correcting the dehydration and acidosis, and correct the very low glucose. We placed an IV catheter and immediately starting giving saline fluids as quickly as possible. Lily received 2 liters (1/2 gallon) of saline in less than one hour. This fluid was chosen because her sodium level was very low and saline contains sodium chloride, and unlike most of our other fluids, it contains no potassium. This helped lower the potassium and correct the dehydration. We gave her 50 cc of dextrose (sugar) intraveneously to help correct the low blood glucose. We immediately began checking Lily’s vital signs with an instrument to monitor the heart rate and EKG. To help bring her body temperature back to normal we covered Lily with a Bair Hugger Warmer, which is a very carefully calibrated piece of equipment also used in human hospitals. Bair Huggers provide warmth without any danger of causing a burn because the warming is done with circulating warm air.
I have been practicing at the Animal Hospital of North Asheville for over 30 years and Lily was the most critically ill young dog I ever remember seeing that has not been severely injured. During the first hour with Lily, I was very concerned she would die at any moment. We considered giving her regular insulin which would have helped bring her potassium down. It was a concern to give insulin since this lowers blood glucose and hers was so low. We closely monitored the heart rate and body temperature. Thankfully, Lily’s heart rate and body temperature gradually increased within the first hour of treatment. Approximately 2 ½ hours later the potassium had dropped from 8.1 to 6.1 and the sodium had risen from 126 to 131. This was a dramatic improvement and Lily was then in much more stable condition.
Quite a number of additional tests were run, since Lily's case was very complicated. We were all extremely happy that Lily continued to improve, especially Lily’s mom. We conducted a test called an ACTH stimulation test that evening. This showed how the adrenal gland was responding to a hormone called Cortrosyn, which is similar to a naturally occuring hormone that stimulates the adrenal gland to produce cortisone. We take a blood sample, give a dose of Cortrosyn, then take another sample an hour later. The normal cortisone level is 1-5, and it should be 5-20 after the Cortrosyn dose. Lily’s test was less than 0.7 before and after stimulation of the adrenal gland. There was no response to the Cortrosyn, which confirmed the diagnosis of Addison’s Disease.
The adrenal glands are tiny glands next to the kidneys. They have many jobs, but their most important functions are to produce corticosteroids (cortisone), which allows the body to physiologically adapt to stress, and mineralocorticoids, which regulate the sodium and potassium levels in the blood. In patients with Addison’s Disease, the adrenal gland is not producing adequate corticosteroids which was why Lily got so sick when she was under stress. The adrenal gland was also not producing adequate mineralocorticoids. Without mineralocorticoids the potassium is too high and the sodium too low.
Lily responded extremely well to her treatment. We are fortunate at the Animal Hospital of North Asheville to have staff in the hospital to provide careful monitoring overnight. We gave her an injection of dexamethasone to supplement the deficient corticosteroid and she continued to have the fluid therapy throughout the night. She received an injection of Percorten, a drug to replace the deficient mineralocorticoids, that will be given every 30 days for the rest of her life. The next morning Lily had made a dramatic improvement and was able to eat, drink, and walk normally. She went home late in the afternoon and was doing amazingly better. Without treatment, Addison’s Disease would have caused Lily’s death. With appropriate treatment and monitoring Lily can live a normal life. She receives an injection of percorten once a month and a small amount of prednisone daily to replace the deficient corticosteroid. We are thrilled that Lily continues to do very well at home. I saw Lily for a medical progress exam on March 28. Her blood work is now totally normal and Lily looks great!