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HYPOGLYCEMIA

HYPOGLYCEMIA. MISSY HORN ACC# 165211. Missy Horn. Acc#164629 6 year old FS Labrador Retriever Presented for progressive generalized weakness and muscle atrophy for 1 year BW done in January by rDVM : WNL. Physical Exam. Frequently sits/lays down during exam

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HYPOGLYCEMIA

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  1. HYPOGLYCEMIA MISSY HORN ACC# 165211

  2. Missy Horn • Acc#164629 • 6 year old FS Labrador Retriever • Presented for progressive generalized weakness and muscle atrophy for 1 year • BW done in January by rDVM: WNL

  3. Physical Exam • Frequently sits/lays down during exam • Mild palmigrade/plantigrade stance • Mild weakness/decreased control and precision when placing paws with each limb advancement • Generalized muscle atrophy; most pronounced over epaxials and pelvic limbs • Neurolocalization: neuromuscular

  4. Bloodwork • Performed prior to performing EMG • Big 4: • PCV 50% • TS 8.0 • BUN normal • Blood glucose: 38 • Insulin levels: Pending • CBC normal

  5. EMG • Spontaneous activity noted on multiple muscles with greatest severity in distal limbs • Slow/abnormal NCV ~41m/s •  Consistent with a peripheral neuropathy

  6. Causes of Hypoglycemia • Excess insulin secretion or insulin-like factors • Insulinoma, extrapancreatic tumors and islet cell hyperplasia • Dec glucose production • Addisons, hypopituitarism, GH deficiency, liver dz, glycogen storage dzs, neonates, and toy breeds • Excess glucose consumption • Sepsis, extreme exercise • Drugs • Insulin, oral hypoglycemics, salicylates, acetaminophen, beta blockers, TCAs, ACE -, tetracycline • Spurious

  7. Paraneoplasitc tumors • Several tumors can cause a paraneoplastic syndrome with the production of insulin like growth factor type II • Causes hypoglycemia • Mesenchymal tumors more common than epithelial • Leiomyosarcoma and leiomyoma of the GI tract are the most frequent mesenchymal tumor • Splenic hemangiosarcoma has also been described • Epithelial tumors most commonly from hepatocellular carcinoma • Sporadic cases of oral melanoma and salivary adenocarcinoma have been reported

  8. Insulinoma • Diagnosis: • Repeated hypoglycemia: BG < 60 • Insulin > 20 • Histopathology of a pancreatic mass/nodule • Clinical Signs: • Mean age: 9 years • Seizures, collapse, weakness, ataxia, disorientation, mental dullness, and visual disturbances • Imaging: • Ultrasonography sensitivity of 56% in dogs and abdominal metastasis identified in 20% • CT: Sensitivity of 71% using conventional pre- and postcontrast CT. sensitivity not determined for dual phase CT angiography but is used for humans

  9. Pathophysiology • Insulin secreting tumor of the pancreatic beta cells • Carcinomas account of 60%, with the remainder being adenomas • Are rare but insulinoma is the most common pancreatic endocrine tumor (insulinoma, gastrinoma, and glucagonoma) • Large breed dogs most affected(Irish Setters, Boxers, and GSDs) but any breed can be affected

  10. Islets of Langerhans: island of endocrine tissue in the otherwise exocrine pancreas Alpha cells: produce glucagon Acts to inc BG 2. Beta cells: produce insulin Acts to dec BG and allows for uptake of glucose into cells 3. Delta cells: produce somatostatin Inhibits insulin and glucagon 4. Pancreatic polypeptide Inhibits both endocrine and exocrine pancreatic secretions

  11. Treatment Planning • Determine if mass is present and/or resectable • If surgically excisable  increases life span • Large percentage of animals has metastasis at time of diagnosis • Removal or mass will still increase prognosis • Median survival time of 12-14 months with partial pancreactomy • Young dogs have a worse prognosis

  12. CT characteristics • Precontrast: typically iso to hypoattenuating to adjacent parenchyma • Arterial phase: contrast enhancing(peak enhancement) • Venous: less contrast enhancing but still hyperattenuating compared to adjacent parenchyma • Delay phase: iso to hypoattenuating • Insulinomas are highly vascular making sense why they have peak enhancement during the arterial phase

  13. CT characteristics • CT angiography is not 100% sensitive in detecting insulinomas, likely depending on the vascular supply and size of the tumor • CT angiography is more sensitive than other imaging modalities and is also more sensitive in detecting metastatic disease • If hypoglycemic and elevated insulin levels, surgical exporatory with histopathology is still needed for diagnosis

  14. Hepatic LN

  15. Hepatic Lymph Node

  16. Right Lobe of Pancreas

  17. Pancreatic Mass Acc#151101 10yr MC Boxer Contrast enhancing mass in the left lobe of the pancreas

  18. Missy • If insulin levels are elevated owners will likely go ahead with abdominal exploratory • In the mean time are feeding small meals frequently and giving prednisone • Prednisone antagonizes the effect of insulin by causing insulin resistance at the level of the insulin receptors

  19. References 1.RobbenJH, Pollak YW, Kirpensteijn J, et al. Comparison of ultrasonography,computedtomography, and single-photon emission computed tomography for the detection and localization of canine insulinoma. J Vet Intern Med 2005;19:15–22. 2. Mai W, Caceres A. Dual-Phase Computed Tomographic Angiography in Three Dogs With Pancreatic Insulinoma. VRUS(2008) 49; 2: p141-148 3. Ettinger S and Feldman, E. Textbook of Veterinary Internal Medicine: Sixth Edition. 2005 Elsevier Saunders: p1560-1563 4. Zini E, Glaus TM, Minuto F, Arvigo M, Hauser B, Reusch CE. Paraneoplastic hypoglycemia due to an insulin-like growth factor type-II secreting hepatocellular carcinoma in a dog. J Vet Intern Med 2007. Jane-Feb; 21(1): 193-5

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