1. “Dillinger” Duckworth 11yo MN Siberian Husky MR# 12957

2. Dillinger 11yo MN Siberian Husky Presenting complaint: PU/PD and urinary incontinence History: 1-year history of slight incontinence. Over the past few months, the owner observed increased thirst and increased frequency of drinking. Consequently, he has been urinating more and appears to be more incontinent. Otherwise, there are no other clinical signs.

3. History Medical history – 12/03: Hpercalcemia = 12.5; USpG = 1.007 No previous surgery besides neuter Travel history – Texas and California Medications – Rimadyl PRN; Cephalexin for hot spots

4. Physical Exam P.E.: BAR, vitals WNL, reluctant to allow palpation of the caudal abdomen, normal rectal exam.

5. Problem List PU/PD Incontinence? Hypercalcemia –Intact PTH – 134.5 (20-130) –Ionized Calcium – 2.16 (1.24-1.43) –Calcium – 12.8 (8.9-11.4)

6. Primary HyperPTH Working diagnosis of primary hyperparathyroidism Additional diagnostics: –Cervical ultrasound –Thoracic radiographs –Abdominal ultrasound SEE RADIOLOGY/US REPORT

7. Adrenal Mass? FNAC –Neuroendocrine/Adrenal tumor High-dose Dexamethasone suppression test –Cortisol, 0hr – 5.2 (0.0-10.0) –Cortisol, 4hr – 0.4 –Cortisol, 8hr – <0.3 (0.0-1.4) Suspect Pheochromocytoma

8. Plan BP = 105 systolic Parathyroidectomy 1 st –PU/PD –↑ Ca2+ +/- Adrenalectomy (Pheo.)? –Incidental finding? (approx 30%) –PU/PD (25%)

9. Other possible diagnostics? Diagnostic Imaging –CT/MRI Rosenstien (MSU) Vet Rad/US 2000 –P-[18F] fluorobenzylguanidine (PET) Berry et. al. (NCSU) Vet Rad/US 2002

10. Other possible diagnostics? Hormonal testing –Plasma catecholamines –Clonidine supression test –Urinary catecholamies/metabolites Metanephrine, Normetanephrine, VMA –Pentolamine test

11. Plan Initiate Phenoxybenzamine –Alpha-adrenergic blocking agent –Minimize hypertensive reactions and cardiac arrhythmias +/- beta blocker –If hypertension present despite phenoxybenzamine –If arrhythmias or tachycardia present

12. Surgery (10/27/04) CBC, Chem, UA Saline diuresis Parathryoidectomy –Intra-operative PVCs –Blood pressure Systolic 70-90 Mean 50-70 –Responded to Lidocaine

13. Surgery (10/27/04) Recovered well post-op –Fluids –ECG, BP –Calcium checks –Analgesia Hypocalcemia (expected) - stabilized Discharged 10/30/04 Parathryoid adenoma

14. Follow-up 11/14/04 Normocalcemic No improvement in the PU/PD Plan  Adrenalectomy

15. Surgery (11/17/04) Anesthetic considerations –Alpha-blocking agent –+/- Lidocaine before induction –Avoid Ketamine – sympathetic stim. –Isoflourane –+/- non-depolarizing NM blocking agent –Fentanyl CRI intra-op –Direct BP –Central line

16. Surgery (11/17/04) Intra-op –Large adrenal mass engulfing the left kidney Nephrectomy and Adrenalectomy –No arrhythmias –BP (60-120 systolic) –HR ↑ 200 in one reading

17. Surgery (11/17/04) Intra-op –Blood loss  hypotension ↑ fluids Hetastarch Whole blood transfusion

18. Surgery (11/17/04) Immediately post-op –Sudden arrest in prep-room as central line being placed –CPR  no response

19. Surgery (11/17/04) Possible causes? –Blood loss –Rapid hypotension post-pheo. removal –Cardiac arrhythmia –Hemorrhage –Thromboembolic episode

20. Histopathology Adrenal carcinoma? –Cushing’s? –Thromboembolic episode?

21. Histopathology Requested special stains –Churukian-Schenk silver stain –Pheochromocytoma

22. Discussion What could have been done differently? –Lidocaine pre-med? –LMWH? –Direct BP? –Beta blocker?