Case Report: Moose

Thank you to Sophie Cressman of The Ohio State University for sending this case write-up our way!  We always love to see the cases that our students work through each and every day!

Moose: Yorkshire Terrier Mix presenting in DKA crisis

Introduction:

Moose was a 5y10m MN Yorkshire terrier mix that presented for lethargy, increased urination, decreased appetite, and acute onset of vomiting with no previous history of systemic illness. After performing a thorough physical exam and in house diagnostics, it was determined that he was experiencing a diabetic ketoacidodic crisis and in a hyperosmolar hyperglycemic state. 

History:

Moose was a 5y10m MN Yorkshire terrier mix presenting for recent lethargy and inappetence, acute onset of frequent vomiting but no diarrhea, weight loss, and increased frequency of urination. He had been previously healthy at annual exams, is up to date on vaccines, has had no change in diet or known foreign material ingestion, and no recent travel. 

Acute inappetence w/ v+ r/o: gastritis, pancreatitis, dietary indiscretion, foreign material ingestion, toxin

Pollakiuria r/o: UTI, cystitis, cystolith, toxin

Clinical Findings:

On physical exam, Moose was 5.6kg (loss of 2lbs since last year), QAR, had a HR of 130, RR of 30, had pink tacky mm with a CRT of <2s, a BCS of 5/9. 

Mouth: mild tartar, no other evidence of dental disease

EENT: no abnormalities

Cardiovascular: no murmur or arrhythmia, strong and synchronous pulses

Pulm: normal bronchovesicular sounds. Eupnic.

MS: ambulatory x4 limbs

Integument: no signs of ectoparasites or other lesions

Abdomen: tense on palpation, mild pain elicited generalized to abdomen, no organomegaly or mass palpated

GI: no diarrhea, vomited several times, anorexic

Rectal: dry hard feces palpated

Neurologic: mentation appropriate, gait appropriate 

Urogenital: increased urination in the middle of the night

Lymphatic: peripheral LN palpate normally

Diagnostics:

3v abdominal radiographs: No overt evidence of kidney stones or bladder disease, no overt signs of obstruction, homogenous fecal material and some gas in the intestines

Urine dipstick: ketonuria, glucosuria, dilute USG

IH CBC+diff: Inflammatory leukogram (mild leukocytosis characterized by a mature neutrophilia), moderate elevation in HCT 

*leukocytosis supports an underlying infection or inflammatory response

*elevated hematocrit supports dehydration

IH chem 12: mild elevation in ALP, mild elevation in BUN, moderate hyperglycemia, mild hypokalemia, mild hypokalemia

*cholestatic pattern (DM, extrahepatic duct obstruction, GB mucocoele, cholangiohepatits, cushings)

*BUN elevated most likely due to dehydration

*hyperglycemia (due to DM or pancreatitis or cholangitis not a stress response)

*hypoK+ (vomiting, acidosis)

*hypoNa+ (vomit, hyperosmolality from high blood glucose)

Did not perform blood gas to confirm acidosis or a UA 

Diagnosis:

Diabetic ketoacidosis in a previously un-diagnosed diabetic patient. 

Treatment:

While waiting for consent to hospitalize: 125ml LRS given SQ, 1mg/kg maropitant administered SQ

Once hospitalized: IV catheter placement, started on 2.5x maintenance fluid rate of 39ml/hr 0.9%NaCl (even though it’s acidifying it is still acceptable for use) to improve hydration, 9ml of KCl  (20meq/10ml) added to the fluid bag to improve hypokalemia. Insulin CRI with Regular insulin started at 10ml/hr. BG was checked q2hr. One reading was 179 so 2.5% dextrose was added to the fluids, fluid rate was decreased to 2x maintenance, and the insulin CRI was reduced to 5ml/hr. Continued monitoring BG. W/d food was offered the next morning and Moose ate a few bites. 

Rechecked dipstick and chem12 at 24 hours and electrolytes had normalized, residual ketonuria but improvement. 

Progress and Outcome:

Moose discharged next day. O. Will feed a bland diet of i/d for 5 days and transition back to regular diet if doing well. Recommend gradual transition to a low carb, high protein diet. Recommend omeprazole 20mg tablets: 1/4tab PO q24h for 5-7 days. O. 

Will start bid administration of a long lasting insulin vetsulin at 0.25units/kg and bring moose back to complete a BG curve and urine dipstick check in 2 weeks as well as  to discuss any improvement to his clinical signs of diabetes (i.e. increased urination). Will adjust insulin therapy as necessary. 

At recheck Moose was doing well. His BG curve showed good control of his glucose and his clinical signs had diminished. He had transitioned back to his original diet and is not going to switch to a lower carb higher fiber diet at the moment.