A prospective randomized clinical trial of vincristine versus human intravenous immunoglobulin for acute adjunctive management of presumptive primary immune-mediated thrombocytopenia in dogs.

BACKGROUND: Dogs with immune-mediated thrombocytopenia (ITP) are at risk of hemorrhage when platelet count is <50,000/µL. Treatment with vincristine (VINC) or human intravenous immunoglobulin (hIVIG) decreases platelet recovery time compared with treatment with corticosteroids alone. OBJECTIVES: To compare the effect of hIVIG versus VINC on platelet recovery in dogs with ITP. METHODS: Prospective, randomized study. Twenty dogs with idiopathic ITP (platelet count <16,000/µL) were enrolled. All dogs were treated with corticosteroids. Dogs were randomly assigned to receive a single dose of hIVIG (0.5 g/kg) or VINC (0.02 mg/kg). Outcome measures were platelet recovery time, duration of hospitalization, and survival to discharge. RESULTS: There was no significant difference in age, sex, weight, or initial platelet count between dogs treated with hIVIG (n = 10) and dogs treated with VINC (n = 10). Median platelet recovery time for both groups was 2.5 days (P = .51). Median hospitalization time for all dogs that survived to discharge was 4 days and not different between groups (P = .29). Seven of 10 dogs in the hIVIG group and 10 of 10 in the VINC group survived to discharge. Survival analysis did not identify any significant difference between the groups at discharge, 6 months, and 1 year after entry into the study. No adverse effects were reported in either group. CONCLUSIONS AND CLINICAL IMPORTANCE: Vincristine should be the first-line adjunctive treatment for the acute management of canine ITP because of lower cost and ease of administration compared with human intravenous immunoglobulin (hIVIG).

Correlation of inflammation with adrenocortical atrophy in canine adrenalitis.

Hypoadrenocorticism or Addison's disease (AD) is a functional disorder in which insufficient mineralocorticoid and glucocorticoid hormones are produced by the adrenal cortex. Human AD is usually attributed to lymphoplasmacytic adrenalitis with autoimmune destruction of the adrenal cortex. Lymphoplasmacytic adrenalitis is also reported in some descriptions of canine AD; however, the histological aspects of adrenalitis or adrenocortical atrophy have not been well characterized because microscopical examination is not required for diagnosis of AD. In this study, sections of adrenal glands from 33 dogs with adrenalitis were compared with those of 37 dogs without adrenal lesions. The affected dogs were classified clinically as having AD (n = 3), being suspected of having AD (n = 17), not having AD (n = 11) or were unclassified (n = 2). The adrenal inflammation was lymphoplasmacytic in 17 dogs, lymphocytic in four, lymphohistiocytic in one, granulomatous in three and neutrophilic in eight cases. Adrenal glands from control dogs lacked leucocyte infiltration and had a cortical to medullary area ratio of 1.1-7.2. All three dogs with AD, 8/17 dogs with suspected AD and 1/11 dogs without AD had a cortical to medullary area ratio <1.1. Because the area ratio was correlated (r = 0.94) with a linear cortical to medullary thickness ratio, a thickness ratio <1.1 could also indicate severe adrenocortical atrophy. Severe adrenocortical atrophy was associated typically with lymphoplasmacytic infiltration and nearly complete loss of cortical cells; however, the zona glomerulosa was partially spared in three dogs with lymphoplasmacytic adrenalitis and severe cortical atrophy. In contrast, non-lymphoid inflammation was generally part of systemic disease, multifocal and was unaccompanied by severe adrenocortical atrophy.

Hyperadrenocorticism associated with excessive sex hormone production by an adrenocortical tumor in two dogs.

An 11-year-old spayed female Labrador Retriever and a 9-year-old castrated male miniature Poodle were evaluated because of clinical signs of hyperadrenocorticism. Cortisol testing did not support a diagnosis of hypercortisolemia in either dog; however, imaging studies revealed unilateral adrenal tumors in both dogs. Serum concentrations of 17-hydroxyprogesterone, progesterone, and estradiol were high in both dogs, and androstenedione concentrations were also high in 1 dog. It is suspected that sex hormone secretion by the adrenal tumors in these dogs resulted in clinical signs of hyperadrenocorticism. Clinical signs and hormonal abnormalities resolved in the male dog after surgical resection of the tumor. There was no improvement in clinical signs after treatment with mitotane in the female dog, which died 2 months after diagnosis. Histologic evaluation confirmed the presence of adrenocortical carcinoma in both dogs.

Hyperadrenocorticism and hyperprogesteronemia in a cat with an adrenocortical adenocarcinoma.

A seven-year-old, neutered male domestic shorthair cat was evaluated for poorly regulated diabetes mellitus and increased skin fragility. Imaging studies revealed a right adrenal gland tumor, but cortisol testing did not support a diagnosis of hyperadrenocorticism. Serum concentrations of progesterone and testosterone were increased compared with a group of normal cats, and the clinical signs were attributed to hyperprogesteronemia. At necropsy, a diagnosis of adrenocortical adenocarcinoma was confirmed, and immunohistochemical staining confirmed the presence of progesterone within the tumor. Clinical signs of hyperadrenocorticism in cats may occur due to increased serum concentrations of hormones other than cortisol.

Human intravenous immunoglobulin therapy.

Human intravenous immunoglobulin (hIVIG) is a preparation of normal polyspecific IgG obtained from the plasma of healthy blood donors. Although purified immunoglobulins were initially developed for treatment of primary immunodeficiency syndromes, they have since been documented to be effective in the treatment of some immune-mediated diseases such as immune-mediated thrombocytopenia purpura and autoimmune hemolytic anemia. Blockade of Fc receptors on mononuclear phagocytic cells has been proposed as the most likely mechanism for the rapid early response to hIVIG treatment. Human IVIG has been used to treat canine immune-mediated hemolytic anemia (IMHA), anemia with myelofibrosis, and immune-mediated thrombocytopenia. Doses from 0.5 to 1.5 g/kg may be effective, although most studies have used a dose of 1 g/kg. Human IVIG is administered as an intravenous infusion over 6 to 12 hours, and dogs should be carefully monitored for adverse reactions during administration. The possibility of a increased risk of thromboembolism should be considered when undertaking hIVIG treatment. The safety of multiple treatments of hIVIG has not been established. In most dogs with IMHA, benefit may be limited to short-term improvement in hematocrit, which may allow time for other treatment modalities to become effective. Dogs with nonregenerative anemia and associated myelofibrosis may have longer-term responses to hIVIG treatment.

Use of the urine cortisol: creatinine ratio to monitor treatment response in dogs with pituitary-dependent hyperadrenocorticism.

OBJECTIVE: To determine the usefulness of measuring urine cortisol:creatinine ratio (UCCR) as a means of monitoring response to mitotane treatment in dogs with pituitary-dependent hyperadrenocorticism (PDH). DESIGN: Case series. ANIMALS: 51 clinically normal dogs and 21 dogs with PDH. PROCEDURE: The reference range for the UCCR was determined by measuring the ratio in 51 clinically normal dogs. The usefulness of measuring UCCR in evaluating response of 21 dogs with PDH to treatment with mitotane was evaluated by comparing ACTH-stimulated blood cortisol concentrations with UCCR at the end of the induction phase of treatment (13 dogs) and during the maintenance phase of treatment (21). RESULTS: UCCR was not useful for identifying dogs with inadequate adrenal reserves at the end of the induction phase of treatment or during the maintenance phase. The UCCR was useful for identifying dogs in which control of cortisol secretion was not adequate. CLINICAL IMPLICATIONS: UCCR should not be used for evaluation of dogs during the induction phase of treatment, because the potential consequences of not identifying dogs with inadequate adrenal reserves are great. The UCCR may be useful as an adjunct means of monitoring treatment response during the maintenance phase of treatment. However, the ACTH stimulation test remains a necessary component when monitoring response to treatment in dogs with PDH receiving mitotane.

Diagnosis of canine hyperadrenocorticism.

Diagnosis of canine hyperadrenocorticism can only be made when a suspicion of the disorder persists after completion of a thorough history and physical examination. The first diagnostic testing steps include a complete blood count, serum biochemical tests, and urinalysis with urine culture. Radiography or ultrasonography may also be necessary, depending on physical findings. Screening tests are next applied to support or exclude the clinical diagnosis of hyperadrenocorticism. After the diagnosis has been made, discrimination tests are applied to determine whether the cause is pituitary or adrenal. The limitations of screening tests, particularly in the presence of nonadrenal diseases, cannot be overemphasized. We recommend that neither screening tests nor discrimination tests for hyperadrenocorticism be used in dogs with concurrent nonadrenal disease.

Central diabetes insipidus in dogs: 20 cases (1986-1995).

OBJECTIVE: To assess clinical signs, biochemical findings, results of modified water deprivation and other diagnostic tests, response to treatment, and survival time in dogs with central diabetes insipidus (CDI). DESIGN: Retrospective study. ANIMALS: 20 dogs with CDI. PROCEDURE: Signalment, history, physical examination, results of diagnostic tests, response to treatment, and survival time were extracted from the medical record of each dog and supplemented with information obtained from owners via telephone. RESULTS: Isosthenuria or hyposthenuria was a consistent finding. Seven dogs with complete CDI and 13 dogs with partial CDI were identified on the basis of results of a modified water deprivation test. Dogs treated with desmopressin acetate responded well to treatment. Seven dogs were alive 18 to 72 months (median, 36 months) after diagnosis, and 10 dogs died or were euthanatized 1 week to 2 years (median, 2 months) after diagnosis. Seven of 10 dogs that died developed neurologic signs after diagnosis of CDI. Computed tomography revealed a mass in the region of the pituitary gland in 5 of 7 dogs. Necropsy of 6 dogs, including 2 dogs on which computed tomography had been performed, revealed neoplasia in the pituitary gland. CLINICAL IMPLICATIONS: Onset of neurologic signs after diagnosis of CDI in middle- to old-aged dogs indicates that CDI may not be a benign disease that is treated easily. Brain imaging is recommended after diagnosis of CDI in middle- to old-aged dogs. Also, because many dogs are isosthenuric on initial examination, CDI cannot be ruled out as a cause of polyuria and polydipsia on the basis of lack of hyposthenuria.

Interleukin-6 activity in dogs with juvenile polyarteritis syndrome: effect of corticosteroids.

Juvenile polyarteritis syndrome (JPS) is an idiopathic febrile disease in dogs. Elevated serum levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) have been reported in human patients with vasculitis. We investigated whether these cytokines are also elevated in serum of dogs with JPS using sensitive bioassays. Increased levels of IL-6 activity were detected in the serum of 12 acutely ill dogs, whereas the IL-6 activity decreased to low or undetectable levels during convalescence. Treatment of 5 acute JPS dogs with prednisone resulted in a rapid clinical improvement accompanied by a decrease of IL-6 activity. Withdrawal of prednisone treatment caused reappearance of clinical symptoms and high serum IL-6 activity within a few days. TNF activity could not be detected in the samples of normal dogs, convalescent JPS, or acute JPS dogs. These studies support a role for IL-6 in the pathogenesis of JPS.

Pathologic features of naturally occurring juvenile polyarteritis in beagle dogs.

Eighteen young Beagle dogs (eight males and 10 females), ages 6-40 months, with canine juvenile polyarteritis syndrome (CJPS), a naturally occurring vasculitis and perivasculitis of unknown etiology, were necropsied, and their tissues were examined by histopathologic and histochemical methods. The condition is characterized by recurring episodes of an acute onset of fever (> 40 C) and neck pain that persist for 3-7 days. The major histopathologic alterations were a systemic vasculitis and perivasculitis. During the febrile, painful period of CJPS, the vascular lesions ranged from a histiocytic-lymphocytic periarterial infiltration to transmural arterial inflammation with concomitant fibrinoid necrosis and vascular thrombosis. Massive periarterial accumulations of inflammatory cells were common and often extended into adjacent tissues. The small- to medium-sized muscular arteries of the heart, cranial mediastinum, and cervical spinal meninges were consistently involved. Vasculitis occasionally occurred in other organ systems. The vascular lesions in dogs examined during clinically normal periods consisted of intimal and medial fibrosis, ruptured elastic laminae, and mild perivasculitis; these lesions were probably related to previous episodes of vasculitis. Eight dogs that had experienced repeated acute episodes also developed splenic, hepatic, and renal amyloidosis. The clinical signs, laboratory abnormalities, and the vascular lesions suggest that the condition may be immune-system mediated. CJPS may serve as a naturally occurring animal model of human immune-system-mediated vasculitides such as polyarteritis nodosa, infantile polyarteritis, and Kawasaki disease.

Treatment of nonregenerative anemia with human gamma-globulin in dogs.

Five dogs with nonregenerative anemia were treated with human immunoglobulin as a 12-hour IV infusion, at dosages ranging from 0.5 to 1.5 g/kg of body weight. All dogs had a rapid response to treatment, with reticulocytosis within 1 to 4 days and a substantial increase in hematocrit within 3 to 8 days of treatment. In 2 of 5 dogs, the hematocrit returned to values within reference range and remained in the reference range for 8 to 14 months after treatment, despite discontinuing or tapering prednisone treatment to a low dose. In 3 of 5 dogs, the hematocrit did not return to the reference range. In 1 of these 3 dogs, the hematocrit remained at the new, increased value (26 to 28%) for 248 days after treatment, at which time the dog was euthanatized. In the other 2 dogs, the hematocrit had decreased to pretreatment values by 52 days after treatment. Retreatment of these 2 dogs resulted in a similar, but blunted, response to human immunoglobulin. Human immunoglobulin may be an effective treatment for some dogs with immune-mediated anemia that fail to respond to conventional treatment.

Plasma and cerebrospinal fluid pharmacokinetics of cytosine arabinoside in dogs.

Cytosine arabinoside (ara-C) is a component of many protocols for the treatment of CNS (central nervous system) leukemia and lymphoma in humans and dogs. It is also used for the prophylaxis of CNS metastasis in acute lymphoblastic leukemia. Although ara-C enters the cerebrospinal fluid (CSF) of human cancer patients after i.v. administration, it is unclear whether a similar CNS distribution occurs in humans whose blood-brain barrier has not been compromised by invasive disease. No information on the penetration of ara-C into the CSF in dogs is available. We studied the plasma and CSF pharmacokinetics of 600 mg/m2 ara-C in ten healthy male dogs after its administration as a rapid i.v. bolus (six dogs) or as a 12-h i.v. infusion (four dogs). Ara-C concentration in blood and CSF samples was determined by high-performance liquid chromatography (HPLC). After an i.v. bolus of ara-C, the mean plasma distribution half-life was 7.1 +/- 4.5 min and the mean elimination half-life was 69 +/- 28 min. The mean plasma clearance was 227 +/- 125 ml min-1 m-2. The peak concentration of ara-C in the CSF was 29 +/- 11 microM, which occurred at 57 +/- 13 min after the ara-C bolus. The CSF elimination half-life was 113 +/- 26 min. During a 12-h infusion of ara-C (50 mg m-2 h-1), the plasma steady-state concentration was 14.1 +/- 4.2 microM, the CSF steady-state concentration was 8.3 +/- 1.1 microM, and the CSF: plasma ratio was 0.62 +/- 0.14. The plasma elimination half-life was 64 +/- 19 min and the plasma clearance was 214 +/- 69 ml min-1 m-2. The CSF elimination half-life was 165 +/- 28 min. No clinically significant toxicity was observed over a 21-day period following drug administration in either of the treatment groups. Our data indicate that ara-C crosses the blood-brain barrier in normal dogs and that i.v. administration of this drug has potential as a treatment modality for neoplasia involving the CNS.

Serum disposition of exogenous progesterone after intramuscular administration in bitches.

Progesterone was administered IM to 6 adult anestrous bitches at a dosage of 2 mg/kg of body weight. Serum progesterone concentrations were measured prior to progesterone administration and for 72 hours thereafter. The serum progesterone concentration time data were analyzed by use of a pharmacokinetics modeling computer program. The mean (+/- SD) peak serum progesterone concentration (34.3 +/- 7.8 ng/ml) was reached at 1.8 +/- 0.2 hours after progesterone administration. The mean serum progesterone concentration was 6.9 +/- 1.4 ng/ml at 24 hours and 2.0 +/- 0.4 ng/ml at 48 hours after progesterone administration. By 72 hours after administration, mean serum progesterone concentration was 0.9 +/- 0.2 ng/ml, which was comparable to serum progesterone concentrations prior to injection. The mean half-life of the absorption phase was 0.5 hours (range, 0.3 to 0.7 hours). The mean half-life of elimination was 12.1 hours (range, 9.5 to 13.8 hours). By analysis of the data, it was established that a dosage of 3 mg/kg, when the hormone was given IM to dogs once a day, would maintain serum progesterone concentration greater than 10 ng/ml.

Acquired myasthenia gravis in a cat with thymoma.

A 4-year-old castrated Abyssinian cat was evaluated for profound neuromuscular weakness. Results of electromyography and repetitive nerve stimulation tests were normal. Thoracic radiography revealed a cranial mediastinal mass, which was excised and identified as a thymoma. Serum acetylcholine receptor antibodies were detected at high concentration, supporting a diagnosis of acquired myasthenia gravis. Clinical signs of disease responded to treatment with pyridostigmine and corticosteroids.