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Paraneoplastic syndrome?

Species: Dog
Breed: Rough Collie (neuter
Age: 8-11 years
In 3/2013 after suffering 2 "seizures," Clark was diagnosed with insulinoma from insulin level tests by the University of Wisconsin-Madison. X-rays, U/S's and CT's showed no tumors. I declined surgery and chemo (18 month expectancy) and decided to medically manage him with low dose prednisone and 4-5 small meals a day (6 month expectancy). Tramadol was also scripted out for some pain/weakness in his lumbosacral spine (I was unaware of this issue). Clark was eventually weaned off the pred in 1/2014 and to 2 meals a day with no seizures. He acted and was perfectly fine - like nothing was wrong since the 3/2013 Madison visit. In 6/2014, I came home from work to find Clark flat on his stomach, legs splayed to the side, and his food & water behind him which he could not reach. He was having a low blood sugar episode but did eat for me; however, he was not weight-bearing. Madison said Clark had paraneoplastic syndrome (suddenly?) with advancing hind end weakness/myelopathy even though his chest-xrays and U/S while there still showed no metastasis. He has no problems with his front legs or lifting his upper body off the ground; he can even pivot his body around in circles and pull himself around a bit (on carpet, grass and concrete). Clark still cannot lift his hindquarters off the ground without assistance and his rear feet both knuckle under when walking (I have NeoPaws boots to help with this though they are not 100%). His gait is unsteady and stumbly but he can walk and does better on smooth/flat surfaces or carpet, worse on slick floors (I have a small video clip I can send you). 10 days ago he had a spinal MRI at Madison which showed no malignancy and no pinched/slipped discs. They still think Clark has paraneoplastic syndrome though. He eats, drinks, is not incontinent, no vomiting or diarrhea, is BARH, barks at doorbells, neighbors, and neighbor dogs, and loves to sit outside. He also has recurrent UTI's. He looks forward to the pet sitter coming midday (for potty break and meal) and is always happy to see me. Couldn't he just have hypoglycemia without having insulinoma? Owners of dogs with degenerative myelopathy say Clark does not have that. What do you think? Could he have hip dysplasia? FCE? Is Madison focusing too much on the insulinoma/paraneoplastic syndrome when there isn't even any evidence of malignancy? What else could be wrong with Clark? Would he benefit from a cart or different booties? Clark is currently on pred, Tramadol, and Gabapentin. I have a degree in Biology and have worked in veterinary offices for many years so I'm not your average pet owner. I assumed I would only get referred to Madison anyway based on his conditions so I just take him there. Should I take Clark somewhere else? I have easily spent over $15,000 on Clark and although he is worth every penny, I also don't have any real answers for all of that money, in my opinion. My husband and I did not have any children (he passed away 31 months ago) so our pets have always been our kids. Thank you very much, Dr. Marie, for your insight and assistance. Clark and I really appreciate it.


Online vet, Dr. Marie

Dr. Marie replied:

This is a really tough question to answer. It sounds like you and your dog have been through an awful lot. Cases like this are so difficult where we do every test in the book and still don't have a conclusive answer for you.

What I can tell you is that the vets at the University of Wisconsin-Madison are known to be some of the best in the country, especially when it comes to potential cancer issues. I don't think you are likely to get better care elsewhere.

There are not a lot of known causes for recurring hypoglycemia (low blood sugar) in a dog. In a dog of your dog's age and size, by far the most common reason is a tumor and the most common tumor would be a pancreatic one. It certainly is frustrating if no tumor can be found, but I think that this can sometimes happen. The other possibilities for hypoglycemia don't really make sense. Other possibilities are sepsis (widespread infection) but that would be easy to diagnose, and severe liver disease (but that would also be easy to diagnose). One remote possibility is something called atypical Addison's disease. Addison's or hypoadrenocorticism is something that normally causes obvious changes in the bloodwork with sodium and potassium levels. But, there can be atypical cases that are hard to diagnose. This really doesn't sound like atypical addison's but you can ask your vets if that is a possibility.

But really, all signs point towards some type of tumor. That is, assuming that there still is low blood sugar.

Do we know for sure that the latest episode was one of hypoglycemia? I have a hard time connecting a hypoglycemic seizure to sudden impairment in the use of his legs.

I would not say that this is a typical case of degenerative myelopathy as dogs with this tend to have symptoms that come on really slowly. I think if the vets at the university are saying that this is likely paraneoplastic syndrome that there is very little chance that they are wrong.

I did find some examples in the literature of cases of dogs that had hypoglycemia. I also found a transcript of a presentation on paraneoplastic syndrome by Drs Zoƫ Belshaw and Jane Dobson that was on Veterinary Information Network, but unfortunately there is no public link for me to give you. In this transcript they describe the symptoms that they have seen with dogs that they have examined with paraneoplastic syndrome. Here are some interesting facts from that article:

-They examined 144 cases of dogs with paraneoplastic syndrome
-For 35 of those dogs the source of the tumor could not be found
-14 of the dogs had something called a peripheral neuropathy. What you are describing in your dog's hind limbs can certainly be a peripheral neuropathy
-2 of the dogs had hypoglycemia

My point in mentioning all this is to say that the symptoms that your dog has certainly can fit with paraneoplastic syndrome. There really isn't another disease condition I can think of that would tie all of these symptoms together.

I wish I had a more concrete answer for you. But, the best advice that I can give is to trust your vets. I have no ties with the University of Madison-Wisconsin, but I know their reputation.

I hope things work out ok.

Dr. Marie



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Disclaimer: Although Dr. Marie is a qualified veterinarian, the information found on this site is not meant to replace the advice of your own veterinarian. AskAVetQuestion.com and Dr. Marie do not accept any responsibility for any loss, damage, injury, death, or disease which may arise from reliance on information contained on this site. Do not use information found on this site for diagnosing or treating your pet. Anything you read here is for information only.

Customer reply:

Thank you very much for your reply.

Even without the surgery, Madison was convinced he had insulinoma even with no other evidence besides the insulin levels test. It was only after the most recent chest x-rays and ultrasound that they started thinking Clark may have had other issues, hence the neurology workup. The working theory was he should have had problems with all 4 limbs and not just the rear legs if it truly was paraneoplastic syndrome. But then when nothing showed up on the MRI, it reverted from neurological back to internal medicine/oncology. Clark would have needed to be off steroids for the EMG's, which would have been difficult for a dog with hypoglycemia. And the same for the Addison's test. That's the test I was really hoping Clark could have had 18 months ago. I just had a gut feeling about Addison's. The very annoying aspect I am being told by Madsion was that Clark was compensating for his rear legs for the last 18 months until he couldn't anymore. I just don't buy this. I would have seen some difficulties upon rising, stiffness, slipping on different surfaces (and definitely on slick ones). I know this first hand from my husband dying from melanoma. He too suffered from paraneoplastic syndrome from the steroids (dexamethasone) that he had been on. He gradually went downhill - arms and legs. Clark didn't have this. It just happened - boom - within 8 hours, he was down and he (his hindquarters) never came back up on his own again without my help. I know pets can compensate but he couldn't hide this, no matter how stoic or strong he was. My husband refused to be put on hospice - he would have none of that. He actually passed away from pneumonia.

On that day back in June, because he slipped/fell and ended up facing away from his food and water bowls, the hypoglycemic episode was brought on. It had probably been 18 hours since he last ate when I came home from work to find him the way I did.

My other issue is if you have a dog that has hypoglycemia due to proposed insulinoma, how does one explain how he can go 10 months on only 2 meals a day and no prednisone/ steroids for 6 months? There's no way Clark could compensate for low blood sugar. I have low blood sugar and become a maniac if I don't eat something and fast! Clark never had surgery on his pancreas, never had any chemo, never had holistic/homemade diets, no metastatic disease found upon hi-tech radiological assessment - nothing that the typical insulinoma dog would have had, tried, or experienced. And yet, Clark has paraneoplastic syndrome due to suspected insulinoma. I just don't see the dots connecting.

I had a cat that had diabetes and Cushings. I had a cat that needed 2 radioiodine injections to control her hyperthyroidism. I had a collie with idiopathic IBD. Another collie had a pelvic bladder but passed away (9 months ago) due to a stroke. I had a cat who went blind from herpes live to be 18 years old. I lost a 10 month old Siamese kitten to FIP. Lost another Siamese cat to lymphoma at 14 years of age. A Siamese-mix cat lived to be 16 years old but even Prozac, Valium, and a cat shrink could help him with his aggression. None of these pets read the veterinary textbooks and neither did Clark. And why have so many problem pets found us? Those odds have to be just as astounding. Because I was Biology major who never continued to get her DVM? Because I worked in the pet/veterinary profession for 20+ years so who better to care for them? Is there some big arrow in the sky pointing at our home for problems pets to stop here? The 3 cats I have now are the most boring, normal pets I have ever owned.

Thank you again for your insight, research (the VIN article was interesting indeed), and how quickly you replied to me. I really appreciate it.

Maureen


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Dr. MarieDr. Marie is a veterinarian who practices in a busy animal hospital in Ottawa, Ontario. She created Ask A Vet Question as a resource for good, accurate veterinary advice online. Dr. Marie treats dogs, cats, hamsters, guinea pigs, and rats. She has been a vet since 1999.

Is an online vet visit just as good as a trip to your veterinarian? No! But, many times, asking an online veterinarian a question can help save you money. While Dr. Marie can't officially diagnose your pet or prescribe medications, she can often advise you on whether a vet visit is necessary. You can also ask Dr. Marie for a second opinion on your pet's condition.