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Adrenal Pathology

Patient Information

Age
8 Years
Gender
Female, Spayed
Species
Canine

Images

Small, flattened left adrenal gland that is isoechoic to surrounding fat. Power Doppler evidences the left renal artery and aorta to ensure that the landmarks are respected for the left adrenal gland. Arrows indicate the cranial and caudal pole of the left adrenal.
The right adrenal gland is barely seen in its triangular shape and is also isoechoic to surrounding fat with flattened contour.

History

ADR = "Aint Doing Right" is often an adrenal problem.
Check out what we may have been missing for years in adrenal pathology with Bailey the Basset Hound; the May 2011 SonoPath case of the month. Case presentation by Lindquist DMV, DABVP.

It may be easy to find adrenal masses as a cause of the "ADR" patient. But what if we can't find the adrenals at all when we normally can readily? Or at least have to struggle to see them and there are vague clinical signs such as diarrhea, anorexia, weight loss, lethargy? Start thinking Addison's disease and the sonographic criteria of Addisonian adrenal glands starting with Bailey the Basset; the Sonopath May 2011 Case Of The Month.

Clinical sonographer: Lindquist DMV, DABVP.

Note: Sonopath.com is currently performing a large study on sonographic criteria for Addisonian adrenal glands to further investigate this type of presentation for typical and atypical hypoadrenocorticism in dogs.

History: (Allicen Kohmescer): An 8-year-old FS Bassett Hound dog was presented for crying throughout the night and vomiting food, fluid, and mucous. On physical examination, she was found to have pink mucous membranes and a normal body temperature. She had bilateral conjunctivitis as well as a bilateral otitis externa (Malassezia). No abnormalities were noted on auscultation of her heart and lungs. The patient was treated symptomatically as an outpatient with anti-emetics and gastroprotectants. Six days later, the dog returned as she was depressed and lethargic. She was in lateral recumbency upon presentation and she was hypothermic with pale pink, tacky and cold mucous membranes. She was admitted to the hospital for I.V. fluid therapy and blood work. The serum biochemical profile revealed elevated liver enzyme activities (ALT, AST, GGT), azotemia, hyperproteinemia, hyperalbuminemia, hyperglobulinemia, hyperbilirubinemia, hyperkalemia, hypercalcemia, hyperphosphatemia, hypermagnesemia, hyperamylasemia, and an elevated CK. The CBC showed an elevated hemoglobin and leukocytosis consisting of a monocytosis and eosinophilia.

Clinical Differential Diagnosis

Clinical Differential Diagnosis (Remo Lobetti PhD, DECVIM): Hypoadrenocorticism with signs of severe dehydration and shock, neoplasia (hemangiosarcoma, mast cell tumor). Gastrointestinal neoplasm, such as lymphoma, adenocarcinoma, leiomyoma, leiomyosarcoma with secondary perforation, sepsis and shock,) hepatic and renal insufficiency secondary to leptospira sp. Infection, necrotizing pancreatitis with hypotensive and/or septic shock.

Image Interpretation

Both adrenal glands were identified by utilizing the land marks of the left renal artery, aorta, and left kidney for the left adrenal, and the vena cava and aorta for the right. Both adrenal glands were subnormal in width (0.25-0.3 cm) flattened in contour, and isoechoic to surrounding fat. In light of appropriate clinical signs such as vague GI signs, lethargy, renal failure, poor recovery from anesthesia, ACTH stimulation would be recommended.

Sonographic Differential Diagnosis

(Lindquist DMV, DABVP): Subnormal adrenal width with flattened contour. Rule out Addison''s disease of potential congenital or acquired origin. This presentation could also be normal for this patient. However, ACTH stimulation is warranted especially prior to any anesthetic procedure such as endoscopy to investigate gastric pathology.

Sampling

None taken.

DX

Addison's disease

Outcome

An ACTH stimulation test was performed and results were consistent with a diagnosis of hypoadrenocorticism (Addison’s disease). Outcome: The patient remained on I.V. fluids and systemic steroids for several days and was subsequently discharged with fludrocortisones and a tapering dose of prednisone. She was to be re-evaluated in two weeks’ time. Blood work at the time of her recheck found all parameters to be within normal limits, including all electrolytes and she was doing very well clinically.

Comments

Special thanks to Basking Ridge Animal Hospital, Basking Ridge, NJ, USA for their referral of this case.

Videos

Video clip of still Image 1 demonstrating the left renal artery and aorta evidenced with Power Doppler i order to make the isoechoic flattened left adrenal gland more visible by contrast and landmark accentuation.
Video clip of still image 2 of the isoechoic right adrenal. The vena cava is clearly visible in long axis and the right adrenal is barely visible to the left of center at 4 cm of depth. Normally the right adrenal gland would come clearly into view in this position. The lack of a normal right adrenal image, when landmarks are respected, could be used as a trigger to consider Addison's disease if the clinical profile for Addison's is present.