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Del Baldo F, Corsini A, Tardo AM, Tirolo A, Sapignoli A, Tumbarello M, Vasylyeva K, Fracassi F. Hypothalamic-pituitary-adrenal axis recovery after intermediate-acting glucocorticoid treatment in client-owned dogs. J Vet Intern Med 2024; 38:942-950. [PMID: 38321784 PMCID: PMC10937487 DOI: 10.1111/jvim.16979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 12/13/2023] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND In dogs, duration of hypothalamic-pituitary-adrenal (HPA) axis suppression after systemic glucocorticoid treatment is reported to vary from a few days to up to 7 weeks after glucocorticoid discontinuation. These data are derived mainly from experimental studies in healthy dogs and not from animals with spontaneous disease. HYPOTHESIS AND OBJECTIVE To determine the timeline for recovery of the HPA axis in a group of ill dogs treated with intermediate-acting glucocorticoids (IAGCs). ANIMALS Twenty client-owned dogs that received IAGC for at least 1 week. METHODS Single-center prospective observational study. An ACTH stimulation test, endogenous ACTH concentration, serum biochemistry profile, and urinalysis were performed at T0 (2-6 days after IAGC discontinuation) and then every 2 weeks (eg, T1, T2, T3) until HPA axis recovery was documented (post-ACTH cortisol concentration > 6 μg/dL). RESULTS The median time of HPA axis recovery was 3 days (range, 2-133 days). Eleven of 20 dogs showed recovery of the HPA axis at T0, 6/20 at T1, and 1 dog each at T2, T5, and T9. Dose and duration of treatment were not correlated with timing of HPA axis recovery. Activities of ALT and ALP were significantly correlated with the post-ACTH cortisol concentration (rs = -0.34, P = .03; rs = -0.31, P = .05). Endogenous ACTH concentration was significantly correlated with pre (r = 0.72; P < .0001) and post-ACTH cortisol concentrations (r = 0.35; P = .02). The timing of HPA axis recovery of the dogs undergoing an alternate-day tapering dose was not different compared to dogs that did not (3.5 vs 3 days, P = .89). CONCLUSION AND CLINICAL IMPORTANCE Most dogs experienced HPA axis recovery within a few days after IAGC discontinuation. However, 2/20 dogs required >8 weeks.
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Affiliation(s)
- Francesca Del Baldo
- Department of Veterinary Medical SciencesUniversity of BolognaOzzano dell'EmiliaItaly
| | - Andrea Corsini
- Department of Veterinary Medical SciencesUniversity of ParmaParmaItaly
| | - Antonio Maria Tardo
- Department of Veterinary Medical SciencesUniversity of BolognaOzzano dell'EmiliaItaly
| | - Alessandro Tirolo
- Department of Veterinary Medical SciencesUniversity of BolognaOzzano dell'EmiliaItaly
| | - Ada Sapignoli
- Department of Veterinary Medical SciencesUniversity of BolognaOzzano dell'EmiliaItaly
| | - Michele Tumbarello
- Department of Veterinary Medical SciencesUniversity of BolognaOzzano dell'EmiliaItaly
| | - Kateryna Vasylyeva
- Department of Veterinary Medical SciencesUniversity of BolognaOzzano dell'EmiliaItaly
| | - Federico Fracassi
- Department of Veterinary Medical SciencesUniversity of BolognaOzzano dell'EmiliaItaly
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Strey S, Mischke R, Rieder J. [Polyendocrine syndromes in dogs]. TIERARZTLICHE PRAXIS. AUSGABE K, KLEINTIERE/HEIMTIERE 2023; 51:313-325. [PMID: 37956663 DOI: 10.1055/a-2183-0654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
The autoimmune polyendocrine syndrome (APS) refers to a combination of autoimmune endocrine disorders. It is rarely described in dogs. The most common combinations are hypoadrenocorticism and hypothyroidism, followed by diabetes mellitus, and less often hypoparathyroidism and orchitis. The diagnosis of the APS is based on the diagnosis of each endocrinopathy, as is the therapy, which involves the substitution of deficient hormones. If a patient was previously stable under treatment and is showing further signs (e.g. polyuria, polydipsia, or weight loss), the development of additional endocrinopathies like hypoadrenocorticism or diabetes mellitus should be considered. The diagnosis of the initially diagnosed endocrinopathy should also be critically questioned. This article summarizes some cases of our own animal hospital and selected cases published in the available literature.
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Affiliation(s)
- Sina Strey
- Klinik für Kleintiere, Stiftung Tierärztliche Hochschule Hannover, Hannover
| | - Reinhard Mischke
- Klinik für Kleintiere, Stiftung Tierärztliche Hochschule Hannover, Hannover
| | - Johanna Rieder
- Klinik für Kleintiere, Stiftung Tierärztliche Hochschule Hannover, Hannover
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Frigerio ED, Guizelini CDC, Jussiani GG, Março KS, de Melo GD, Watanabe TTN, Machado GF. Lymphocytic hypophysitis in dogs infected with Leishmania spp. Front Vet Sci 2023; 10:1208919. [PMID: 37781278 PMCID: PMC10537919 DOI: 10.3389/fvets.2023.1208919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/31/2023] [Indexed: 10/03/2023] Open
Abstract
Background Morphological involvement of endocrine glands, such as the pituitary gland, remain uninvestigated in dogs with canine visceral leishmaniasis. Therefore, this study investigated the presence of amastigotes of Leishmania spp. and characterized inflammatory changes, highlighting the involvement of TCD3+ lymphocytes in different regions of the pituitary gland of dogs. Methods Samples were collected from 21 naturally infected dogs and 5 control, uninfected dogs. The different pituitary regions were analyzed in histological sections stained with hematoxylin and eosin (HE) under light microscopy. Inflammation was classified by intensity in a score from 0 to 3, absent (0), mild (1), moderate (2), and marked (3). The immunohistochemical (IHC) evaluation was performed in five high-power fields (hot spot) in a 40x objective of each region with manual counting (Image J1.52ª) of the TCD3+ lymphocytes and for amastigotes analyzed in 40x and 100x objectives. The Shapiro-Wilk test was used to assess the normality of the data. Differences between groups were determined by the Mann Whitney test. The correlation between variables was assessed by Sperman's correlation test. p < 0.05 were considered statistically significant. Results Amastigotes from the pituitary glands of two infected dogs were identified using IHC. The histopathological evaluation stained with hematoxylin and eosin showed greater intensity of inflammation in the pars distalis and pars intermedia regions of infected dogs. IHC for TCD3+ lymphocytes showed a higher median number of immunolabeled cells in pars nervosa in the infected group than in the control group (p < 0.05); and expecting a variation in the distribution and number of these cells in naturally infected dogs, the median of the control group was considered a cut-off point, an increase in T lymphocytes (p < 0.05) was also observed in the pars intermedia and pars distalis of an infected subgroup (n = 10). A moderate significant correlation between the intensity of inflammation and the number of immunolabeled TCD3+ lymphocytes was established in the analyzed pituitary regions, characterizing the occurrence of hypophysitis. Conclusion These findings presuppose that inflammation and/or the parasite in the pituitary region can result in gland dysfunction, worsening the clinical condition of the patient and compromising the efficiency of treatment and prognosis.
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Affiliation(s)
- Edenilson Doná Frigerio
- Department of Veterinary Clinics, Surgery and Reproduction, Faculty of Veterinary Medicine, São Paulo State University, UNESP, Araçatuba, Brazil
| | - Cecilia de Castro Guizelini
- Department of Veterinary Clinics, Surgery and Reproduction, Faculty of Veterinary Medicine, São Paulo State University, UNESP, Araçatuba, Brazil
| | - Giulia Gonçalves Jussiani
- Department of Veterinary Clinics, Surgery and Reproduction, Faculty of Veterinary Medicine, São Paulo State University, UNESP, Araçatuba, Brazil
| | - Karen Santos Março
- Department of Veterinary Clinics, Surgery and Reproduction, Faculty of Veterinary Medicine, São Paulo State University, UNESP, Araçatuba, Brazil
| | - Guilherme Dias de Melo
- Institut Pasteur, Université Paris Cité, Lyssavirus Epidemiology and Neuropathology Unit, Paris, France
| | - Tatiane Terumi Negrão Watanabe
- Department Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Gisele Fabrino Machado
- Department of Veterinary Clinics, Surgery and Reproduction, Faculty of Veterinary Medicine, São Paulo State University, UNESP, Araçatuba, Brazil
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HATOYA S, KANEGI R, NABETANI T, OJI S, IZAWA T, HIRAI S, SUGIURA K. Atypical hypoadrenocorticism with intact zona glomerulosa of the adrenal cortex after long-term observation: a case report of a dog. J Vet Med Sci 2023; 85:9-13. [PMID: 36372430 PMCID: PMC9887220 DOI: 10.1292/jvms.22-0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
An 8-year-old intact male pointer presented with lethargy and hypoalbuminemia. On abdominal ultrasonography, both adrenal glands were reduced in thickness. Based on the ACTH stimulation test results and the absence of electrolyte abnormalities, the dog was diagnosed with atypical hypoadrenocorticism. After treatment with low-dose prednisolone, his general condition improved, and blood tests normalized. The dog died 818 days later, and a complete autopsy was performed. Histologically, the architecture of the zonae fasciculata and reticularis was disrupted in both adrenal glands; however, the zona glomerulosa remained relatively normal. In summary, in this study, we detailed the pathological presentation of atypical hypoadrenocorticism without electrolyte abnormalities.
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Affiliation(s)
- Shingo HATOYA
- Laboratory of Cell Pathobiology, Graduate School of Life and Environmental Sciences, Osaka Prefecture University, Osaka, Japan,Present address: Laboratory of Cell Pathobiology, Graduate School of Veterinary Sciences, Osaka Metropolitan University, Osaka, Japan,Correspondence to: Hatoya S: , Laboratory of Cell Pathobiology, Graduate School of Veterinary
Sciences, Osaka Metropolitan University, 1-58 Rinku-oraikita, Izumisano, Osaka 598-8531, Japan
| | - Ryoji KANEGI
- Veterinary Medical Center, Osaka Prefecture University, Osaka, Japan,Present address: Veterinary Medical Center, Osaka Metropolitan University, Osaka, Japan
| | - Tomoyo NABETANI
- Veterinary Medical Center, Osaka Prefecture University, Osaka, Japan,Present address: Veterinary Medical Center, Osaka Metropolitan University, Osaka, Japan
| | - Shoko OJI
- Laboratory of Veterinary Pathology, Graduate School of Life and Environmental Sciences, Osaka Prefecture University, Osaka, Japan
| | - Takeshi IZAWA
- Laboratory of Veterinary Pathology, Graduate School of Life and Environmental Sciences, Osaka Prefecture University, Osaka, Japan,Present address: Laboratory of Veterinary Pathology, Graduate School of Veterinary Sciences, Osaka Metropolitan University, Osaka, Japan
| | | | - Kikuya SUGIURA
- Laboratory of Cell Pathobiology, Graduate School of Life and Environmental Sciences, Osaka Prefecture University, Osaka, Japan,Present address: Laboratory of Cell Pathobiology, Graduate School of Veterinary Sciences, Osaka Metropolitan University, Osaka, Japan
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Roberts E, Dobromylskyj MJ. Histopathological evaluation of the adrenal glands in a cat with primary hypoadrenocorticism and multiple endocrine disease. JFMS Open Rep 2022; 8:20551169221125207. [PMID: 36226303 PMCID: PMC9549196 DOI: 10.1177/20551169221125207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Case summary A 6-year-old male neutered domestic longhair cat was referred for investigation of weight loss, hyporexia, vomiting and diarrhoea. The cat was diagnosed with primary hypoadrenocorticism, exocrine pancreatic insufficiency, cobalamin deficiency and a chronic enteropathy, and started on therapeutic treatment. Diabetes mellitus developed 4.5 months later, and the cat was started on insulin therapy. The cat was euthanased 10 months following the diagnosis of hypoadrenocorticism due to the development of status epilepticus, which was not associated with glucose or electrolyte abnormalities. Histopathological assessment of the adrenal glands at post-mortem examination documented lymphoplasmacytic adrenalitis, with the lymphocytic population being predominant. Immunohistochemical staining classified the lymphocytic infiltrate as T-cell rich, supportive of the cat's hypoadrenocorticism being due to autoimmune disease. Relevance and novel information This case documents the novel use of immunohistochemical staining in combination with histopathology to further assess the adrenal glands in non-neoplastic-associated primary hypoadrenocorticism in a cat. This identified similar pathological changes to those previously described in dogs with autoimmune primary hypoadrenocorticism. Additionally, this is the first report of a cat with multiple endocrine disease that included primary hypoadrenocorticism and highlights that monitoring for the development of additional endocrine disease should be advised in these cases.
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Affiliation(s)
- Emma Roberts
- Highcroft Veterinary Referrals,
Bristol, UK
- Emma Roberts BVetMed (Hons), MVM,
DipECVIM-CA, Highcroft Veterinary Referrals, 615 Wells Road, Bristol BS14 9BE,
UK
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6
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Guzmán Ramos PJ, Bennaim M, Shiel RE, Mooney CT. Diagnosis of canine spontaneous hypoadrenocorticism. Canine Med Genet 2022; 9:6. [PMID: 35505424 PMCID: PMC9066729 DOI: 10.1186/s40575-022-00119-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 04/13/2022] [Indexed: 11/10/2022] Open
Abstract
Hypoadrenocorticism is characterized by a reduction in mineralocorticoid and/or glucocorticoid production by the adrenal glands. Several subtypes have been described with different clinical and clinicopathological consequences. Most affected dogs have vague and non-specific signs that precede an eventual life-threatening crisis. This review aims to appraise classification, the available data on epidemiology and the clinical and laboratory features of naturally occurring canine hypoadrenocorticism. Canine hypoadrenocorticism is a relatively uncommon endocrine disease that can present with a wide variety of clinical signs resulting from cortisol or aldosterone deficiency or both. Hypoadrenocorticism should be considered in all dogs with severe illness and typical electrolyte abnormalities but also in those with waxing and waning clinical signs. Multiple clinical and laboratory features are suggestive of the disease and should prompt evaluation of adrenal function. The ACTH stimulation test is the best test for diagnosing hypoadrenocorticism but, in those cases without the typical presentation, evaluation of aldosterone secretory capacity and endogenous ACTH concentrations should be performed to distinguish primary from secondary disease. In this review we discuss the pathophysiology of the disease, the clinical signs and laboratory features that should raise suspicion of hypoadrenocorticism and the performance of the different diagnostic tests.
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Affiliation(s)
- Pedro J Guzmán Ramos
- University College Dublin Veterinary Hospital, University College Dublin, Dublin, Ireland.
| | - Michael Bennaim
- Centre Hospitalier Vétérinaire Anicura Aquivet, Eysines, France
| | - Robert E Shiel
- University College Dublin Veterinary Hospital, University College Dublin, Dublin, Ireland
| | - Carmel T Mooney
- University College Dublin Veterinary Hospital, University College Dublin, Dublin, Ireland
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Kuijlaars M, Yool DA, Ridyard AE. Autoimmune polyendocrine syndrome in a standard poodle with concurrent non‐endocrine immune‐mediated diseases. VETERINARY RECORD CASE REPORTS 2021. [DOI: 10.1002/vrc2.90] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Margaux Kuijlaars
- University of Glasgow Small Animal Hospital, Division of Small Animal Clinical Sciences, School of Veterinary Medicine Glasgow UK
| | - Donald A. Yool
- University of Glasgow Small Animal Hospital, Division of Small Animal Clinical Sciences, School of Veterinary Medicine Glasgow UK
| | - Alison E. Ridyard
- University of Glasgow Small Animal Hospital, Division of Small Animal Clinical Sciences, School of Veterinary Medicine Glasgow UK
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Furukawa S, Meguri N, Koura K, Koura H, Matsuda A. A Case of Canine Polyglandular Deficiency Syndrome with Diabetes Mellitus and Hypoadrenocorticism. Vet Sci 2021; 8:vetsci8030043. [PMID: 33800028 PMCID: PMC8000634 DOI: 10.3390/vetsci8030043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/01/2021] [Accepted: 03/05/2021] [Indexed: 11/29/2022] Open
Abstract
This report describes the first clinical case, to our knowledge, of a dog with polyglandular deficiency syndrome with diabetes mellitus and hypoadrenocorticism. A six-year-old female Cavalier King Charles Spaniel presented with a history of lethargy and appetite loss. The dog was diagnosed with diabetic ketoacidosis based on hyperglycemia and renal glucose and ketone body loss. The dog’s condition improved on intensive treatment of diabetes mellitus; daily subcutaneous insulin detemir injection maintained an appropriate blood glucose level over half a year. However, the dog’s body weight gradually decreased from day 207, and on day 501, it presented with a decreased appetite; the precise cause could not be determined. Based on mild hyponatremia and hyperkalemia, hypoadrenocorticism was suggested; the diagnosis was made using an adrenocorticotropic hormone stimulation test. Daily fludrocortisone with low-dose prednisolone oral administration resulted in poor recovery of the blood chemistry abnormalities; however, monthly desoxycorticosterone pivalate (DOCP) subcutaneous injection with daily low-dose prednisolone oral administration helped in the significant recovery of the abnormalities. Therefore, clinicians should consider the possibility of coexistence of hypoadrenocorticism in dogs with diabetes mellitus presenting with undifferentiated weight loss. Additionally, DOCP (not fludrocortisone) may be useful in treating dogs with diabetes mellitus complicated with hypoadrenocorticism.
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Affiliation(s)
- Sho Furukawa
- Earth Animal Hospital, 4-3-43 Hokushin-cho, Kitami, Hokkaido 090-0052, Japan; (S.F.); (N.M.); (H.K.)
| | - Natsuko Meguri
- Earth Animal Hospital, 4-3-43 Hokushin-cho, Kitami, Hokkaido 090-0052, Japan; (S.F.); (N.M.); (H.K.)
| | - Kazue Koura
- Bihoro Animal Hospital, 51-8 Aoyamakita, Bihoro, Hokkaido 092-0066, Japan;
| | - Hiroyuki Koura
- Earth Animal Hospital, 4-3-43 Hokushin-cho, Kitami, Hokkaido 090-0052, Japan; (S.F.); (N.M.); (H.K.)
| | - Akira Matsuda
- Earth Animal Hospital, 4-3-43 Hokushin-cho, Kitami, Hokkaido 090-0052, Japan; (S.F.); (N.M.); (H.K.)
- Faculty of Veterinary Medicine, Okayama University of Science, 1-3 Ikoinooka, Imabari, Ehime 794-8555, Japan
- Correspondence: ; Tel.: +81-898-52-9240
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9
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Schofield I, Woolhead V, Johnson A, Brodbelt DC, Church DB, O'Neill DG. Hypoadrenocorticism in dogs under UK primary veterinary care: frequency, clinical approaches and risk factors. J Small Anim Pract 2021; 62:343-350. [PMID: 33555046 PMCID: PMC8248152 DOI: 10.1111/jsap.13285] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 11/09/2020] [Accepted: 11/26/2020] [Indexed: 01/06/2023]
Abstract
Objectives To estimate the frequency, clinical approaches and risk factors of hypoadrenocorticism in dogs under UK primary veterinary care. Materials and Methods Dogs diagnosed with hypoadrenocorticism were identified from the UK VetCompass™ programme by searching anonymised electronic patient records. Pre‐existing and newly diagnosed cases of disease during 2016 were included. Cases were further sub‐categorised as having a laboratory‐confirmed or presumed diagnosis of hypoadrenocorticism based on the information recorded in the electronic patient records. Descriptive data were manually extracted. Multivariable logistic regression methods were used to identify demographic risk factors. Results There were 177 hypoadrenocorticism cases identified from 905,543 dogs in 2016; 72 laboratory‐confirmed and 105 presumed. The 1‐year period prevalence for hypoadrenocorticism in all dogs was 0.06% (95% confidence interval: 0.05‐0.07%). The most common presenting clinical signs in laboratory‐confirmed dogs were lethargy (51/66, 77.3%), anorexia (48/66, 66.7%) and vomiting (48/66, 66.7%). Hyperkalaemia was reported in 47 of 53 (88.7%), hyponatraemia in 46 of 53 (86.8%). Median sodium: potassium ratio was 19.00 (interquartile range: 16.20‐20.60). Breed, age, neuter status and insurance status were associated with a laboratory‐confirmed diagnosis of hypoadrenocorticism. No sex association with hypoadrenocorticism was observed in the multivariable model. The standard poodle had 51.38 times the odds (95% CI: 14.49‐182.18) of hypoadrenocorticism compared with crossbreeds. The labradoodle and West Highland white terrier also had increased odds. Clinical Significance This is the first epidemiological study to report on hypoadrenocorticism in dogs within the UK primary‐care population. These results provide benchmark data of current veterinary activity relating to hypoadrenocorticism in primary‐care practices.
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Affiliation(s)
- I Schofield
- Pathobiology and Population Sciences, The Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Herts, AL9 7TA, UK
| | - V Woolhead
- Eastcott Referrals, Edison Park, Dorcan Way, Swindon, SN3 3RB, UK
| | - A Johnson
- Pathobiology and Population Sciences, The Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Herts, AL9 7TA, UK
| | - D C Brodbelt
- Pathobiology and Population Sciences, The Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Herts, AL9 7TA, UK
| | - D B Church
- Clinical Science and Services, The Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Herts, AL9 7TA, UK
| | - D G O'Neill
- Pathobiology and Population Sciences, The Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Herts, AL9 7TA, UK
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10
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Reagan KL, Reagan BA, Gilor C. Machine learning algorithm as a diagnostic tool for hypoadrenocorticism in dogs. Domest Anim Endocrinol 2020; 72:106396. [PMID: 32006871 DOI: 10.1016/j.domaniend.2019.106396] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/03/2019] [Accepted: 09/06/2019] [Indexed: 11/23/2022]
Abstract
Canine hypoadrenocorticism (CHA) is a life-threatening condition that affects approximately 3 of 1,000 dogs. It has a wide array of clinical signs and is known to mimic other disease processes, including kidney and gastrointestinal diseases, creating a diagnostic challenge. Because CHA can be fatal if not appropriately treated, there is risk to the patient if the condition is not diagnosed. However, the prognosis is excellent with appropriate therapy. A major hurdle to diagnosing CHA is the lack of awareness and low index of suspicion. Once suspected, the application and interpretation of conclusive diagnostic tests is relatively straight forward. In this study, machine learning methods were employed to aid in the diagnosis of CHA using routinely collected screening diagnostics (complete blood count and serum chemistry panel). These data were collected for 908 control dogs (suspected to have CHA, but disease ruled out) and 133 dogs with confirmed CHA. A boosted tree algorithm (AdaBoost) was trained with 80% of the collected data, and 20% was then utilized as test data to assess performance. Algorithm learning was demonstrated as the training set was increased from 0 to 600 dogs. The developed algorithm model has a sensitivity of 96.3% (95% CI, 81.7%-99.8%), specificity of 97.2% (95% CI, 93.7%-98.8%), and an area under the receiver operator characteristic curve of 0.994 (95% CI, 0.984-0.999), and it outperforms other screening methods including logistic regression analysis. An easy-to-use graphical interface allows the practitioner to easily implement this technology to screen for CHA leading to improved outcomes for patients and owners.
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Affiliation(s)
- K L Reagan
- Department of Veterinary Medicine and Epidemiology, University of California, Davis, 1 Shields Ave, Davis, CA 95616, USA
| | - B A Reagan
- Department of Electrical and Computer Engineering, Colorado State University, Fort Collins, CO, USA
| | - C Gilor
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL 32608, USA.
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11
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Presence of CD3 + and CD79a + Lymphocytes in the Pituitary Gland of Dogs at Post-mortem Examination. J Comp Pathol 2020; 176:116-121. [PMID: 32359623 DOI: 10.1016/j.jcpa.2020.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 02/17/2020] [Accepted: 02/22/2020] [Indexed: 11/22/2022]
Abstract
Hypophysitis has been reported occasionally in dogs, with most cases resembling primary lymphocytic hypophysitis in man. Although it is generally assumed that lymphocytes are not present normally in the canine pituitary gland, few studies have investigated this hypothesis. However, lymphocytes are recognized in the pituitary gland of people and horses without signs of pituitary disease. It is unknown to what degree lymphocyte infiltration of the pituitary gland might occur as an incidental finding in dogs. The aim of the present study was to investigate the presence and distribution of lymphocytes in the pituitary gland of dogs without clinical suspicion of pituitary disease. Twenty dogs were subjected to routine necropsy examination. Formalin-fixed and paraffin wax-embedded sections of pituitary were stained with haematoxylin and eosin (HE) or subjected to immunohistochemistry (IHC) using primary antibodies specific for the T-cell marker CD3 and the B-cell marker CD79a. The number of CD3+ and CD79a+ cells per area unit (CPA) was determined for different pituitary regions. Two dogs had extensive neoplastic lesions in the pituitary gland and were excluded from analysis. In the remaining 18 dogs, occasional scattered CD3+ cells were found in the pituitary gland. There was a significant difference in CD3+ CPA between pituitary regions (P = 0.001). The highest CD3+ CPA was found in the pars tuberalis (median 41.3 cells/mm2, interquartile range 20.9-50.5 cells/mm2). In six of the 18 dogs (33%), CD79a+ cells were detected in small number (median total cell number 0 cells/section, interquartile range 0-1.0 cells/section). This study shows that T cell, and fewer B cells, may be found in the pituitary gland of dogs without clinical suspicion of pituitary disease. Regional difference in T-cell density, with the highest CD3+ CPA in the pars tuberalis, may imply regional immunoregulatory functions in the canine pituitary gland.
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12
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Sasaki J, Uehara M, Sato I, Satoh H, Deguchi Y, Chida H, Natsuhori M, Murata T, Ochiai K, Otani K, Okada K, Ito N. Pathological characteristics of thyroid glands from Japanese Black Cattle living in the restricted area of the Fukushima Daiichi Nuclear Power Plant accident. Anim Sci J 2019; 90:1333-1339. [PMID: 31309667 DOI: 10.1111/asj.13269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/11/2019] [Accepted: 06/13/2019] [Indexed: 11/28/2022]
Abstract
To study the effect of ionizing radiation on thyroid glands, 66 Japanese Black cattle residing in the restricted area of the Fukushima Daiichi Nuclear Power Plant in 2013-2017 were pathologically examined. There were no clinical symptoms of thyroid disease in these cattle. Three cases of goiter and seven of atrophy were found in two among the four farms examined. Cases of goiter exhibited normal morphological structure without mass or nodule formation in thyroid glands. Cellular atypia or capsular invasion of the follicular epithelium was absent. The estimated integrated dose of external radiation in goiter cases ranged from maximum 797 mSv to minimum 24 mSv. All lobules in the seven atrophic thyroid glands were affected, but pathological findings, such as inflammatory cell infiltration or stromal fibrosis, were not observed. The estimated integrated dose of external radiation in atrophic thyroids ranged from maximum 589 mSv to minimum 8 mSv. Immunohistochemical analysis of anti-nitroguanosine and the TUNEL method in goiter and atrophic thyroid glands did not reveal any positive findings. The present study indicates that there was no significant relationship between a radiation effect and pathological findings in any thyroid glands.
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Affiliation(s)
- Jun Sasaki
- Department of Veterinary Pathology, Faculty of Agriculture, Iwate University, Morioka, Iwate, Japan
| | - Megumi Uehara
- Department of Veterinary Pathology, Faculty of Agriculture, Iwate University, Morioka, Iwate, Japan
| | - Itaru Sato
- Food Animal Medicine and Food Safety Research Center, Faculty of Agriculture, Iwate University, Morioka, Iwate, Japan
| | - Hiroshi Satoh
- Laboratory of Veterinary Pharmacology and Toxicology, Faculty of Agriculture, Iwate University, Morioka, Iwate, Japan
| | - Yoshitaka Deguchi
- Laboratory of Animal Management, Faculty of Agriculture, Iwate University, Morioka, Iwate, Japan
| | - Hiroyuki Chida
- Field Science Center, Faculty of Agriculture, Iwate University, Morioka, Iwate, Japan
| | - Masahiro Natsuhori
- Laboratory of Veterinary Radiology and Radiation Biology, School of Veterinary Medicine, Kitasato University, Towada, Aomori, Japan
| | - Takahisa Murata
- Department of Animal Radiology, Graduate School of Agriculture and Life Sciences, The University of Tokyo, Tokyo, Japan
| | - Kenji Ochiai
- Department of Veterinary Pathology, Faculty of Agriculture, Iwate University, Morioka, Iwate, Japan
| | - Kumiko Otani
- Society for Animal Refugee and Environment post Nuclear Disaster, Tokyo, Japan
| | - Keiji Okada
- Department of Veterinary Medicine, Faculty of Agriculture, Iwate University, Morioka, Iwate, Japan
| | - Nobuhiko Ito
- Laboratory of Veterinary Radiology and Radiation Biology, School of Veterinary Medicine, Kitasato University, Towada, Aomori, Japan
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13
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Béguin JS, Chevallier L, Rannou B, Fontaine JJ, Benchekroun G. Primary hypoaldosteronism in a dog with pituitary and adrenal T-cell lymphoma. J Small Anim Pract 2018; 61:588-592. [PMID: 30390298 DOI: 10.1111/jsap.12955] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 07/19/2018] [Accepted: 09/28/2018] [Indexed: 11/24/2022]
Abstract
A 7-year-old mixed breed dog was presented with a 2-week history of vomiting, diarrhoea, weakness and loss of appetite. Initial laboratory tests revealed hyponatraemia and hyperkalaemia consistent with hypoadrenocorticism. Basal plasma cortisol and adrenocorticotropic hormone concentrations were not suggestive of primary hypoadrenocorticism but the aldosterone concentration was undetectable. Abdominal ultrasound scan showed a mass within the left kidney and a nodular enlargement of the left adrenal gland. Cytological analysis revealed a large granular lymphoma. The dog died 17 days later. Post mortem histological and immunohistochemical examinations revealed a diffuse large granular T-cell lymphoma involving the mediastinal lymph node, kidneys, pancreas, adrenal and pituitary glands.
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Affiliation(s)
- J S Béguin
- Department of Internal Medicine, Ecole nationale vétérinaire d'Alfort, Paris, F-94700, France
| | - L Chevallier
- Department of Pathology, Ecole nationale vétérinaire d'Alfort, Paris, F-94700, France
| | - B Rannou
- Department of Biochemistry, VetAgro Sup Campus Vétérinaire de Lyon, Université de Lyon, 69280, Lyon, France
| | - J J Fontaine
- Department of Pathology, Ecole nationale vétérinaire d'Alfort, Paris, F-94700, France
| | - G Benchekroun
- Department of Internal Medicine, Ecole nationale vétérinaire d'Alfort, Paris, F-94700, France
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14
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Polledo L, Grinwis GCM, Graham P, Dunning M, Baiker K. Pathological Findings in the Pituitary Glands of Dogs and Cats. Vet Pathol 2018; 55:880-888. [DOI: 10.1177/0300985818784162] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
With the exception of classic functional adenomas in dogs and horses, pituitary lesions are infrequently described in the veterinary literature. Approximately 10% of pituitary glands from asymptomatic humans contain abnormalities, but the equivalent proportion in small animals is unknown. Pituitary glands from 136 dogs and 65 cats collected during routine necropsies were examined to determine the prevalence of pituitary lesions and their histopathological diagnosis. Lesions were characterized in sections stained with hematoxylin and eosin, periodic acid-Schiff (PAS), Gordon and Sweet’s and reticulin stains, and immunohistochemistry for adrenocorticotropic hormone (ACTH), growth hormone, melanocyte stimulating hormone–α, and prolactin. Pituitary abnormalities were identified in 36 of 136 (26.4%) dogs and 10 of 65 (15.3%) cats. Cystic changes were the most common lesion, occurring in 18 (13.2%) dogs and 8 (12.3%) cats. Pituitary neoplasia was detected in 14.1% (12/85) of middle-aged and old dogs; 1 (1.5%) cat had pituitary nodular hyperplasia. PAS and reticulin stains helped differentiate ACTH-immunoreactive adenomas from hyperplastic nodules: adenomas contained PAS-positive intracytoplasmic granules and loss of the normal reticulin network. One dog had a pituitary carcinoma with infiltration into the thalamus. Other pituitary abnormalities included secondary metastases (2 dogs) and hypophysitis (4 dogs, 1 cat). In most cases, the lesion appeared to be subclinical and could be considered incidental, whereas clinical manifestations were apparent in only 4 dogs (2.9%) and none of the cats with pituitary lesions. Pituitary abnormalities are common in dogs and cats, and their clinical relevance requires further investigation.
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Affiliation(s)
- Laura Polledo
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington, UK
| | - Guy C. M. Grinwis
- Department of Pathobiology, Faculty of Veterinary Medicine, Utrecht, the Netherlands
| | - Peter Graham
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington, UK
| | - Mark Dunning
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington, UK
| | - Kerstin Baiker
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington, UK
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15
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Boag AM, Christie MR, McLaughlin KA, Syme HM, Graham P, Catchpole B. A longitudinal study of autoantibodies against cytochrome P450 side-chain cleavage enzyme in dogs (Canis lupus familiaris) affected with hypoadrenocorticism (Addison's disease). Vet Immunol Immunopathol 2018; 202:41-45. [PMID: 30078597 DOI: 10.1016/j.vetimm.2018.05.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 05/09/2018] [Accepted: 05/25/2018] [Indexed: 01/02/2023]
Abstract
Autoantibodies directed against the P450 side chain cleavage enzyme (P450scc) have been recently described in dogs affected with hypoadrenocorticism, consistent with an immune-mediated pathogenesis of this endocrinopathy. In human autoimmune Addison's disease, autoantibodies may have a predictive value, being detectable before clinical signs developing, and have been shown to persist for a period of time after diagnosis. Furthermore, an autoantibody positive status post-diagnosis has been associated with successful remission of Addison's disease following B-cell depletion, suggesting active immunopathology in these cases. The current study was designed to investigate changes in serum P450scc autoantibody status over time in dogs diagnosed with spontaneous hypoadrenocorticism. P450scc autoantibodies were measured using a species-specific radioimmunoprecipitation assay in an initial cohort of 213 dogs, indicating a prevalence of 24%. Thirty two of these dogs had repeat samples (n = 80 in total) available for analysis. Five dogs were consistently P450scc autoantibody positive in all samples, for up to 425 days following first sampling. Three dogs were initially autoantibody positive, then became seronegative at later time points. One dog, a 1 year old female entire standard poodle, was initially negative for P450scc autoantibodies, but seroconverted 18 months after diagnosis. The remaining 23 dogs with multiple samples available were consistently P450scc autoantibody negative. Persistence was not associated with sex (p = .673). This study demonstrates persistence of P450scc autoantibodies in a subset of dogs affected with hypoadrenocorticism and seroconversion over one year post-diagnosis. P450scc autoantibody reactivity in human autoimmune Addison's disease has been associated with sex, with females having a higher prevalence, possibly due to P450scc expression in the ovary acting as an additional source of antigenic stimulation. However, there was no sex difference in autoantibody persistence in the dogs affected with hypoadrenocorticism. Autontibody persistence in dogs with hypoadrenocorticism might represent persistent pathology, due to residual antigenic stimulation and autoimmune inflammation in the adrenal gland.
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Affiliation(s)
- Alisdair M Boag
- Department of Pathobiology and Population Sciences, Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire, United Kingdom; The Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush Campus, Midlothian, United Kingdom
| | | | - Kerry A McLaughlin
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, Oxford, United Kingdom
| | - Harriet M Syme
- Department of Clinical Sciences and Services, Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire, United Kingdom
| | - Peter Graham
- Faculty of Medicine and Health Sciences, University of Nottingham, Sutton Bonington, Leicestershire, United Kingdom
| | - Brian Catchpole
- Department of Pathobiology and Population Sciences, Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire, United Kingdom.
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16
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Miller MA, Bruyette DS, Scott-Moncrieff JC, Owen TJ, Ramos-Vara JA, Weng HY, Vanderpool AL, Chen AV, Martin LG, DuSold DM, Jahan S. Histopathologic Findings in Canine Pituitary Glands. Vet Pathol 2018; 55:871-879. [PMID: 29665752 DOI: 10.1177/0300985818766211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To optimize the histologic evaluation of hypophysectomy specimens, sections of 207 canine pituitary glands (196 postmortem, 11 hypophysectomy specimens) were reviewed. Adenohypophyseal proliferation was the most common (n = 79) lesion. Proliferative lesions were sparsely to densely granulated; the granules were usually basophilic to chromophobic and periodic acid-Schiff-positive. Adenohypophyseal proliferation was classified as hyperplasia (n = 40) if ≤2 mm diameter with intact reticulin network, as microadenoma (n = 22) for 1–5 mm homogeneous nodules with lost reticulin network, or as macroadenoma (n = 17) for larger tumors. Craniopharyngeal duct cysts were common incidental lesions and the only lesion in 15 dogs. Uncommon diagnoses included lymphoma (n = 4), hemorrhagic necrosis (n = 4), metastatic carcinoma (n = 3), hypophysitis (n = 3), ependymoma (n = 2), craniopharyngioma (n = 2), and 1 case each of metastatic melanoma, pituicytoma, gliomatosis, germ cell tumor, meningioma, and atrophy. The pituitary histologic diagnosis was associated with hyperadrenocorticism (HAC; P < .001) and adrenocortical histologic diagnosis ( P = .025). Both HAC and adrenocortical hyperplasia showed a positive trend with the degree of adenohypophyseal proliferation. The association of adrenocortical hyperplasia with HAC was not significant ( P = .077). Dogs with adenohypophyseal proliferations were older than dogs with normal pituitary glands ( P < .05). Brachycephalic breeds were overrepresented among dogs with pituitary macroadenoma or craniopharyngeal duct cysts, but the association was not statistically significant ( P = .076). Adenohypophyseal hyperplasia was more common than adenoma among postmortem specimens, but was unexpected in >80% of cases. Pituitary macroadenoma was the most common diagnosis in hypophysectomy specimens.
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Affiliation(s)
- Margaret A. Miller
- Indiana Animal Disease Diagnostic Laboratory, Purdue University, West Lafayette, IN, USA
- Department of Comparative Pathobiology, Purdue University, West Lafayette, IN, USA
| | | | - J. Catharine Scott-Moncrieff
- Department of Veterinary Clinical Sciences and Veterinary Teaching Hospital, Purdue University, West Lafayette, IN, USA
| | - Tina Jo Owen
- Department of Veterinary Clinical Sciences and Veterinary Teaching Hospital, Washington State University, Pullman, WA, USA
| | - José A. Ramos-Vara
- Indiana Animal Disease Diagnostic Laboratory, Purdue University, West Lafayette, IN, USA
- Department of Comparative Pathobiology, Purdue University, West Lafayette, IN, USA
| | - Hsin-Yi Weng
- Department of Comparative Pathobiology, Purdue University, West Lafayette, IN, USA
| | - Andrea L. Vanderpool
- Indiana Animal Disease Diagnostic Laboratory, Purdue University, West Lafayette, IN, USA
- Department of Comparative Pathobiology, Purdue University, West Lafayette, IN, USA
| | - Annie V. Chen
- Department of Veterinary Clinical Sciences and Veterinary Teaching Hospital, Washington State University, Pullman, WA, USA
| | - Linda G. Martin
- Department of Veterinary Clinical Sciences and Veterinary Teaching Hospital, Washington State University, Pullman, WA, USA
| | - Deidre M. DuSold
- Indiana Animal Disease Diagnostic Laboratory, Purdue University, West Lafayette, IN, USA
| | - Sina Jahan
- Department of Internal Medicine, Small Animal Hospital of Veterinary Faculty, University of Tehran, Tehran, Iran
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17
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Polledo L, Oliveira M, Adamany J, Graham P, Baiker K. Hypophysitis, Panhypopituitarism, and Hypothalamitis in a Scottish Terrier Dog. J Vet Intern Med 2017; 31:1527-1532. [PMID: 28745808 PMCID: PMC5598883 DOI: 10.1111/jvim.14790] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 05/18/2017] [Accepted: 06/22/2017] [Indexed: 12/27/2022] Open
Abstract
A 6‐year old male neutered Scottish Terrier was referred with a 1 week history of progressive lethargy and anorexia. Neurological examination localized a lesion to the forebrain and hormonal testing showed panhypopituitarism. Magnetic resonance imaging (MRI) of the brain revealed a rounded, well‐defined, suprasellar central mass. The mass was slightly hyperintense to the cortical grey matter on T2‐weighted (T2W), hypointense on T1‐weighted (T1W) images and without T2* signal void. There was a central fusiform enhancement of the mass after contrast administration which raised the suspicion of a pituitary neoplasm. Rapid deterioration of the dog prevented further clinical investigations. Histopathologic examination revealed a lymphocytic panhypophysitis of unknown origin suspected autoimmune involving the hypothalamus (hypothalamitis). This is a unique case report of a dog presenting with inflammatory hypophysitis and hypothalamitis of suspected autoimmune origin with detailed clinical, MRI, histology and immunohistochemistry findings.
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Affiliation(s)
- L Polledo
- Pathology Department, Veterinary Medicine and Science, University of Nottingham, Nottingham, UK
| | | | | | - P Graham
- Pathology Department, Veterinary Medicine and Science, University of Nottingham, Nottingham, UK
| | - K Baiker
- Pathology Department, Veterinary Medicine and Science, University of Nottingham, Nottingham, UK
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18
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Rzechorzek NM, Liuti T, Stalin C, Marioni-Henry K. Restored vision in a young dog following corticosteroid treatment of presumptive hypophysitis. BMC Vet Res 2017; 13:63. [PMID: 28241874 PMCID: PMC5330113 DOI: 10.1186/s12917-017-0983-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 02/21/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypophysitis is an umbrella term for a group of disorders involving inflammation of the pituitary gland. A rare occurrence in humans, hypophysitis can produce a range of clinical signs including (but not limited to) visual deficits and diabetes insipidus. Only five cases of canine hypophysitis exist in the literature, all presenting in mature dogs with no visual deficits and a grave outcome. This case report describes the clinical and advanced imaging features of blindness-inducing presumptive hypophysitis in a dog, which rapidly resolved with medical management. CASE PRESENTATION A 1-year-and-seven-month-old neutered male Standard Poodle presented with subacute blindness, ataxia, and polyuria/polydipsia (PUPD). Magnetic resonance imaging (MRI) detected a contrast-enhancing pituitary mass with perilesional oedema compromising the optic chiasm. Suspecting neoplasia, anti-inflammatory corticosteroid was commenced prior to radiation therapy planning. Complete resolution of neurological and visual deficits occurred within 12 days of starting steroid treatment. Repeated advanced imaging indicated macroscopic resolution of the lesion. An extended thyroid panel with insulin-like growth factor-1 analysis supported a diagnosis of hypophysitis. Resolution of PUPD was achieved with tapering courses of prednisolone and desmopressin; the dog has since been clinically normal for 14 months and treatment-free for 11 months. CONCLUSIONS To the authors' knowledge, this is the first instance in which a canine pituitary mass has demonstrated long-term resolution with palliative medical treatment alone, alongside reversal of associated blindness and presumptive diabetes insipidus. We suspect this lesion to be a form of hypophysitis, which should be included among differential diagnoses for pituitary masses, and for subacute blindness in dogs. Where possible, we advocate biopsy-confirmation of hypophysitis prior to timely intervention with anti-inflammatory treatment.
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Affiliation(s)
- Nina Marie Rzechorzek
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, EH16 4SB UK
- Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Easter Bush Campus, Roslin, Midlothian EH25 9RG UK
| | - Tiziana Liuti
- Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Easter Bush Campus, Roslin, Midlothian EH25 9RG UK
| | - Catherine Stalin
- The Neurology Service, Small Animal Hospital, School of Veterinary Medicine, University of Glasgow, Garscube Campus, Bearsden Road, Glasgow, G61 1QH UK
| | - Katia Marioni-Henry
- Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Easter Bush Campus, Roslin, Midlothian EH25 9RG UK
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19
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Grau-Roma L, Peckham R, Paton J, Stahel A, de Brot S. Occurrence of primary lymphocytic hypophysitis in two horses and presence of scattered T-lymphocytes in the normal equine pituitary gland. J Vet Diagn Invest 2016; 29:115-121. [DOI: 10.1177/1040638716676292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The postmortem examination of a 14-y-old Appaloosa gelding with clinically diagnosed pituitary pars intermedia dysfunction showed a unique finding of moderate multifocal lymphocytic hypophysitis (LH). The pituitary glands of 24 horses submitted for postmortem examination were examined grossly and examined histologically for the presence of lymphocytes. Of these 23 horses, 1 additional case suffered from moderate LH. The 2 cases with LH tested negative for Equid herpesvirus 1 and 4 by polymerase chain reaction and immunohistochemistry (IHC), and no viral particles were observed by electron microscopy in 1 case examined. The cause of LH remains unknown, but based on the T-lymphocytic nature of the inflammation and the human literature, an immune-mediated origin is hypothesized. In addition, the review of 24 cases revealed that 10 horses had few and small multifocal lymphocytic infiltrates within the pituitary gland; the remaining 12 horses showed no evident lymphocytes when examined by hematoxylin and eosin. IHC for CD3 showed the presence of a small number of individual T-lymphocytes scattered through the gland in all examined horses, which appears therefore to be a normal feature of the pituitary gland in horses.
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Affiliation(s)
- Llorenç Grau-Roma
- School of Veterinary Medicine and Sciences, University of Nottingham, Sutton Bonington Campus, Loughborough, UK (Grau-Roma, de Brot)
- University College Dublin, Equine Veterinary Hospital, University College Dublin Campus, Belfield, Dublin, Ireland (Peckham)
- Scarsdale Equine Veterinary Practice, Derby, UK (Paton)
- Institute of Virology, University of Zurich, Vetsuisse Faculty, Zurich, Switzerland (Stahel)
| | - Robert Peckham
- School of Veterinary Medicine and Sciences, University of Nottingham, Sutton Bonington Campus, Loughborough, UK (Grau-Roma, de Brot)
- University College Dublin, Equine Veterinary Hospital, University College Dublin Campus, Belfield, Dublin, Ireland (Peckham)
- Scarsdale Equine Veterinary Practice, Derby, UK (Paton)
- Institute of Virology, University of Zurich, Vetsuisse Faculty, Zurich, Switzerland (Stahel)
| | - Jacqui Paton
- School of Veterinary Medicine and Sciences, University of Nottingham, Sutton Bonington Campus, Loughborough, UK (Grau-Roma, de Brot)
- University College Dublin, Equine Veterinary Hospital, University College Dublin Campus, Belfield, Dublin, Ireland (Peckham)
- Scarsdale Equine Veterinary Practice, Derby, UK (Paton)
- Institute of Virology, University of Zurich, Vetsuisse Faculty, Zurich, Switzerland (Stahel)
| | - Anina Stahel
- School of Veterinary Medicine and Sciences, University of Nottingham, Sutton Bonington Campus, Loughborough, UK (Grau-Roma, de Brot)
- University College Dublin, Equine Veterinary Hospital, University College Dublin Campus, Belfield, Dublin, Ireland (Peckham)
- Scarsdale Equine Veterinary Practice, Derby, UK (Paton)
- Institute of Virology, University of Zurich, Vetsuisse Faculty, Zurich, Switzerland (Stahel)
| | - Simone de Brot
- School of Veterinary Medicine and Sciences, University of Nottingham, Sutton Bonington Campus, Loughborough, UK (Grau-Roma, de Brot)
- University College Dublin, Equine Veterinary Hospital, University College Dublin Campus, Belfield, Dublin, Ireland (Peckham)
- Scarsdale Equine Veterinary Practice, Derby, UK (Paton)
- Institute of Virology, University of Zurich, Vetsuisse Faculty, Zurich, Switzerland (Stahel)
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20
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Paik J, Kang JH, Chang D, Yang MP. Cardiogenic Pulmonary Edema in a Dog Following Initiation of Therapy for Concurrent Hypoadrenocorticism and Hypothyroidism. J Am Anim Hosp Assoc 2016; 52:378-384. [PMID: 27685367 DOI: 10.5326/jaaha-ms-6225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A 5 yr old intact female cocker spaniel dog weighing 7.8 kg was referred with anorexia, vomiting, and depression. At referral, the dog was diagnosed initially with typical hypoadrenocorticism, and 2 d later, concurrent primary hypothyroidism was detected. Hormonal replacement therapies, including fludrocortisone, prednisolone, and levothyroxine, were initiated, but a few days later the dog became abruptly tachypneic, and thoracic radiographs indicated the development of pulmonary edema. Echocardiography showed that there were abnormalities indicating impaired left ventricular function, although the heart valves were normal. Following treatment with pimobendan and furosemide, the pulmonary edema resolved. The dog had no recurrence of the clinical signs after 10 mo of follow-up, despite being off all cardiac medications; consequently, the cardiac failure was transient or reversible in this dog. The case report describes the stepwise diagnosis and successful treatment of cardiogenic pulmonary edema after initiation of hormonal replacement therapy for concurrent hypoadrenocorticism and hypothyroidism in a dog.
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Affiliation(s)
- Jooyae Paik
- From the Chungbuk National University College of Veterinary Medicine, Cheongju, South Korea
| | - Ji-Houn Kang
- From the Chungbuk National University College of Veterinary Medicine, Cheongju, South Korea
| | - Dongwoo Chang
- From the Chungbuk National University College of Veterinary Medicine, Cheongju, South Korea
| | - Mhan-Pyo Yang
- From the Chungbuk National University College of Veterinary Medicine, Cheongju, South Korea
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21
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Cartwright JA, Stone J, Rick M, Dunning MD. Polyglandular endocrinopathy type II (Schmidt's syndrome) in a Dobermann pinscher. J Small Anim Pract 2016; 57:491-4. [DOI: 10.1111/jsap.12535] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/11/2015] [Accepted: 12/16/2015] [Indexed: 10/21/2022]
Affiliation(s)
- J. A. Cartwright
- Royal (Dick) School of Veterinary Studies and The Roslin Institute, Division of Veterinary Clinical Studies; The University of Edinburgh, Hospital for Small Animals, Easter Bush Veterinary Centre; Roslin Midlothian EH25 9RG
| | - J. Stone
- Pride Veterinary Centre; Derbyshire DE24 8HX
| | - M. Rick
- Diagnostic Center for Population and Animal Health, College of Veterinary Medicine; Michigan State University; Lansing Michigan MI 48910-8104 USA
| | - M. D. Dunning
- School of Veterinary Medicine and Science; University of Nottingham; Leicestershire NG7 2RD
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22
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Voorbij AMWY, Leegwater PAJ, Buijtels JJCWM, Daminet S, Kooistra HS. Central Hypothyroidism in Miniature Schnauzers. J Vet Intern Med 2015; 30:85-91. [PMID: 26696394 PMCID: PMC4913645 DOI: 10.1111/jvim.13818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 09/24/2015] [Accepted: 11/23/2015] [Indexed: 11/29/2022] Open
Abstract
Background Primary hypothyroidism is a common endocrinopathy in dogs. In contrast, central hypothyroidism is rare in this species. Objectives The objective of this article is to describe the occurrence and clinical presentation of central hypothyroidism in Miniature Schnauzers. Additionally, the possible role of the thyroid‐stimulating hormone (TSH)‐releasing hormone receptor (TRHR) gene and the TSHβ (TSHB) gene was investigated. Animals Miniature Schnauzers with proven central hypothyroidism, based on scintigraphy, and the results of a 3‐day‐TSH‐stimulation test, or a TSH‐releasing hormone (TRH)‐stimulation test or both, presented to the Department of Clinical Sciences of Companion Animals at Utrecht University or the Department of Medicine and Clinical Biology of Small Animals at Ghent University from 2008 to 2012. Methods Retrospective study. Pituitary function tests, thyroid scintigraphy, and computed tomography (CT) of the pituitary area were performed. Gene fragments of affected dogs and controls were amplified by polymerase chain reaction (PCR). Subsequently, the deoxyribonucleic acid (DNA) sequences of the products were analyzed. Results Central hypothyroidism was diagnosed in 7 Miniature Schnauzers. Three dogs had disproportionate dwarfism and at least one of them had a combined deficiency of TSH and prolactin. No disease‐causing mutations were found in the TSHB gene and the exons of the TRHR gene of these Schnauzers. Conclusions and clinical importance Central hypothyroidism could be underdiagnosed in Miniature Schnauzers with hypothyroidism, especially in those of normal stature. The fact that this rare disorder occurred in 7 dogs from the same breed suggests that central hypothyroidism could have a genetic background in Miniature Schnauzers.
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Affiliation(s)
- Annemarie M W Y Voorbij
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Peter A J Leegwater
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Jenny J C W M Buijtels
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Sylvie Daminet
- Department of Medicine and Clinical Biology of Small Animals, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Hans S Kooistra
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
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23
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Boag AM, Christie MR, McLaughlin KA, Syme HM, Graham P, Catchpole B. Autoantibodies against Cytochrome P450 Side-Chain Cleavage Enzyme in Dogs (Canis lupus familiaris) Affected with Hypoadrenocorticism (Addison's Disease). PLoS One 2015; 10:e0143458. [PMID: 26618927 PMCID: PMC4664467 DOI: 10.1371/journal.pone.0143458] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 11/04/2015] [Indexed: 12/15/2022] Open
Abstract
Canine hypoadrenocorticism likely arises from immune-mediated destruction of adrenocortical tissue, leading to glucocorticoid and mineralocorticoid deficiency. In humans with autoimmune Addison's disease (AAD) or autoimmune polyendocrine syndrome (APS), circulating autoantibodies have been demonstrated against enzymes associated with adrenal steroid synthesis. The current study investigates autoantibodies against steroid synthesis enzymes in dogs with spontaneous hypoadrenocorticism. Coding regions of canine CYP21A2 (21-hydroxylase; 21-OH), CYP17A1 (17-hydroxylase; 17-OH), CYP11A1 (P450 side-chain cleavage enzyme; P450scc) and HSD3B2 (3β hydroxysteroid dehydrogenase; 3βHSD) were amplified, cloned and expressed as 35S-methionine radiolabelled recombinant protein. In a pilot study, serum samples from 20 dogs with hypoadrenocorticism and four unaffected control dogs were screened by radio-immunoprecipitation assay. There was no evidence of reactivity against 21-OH, 17-OH or 3βHSD, but five dogs with hypoadrenocorticism showed immunoreactivity to P450scc compared with controls. Serum samples were subsequently obtained from 213 dogs diagnosed with hypoadrenocorticism and 110 dogs from a hospital control population. Thirty control dogs were randomly selected to establish a threshold for antibody positivity (mean + 3 × standard deviation). Dogs with hypoadrenocorticism were more likely to be P450scc autoantibody positive than hospital controls (24% vs. 1.2%, respectively; p = 0.0016). Sex was significantly associated with the presence of P450scc autoantibodies in the case population, with 30% of females testing positive compared with 17% of males (p = 0.037). Significant associations with breed (p = 0.015) and DLA-type (DQA1*006:01 allele; p = 0.017) were also found. This cross-sectional study indicates that P450scc autoantibodies are present in a proportion of dogs affected with hypoadrenocorticism.
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Affiliation(s)
- Alisdair M. Boag
- The Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush Campus, Midlothian, United Kingdom
| | - Michael R. Christie
- Division of Diabetes & Nutritional Sciences, King’s College London, Hodgkin Building, Guy’s Campus, London, United Kingdom
- School of Life Sciences, University of Lincoln, Lincoln, United Kingdom
| | - Kerry A. McLaughlin
- Division of Diabetes & Nutritional Sciences, King’s College London, Hodgkin Building, Guy’s Campus, London, United Kingdom
| | - Harriet M. Syme
- Department of Clinical Sciences and Services, Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire, United Kingdom
| | - Peter Graham
- Faculty of Medicine and Health Sciences, University of Nottingham, Sutton Bonington, Leicestershire, United Kingdom
| | - Brian Catchpole
- Department of Pathology and Pathogen Biology, Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire, United Kingdom
- * E-mail:
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24
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Rudinsky AJ, Clark ES, Russell DS, Gilor C. Adrenal insufficiency secondary to lymphocytic panhypophysitis in a cat. Aust Vet J 2015; 93:327-31. [DOI: 10.1111/avj.12354] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 01/19/2015] [Accepted: 01/26/2015] [Indexed: 11/27/2022]
Affiliation(s)
- AJ Rudinsky
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine; The Ohio State University; Columbus Ohio USA
| | - ES Clark
- Department of Veterinary Biosciences, College of Veterinary Medicine; The Ohio State University; Columbus Ohio USA
| | - DS Russell
- Department of Veterinary Biosciences, College of Veterinary Medicine; The Ohio State University; Columbus Ohio USA
| | - C Gilor
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine; The Ohio State University; Columbus Ohio USA
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25
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Abstract
Hypoadrenocorticism is an uncommon disease in dogs and rare in humans, where it is known as Addison disease (ADD). The disease is characterized by a deficiency in corticosteroid production from the adrenal cortex, requiring lifelong hormone replacement therapy. When compared with humans, the pathogenesis of hypoadrenocorticism in dogs is not well established, although the evidence supports a similar autoimmune etiology of adrenocortical pathology. Several immune response genes have been implicated in determining susceptibility to Addison disease in humans, some of which are shared with other autoimmune syndromes. Indeed, other types of autoimmune disease are common (approximately 50%) in patients affected with ADD. Several lines of evidence suggest a genetic component to the etiology of canine hypoadrenocorticism. Certain dog breeds are overrepresented in epidemiologic studies, reflecting a likely genetic influence, supported by data from pedigree analysis. Molecular genetic studies have identified similar genes and signaling pathways, involved in ADD in humans, to be also associated with susceptibility to canine hypoadrenocorticism. Immune response genes such as the dog leukocyte antigen (DLA) and cytotoxic T-lymphocyte-associated protein 4 (CTLA4) genes seem to be particularly important. It is clear that there are genetic factors involved in determining susceptibility to canine hypoadrenocorticism, although similar to the situation in humans, this is likely to represent a complex genetic disorder.
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Affiliation(s)
- Alisdair M Boag
- Hospital for Small Animals, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Midlothian, Scotland.
| | - Brian Catchpole
- Department of Pathology and Pathogen Biology, Royal Veterinary College, University of London, Hatfield, UK
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26
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Baumstark ME, Sieber-Ruckstuhl NS, Müller C, Wenger M, Boretti FS, Reusch CE. Evaluation of aldosterone concentrations in dogs with hypoadrenocorticism. J Vet Intern Med 2013; 28:154-9. [PMID: 24428320 PMCID: PMC4895548 DOI: 10.1111/jvim.12243] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 08/29/2013] [Accepted: 09/25/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Some dogs with primary hypoadrenocorticism (HA) have normal sodium and potassium concentrations, a phenomenon called atypical Addison's disease. The assumption that the zona glomerulosa and aldosterone secretion in these dogs are normal seems widely accepted; however, aldosterone measurements are missing in most published cases. OBJECTIVES To measure aldosterone in dogs with HA with and without electrolyte abnormalities and to determine the time point of aldosterone peak concentrations during ACTH stimulation. ANIMALS Seventy dogs with HA, 22 dogs with diseases mimicking HA, and 19 healthy dogs. METHODS Prospective study. Blood samples were taken before and 60 minutes after injection of 250 μg ACTH in all dogs. Additional blood samples were taken 15, 30, and 45 minutes after ACTH in 7 dogs with HA and in 22 with diseases mimicking HA. RESULTS Baseline and ACTH-stimulated aldosterone was significantly lower in dogs with HA than in the other groups. Aldosterone was low or undetectable in 67/70 dogs with HA independently of sodium and potassium levels. In 3 dogs, sodium/potassium concentrations were normal; in 1 dog, sodium was normal and potassium decreased. In all 4, ACTH-stimulated aldosterone concentrations were below the detection limit of the assay. Aldosterone concentrations were not different at 30, 45, or 60 minutes after ACTH administration. CONCLUSION AND CLINICAL IMPORTANCE Cortisol and aldosterone secretion is compromised in dogs with HA with and without electrolyte abnormalities. The term atypical Addison's disease, used for dogs with primary HA and normal electrolytes, must be reconsidered; other mechanisms allowing normal electrolyte balance without aldosterone should be evaluated in these dogs.
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Affiliation(s)
- M E Baumstark
- Clinic for Small Animal Internal Medicine, Vetsuisse Faculty University of Zurich, Zurich, Switzerland
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27
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Short AD, Boag A, Catchpole B, Kennedy LJ, Massey J, Rothwell S, Husebye E, Ollier B. A candidate gene analysis of canine hypoadrenocorticism in 3 dog breeds. J Hered 2013; 104:807-20. [PMID: 23997205 DOI: 10.1093/jhered/est051] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Canine hypoadrenocorticism is believed to be an immune-related condition. It is rare in the overall dog population but shows a breed-related predisposition with Standard poodles and Portuguese water dogs having a greater prevalence of the condition. It shares many similarities with human primary adrenal insufficiency and is believed to be a naturally occurring, spontaneous model for the human condition. Short haplotype blocks and low levels of linkage disequilibrium in the human genome mean that the identification of genetic contributors to the condition requires large sample numbers. Pedigree dogs have high linkage disequilibrium and long haplotypes within a breed, increasing the potential of identifying novel genes that contribute to canine genetic disease. We investigated 222 SNPs from 42 genes that have been associated or may be implicated in human Addison's disease. We conducted case-control analyses in 3 pedigree dog breeds (Labrador retriever: affected n = 30, unaffected = 76; Cocker Spaniel: affected n = 19, unaffected = 53; Springer spaniel: affected n = 26, unaffected = 46) and identified 8 associated alleles in genes COL4A4, OSBPL9, CTLA4, PTPN22, and STXBP5 in 3 pedigree breeds. Association with immune response genes PTPN22 and CTLA4 in certain breeds suggests an underlying immunopathogenesis of the disease. These results suggest that canine hypoadrenocorticism could be a useful model for studying comparative genetics relevant to human Addison's disease.
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Affiliation(s)
- Andrea D Short
- the Centre for Integrated Genomic Medical Research, The University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT, UK
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Frank CB, Valentin SY, Scott-Moncrieff JCR, Miller MA. Correlation of inflammation with adrenocortical atrophy in canine adrenalitis. J Comp Pathol 2013; 149:268-79. [PMID: 23348017 DOI: 10.1016/j.jcpa.2012.11.242] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 10/17/2012] [Accepted: 11/29/2012] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- C B Frank
- Department of Comparative Pathobiology, Purdue University, West Lafayette, IN 47907, USA
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29
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Lymphocytic Hypophysitis in a Dog with Diabetes Insipidus. J Comp Pathol 2012; 147:503-7. [DOI: 10.1016/j.jcpa.2012.04.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Revised: 03/19/2012] [Accepted: 04/28/2012] [Indexed: 11/18/2022]
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