Strongyle egg shedding and egg reappearance periods in horses with pituitary pars intermedia dysfunction

Pituitary pars intermedia dysfunction (PPID) is the most common endocrine disorder of older horses. Immune dysfunction in horses with PPID could increase susceptibility to infectious diseases, including strongyle infections; however, few data are available. The aim of this study was to determine if horses with PPID had increased strongyle faecal egg counts (FEC) compared with control horses, over a fourteen-week period in Victoria, Australia. Clinical signs and plasma adrenocorticotropic hormone (ACTH) concentrations were used to categorise horses into PPID (n=14) or control (n=31) groups. Faecal samples were collected for FEC determination prior to anthelmintic treatment, and fortnightly post-treatment for each horse. Generalised linear mixed modelling, using a gamma distribution, was used to compare differences between groups in the repeated measures study. The confounding variable of age was controlled for as a fixed effect. Following anthelmintic treatment, mean FEC was greater for the PPID group compared to the control group on day 56 (405 ± 756 eggs per gram [EPG] vs 40 ± 85 EPG, p=0.05) and day 70 (753 ±1598 EPG vs 82 ±141 EPG, p=0.04). There were no differences in mean FEC between groups on days 84 and 98. Cumulative FEC (day 14 to day 98) was significantly greater for the PPID horses than control horses (2118 ± 4016 EPG vs 798 ± 768 EPG, p<0.0001). Group egg reappearance period was shorter for PPID horses (day 56 post-anthelmintic treatment) compared to control horses (day 70) and 30% of the PPID horses reached a FEC threshold of >200 EPG on day 42, compared to 0% of control horses (p=0.02). These results suggest that the rate of a re-established patent infection between groups could be different due to a comprised immune response in PPID horses or differences in the host-parasite relationship regarding encysted stage larvae. However, despite differences between groups, some horses with PPID consistently had no detectable or low FEC (<200 EPG) during the study period. These findings highlight the importance of individual FEC monitoring to determine if anthelmintic treatment is required, in line with sustainable parasite management practices.

Factors affecting measurement of basal adrenocorticotropic hormone in adult domestic equids: A scoping review

Measurement of basal adrenocorticotropic hormone (ACTH) concentration is the most commonly used diagnostic test for pituitary pars intermedia dysfunction (PPID). Although several pre-analytical and analytical factors have been reported to affect basal ACTH concentrations in equids, the extent to which these have been evaluated in the context of PPID diagnosis is unclear. The objectives of this scoping review were to identify and systematically chart current evidence about pre-analytical and analytical factors affecting basal ACTH concentrations in adult domestic equids. Systematic searches of electronic databases and conference proceedings were undertaken in June 2022, repeated in October 2022 and updated in August 2023. English language publications published prior to these dates were included. Screening and data extraction were undertaken individually by the authors, using predefined criteria and a modified scoping review data extraction template. After removal of duplicates, 903 publications were identified, of which 235 abstracts were screened for eligibility and 134 publications met inclusion criteria. Time of year, exercise, breed/type and transportation were the factors most frequently associated with significant increases in ACTH concentration (n = 26, 16, 13 and 10 publications, respectively). Only 25 publications reported inclusion of PPID cases in the study population, therefore the relationship between many factors affecting basal ACTH concentration and diagnostic accuracy for PPID remains undefined. However, several factors were identified that could impact interpretation of basal ACTH results. Findings also highlight the need for detailed reporting of pre-analytical and analytical conditions in future research to facilitate translation of evidence to practice.

BEVA primary care clinical guidelines: Diagnosis and management of equine pituitary pars intermedia dysfunction

BACKGROUND

Pituitary pars intermedia dysfunction (PPID) is a prevalent, age-related chronic disorder in equids. Diagnosis of PPID can be challenging because of its broad spectrum of clinical presentations and disparate published diagnostic criteria, and there are limited available treatment options.

OBJECTIVES

To develop evidence-based primary care guidelines for the diagnosis and treatment of equine PPID based on the available literature.

STUDY DESIGN

Evidence-based clinical guideline using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework.

METHODS

Research questions were proposed by a panel of veterinarians and developed into PICO or another structured format. VetSRev and Veterinary Evidence were searched for evidence summaries, and systematic searches of the NCBI PubMed and CAB Direct databases were conducted using keyword searches in July 2022 and updated in January 2023. The evidence was evaluated using the GRADE framework.

RESULTS AND RECOMMENDATIONS

The research questions were categorised into four areas: (A) Case selection for diagnostic testing, pre-test probability and diagnostic test accuracy, (B) interpretation of test results, (C) pharmacological treatments and other treatment/management options and (D) monitoring treated cases. Relevant veterinary publications were identified and assessed using the GRADE criteria. The results were developed into recommendations: (A) Case selection for diagnostic testing and diagnostic test accuracy: (i) The prevalence of PPID in equids aged ≥15 years is between 21% and 27%; (ii) hypertrichosis or delayed/incomplete hair coat shedding provides a high index of clinical suspicion for PPID; (iii) the combination of clinical signs and age informs the index of clinical suspicion prior to diagnostic testing; (iv) estimated pre-test probability of PPID should be considered in interpretation of diagnostic test results; (v) pre-test probability of PPID is low in equids aged <10 years; (vi) both pre-test probability of disease and season of testing have strong influence on the ability to diagnose PPID using basal adrenocorticotropic hormone (ACTH) or ACTH after thyrotropin-releasing hormone (TRH) stimulation. The overall diagnostic accuracy of basal ACTH concentrations for diagnosing PPID ranged between 88% and 92% in the autumn and 70% and 86% in the non-autumn, depending on the pre-test probability. Based on a single study, the overall diagnostic accuracy of ACTH concentrations in response to TRH after 30 minutes for diagnosing PPID ranged between 92% and 98% in the autumn and 90% and 94% in the non-autumn, depending on the pre-test probability. Thus, it should be remembered that the risk of a false positive result increases in situations where there is a low pre-test probability, which could mean that treatment is initiated for PPID without checking for a more likely alternative diagnosis. This could compromise horse welfare due to the commencement of lifelong therapy and/or failing to identify and treat an alternative potentially life-threatening condition. (B) Interpretation of diagnostic tests: (i) There is a significant effect of breed on plasma ACTH concentration, particularly in the autumn with markedly higher ACTH concentrations in some but not all 'thrifty' breeds; (ii) basal and/or post-TRH ACTH concentrations may also be affected by latitude/location, diet/feeding, coat colour, critical illness and trailer transport; (iii) mild pain is unlikely to have a large effect on basal ACTH, but caution may be required for more severe pain; (iv) determining diagnostic thresholds that allow for all possible contributory factors is not practical; therefore, the use of equivocal ranges is supported; (v) dynamic insulin testing and TRH stimulation testing may be combined, but TRH stimulation testing should not immediately follow an oral sugar test; (vi) equids with PPID and hyperinsulinaemia appear to be at higher risk of laminitis, but ACTH is not an independent predictor of laminitis risk. (C) Pharmacologic treatments and other treatment/management options: (i) Pergolide improves most clinical signs associated with PPID in the majority of affected animals; (ii) Pergolide treatment lowers basal ACTH concentrations and improves the ACTH response to TRH in many animals, but measures of insulin dysregulation (ID) are not altered in most cases; (iii) chasteberry has no effect on ACTH concentrations and there is no benefit to adding chasteberry to pergolide therapy; (iv) combination of cyproheptadine with pergolide is not superior to pergolide alone; (v) there is no evidence that pergolide has adverse cardiac effects in horses; (vi) Pergolide does not affect insulin sensitivity. (D) Monitoring pergolide-treated cases: (i) Hormone assays provide a crude indication of pituitary control in response to pergolide therapy, however it is unknown whether monitoring of ACTH concentrations and titrating of pergolide doses accordingly is associated with improved endocrinological or clinical outcome; (ii) it is unknown whether monitoring the ACTH response to TRH or clinical signs is associated with an improved outcome; (iii) there is very weak evidence to suggest that increasing pergolide dose in autumn months may be beneficial; (iv) there is little advantage in waiting for more than a month to perform follow-up endocrine testing following initiation of pergolide therapy; there may be merit in performing repeat tests sooner; (v) timing of sampling in relation to pergolide dosing does not confound measurement of ACTH concentration; (vi) there is no evidence that making changes after interpretation of ACTH concentrations measured at certain times of the year is associated with improved outcomes; (vii) evidence is very limited, however, compliance with PPID treatment appears to be poor and it is unclear whether this influences clinical outcome; (viii) evidence is very limited, but horses with clinical signs of PPID are likely to shed more nematode eggs than horses without clinical signs of PPID; it is unclear whether this results in an increased risk of parasitic disease or whether there is a need for more frequent assessment of faecal worm egg counts.

MAIN LIMITATIONS

Limited relevant publications in the veterinary scientific literature.

CONCLUSIONS

These findings should be used to inform decision-making in equine primary care practice.

Clinical implications of imprecise sampling time for 10- and 30-min thyrotropin-releasing hormone stimulation tests in horses

BACKGROUND

The thyrotropin-releasing hormone (TRH) stimulation test is used to diagnose pituitary pars intermedia dysfunction (PPID) using 10- or 30-min protocols. Imprecise sampling time for the 10-min protocol can lead to misdiagnoses.

OBJECTIVES

To determine the effect of imprecise sampling time for the 30-min protocol of the TRH stimulation test.

STUDY DESIGN

In vivo experiment.

METHODS

Plasma immunoreactive adrenocorticotropin (ACTH) concentrations were measured 9, 10, 11, 29, 30 and 31 min after intravenous administration of 1 mg of TRH in 15 control and 12 PPID horses. Differences in ACTH concentrations between sampling times, variability in ACTH concentrations between protocols, and diagnostic classification of PPID were assessed using Friedman's test, Bland-Altman plots, and Fisher's exact test, respectively, with 95% confidence intervals reported and significance set at p < 0.05.

RESULTS

Imprecise sampling time resulted in variable ACTH concentrations, but significant differences in absolute ACTH concentrations were not detected for imprecise sampling within each protocol or between protocols. Imprecise sampling changed PPID diagnostic classification for 3/27 (11 [4-28] %) horses for both protocols. Using the 30-min protocol as a reference, 1/12 (8 [1-35] %) horses returned a negative test result and 5/12 (42 [19-68] %) horses returned equivocal test results that would be considered positive in practice due to the presence of supportive clinical signs.

MAIN LIMITATIONS

Limited sample size and inter-horse variability reduced the ability to detect small but potentially relevant differences.

CONCLUSIONS

Overall, the impact of imprecise sampling was not significantly different between the 10- and 30-min TRH stimulation test protocols. However, diagnostic classification for PPID would have varied between the 10- and 30-min protocols in this population, if clinical signs had been ignored. Precise timing during TRH stimulation tests and contextual interpretation of ACTH concentrations remain fundamental for the diagnosis of PPID.

Lumbar vertebral bone density is decreased in horses with pituitary pars intermedia dysfunction

BACKGROUND

Pathological fractures have been reported in equids with pituitary pars intermedia dysfunction (PPID) but their prevalence and pathogenesis is unknown.

OBJECTIVES

To compare: (1) bone mineral density (BMD) in weight bearing and nonweight bearing bones in PPID+ equids and aged and young PPID- controls; and (2) biomechanical properties of the fourth lumbar vertebral body in PPID+ equids and aged PPID- equids.

STUDY DESIGN

Case-control study: five PPID+ equids and six aged and four young PPID- control horses.

METHODS

PPID status was based on clinical signs and necropsy examination of the pituitary gland (PG). The lumbar vertebral column, right front third metacarpus (MC3), left hind third metatarsus (MT3), and PG were removed after euthanasia. BMD was determined by quantitative computed tomography of regions of interest (ROI) in each bone and biomechanical testing was performed on the fourth lumbar vertebral body. Serum concentrations of parathormone (PTH), ionised Ca++ , 25-hydroxyvitamin D, and osteocalcin (OC) were also measured. Data were analysed using one-way ANOVA and correlation analyses.

RESULTS

BMD of trabecular and cortical regions of interest (ROI) of the third, fourth (L4), and fifth lumbar vertebrae were significantly lower in PPID+ equids as compared with aged (p < 0. 001) and young (p < 0.01) PPID- controls. In contrast, no differences were found in BMD of trabecular or cortical ROIs of MC3 and MT3 between groups. No differences were detected in force at fracture, displacement at fracture, Young's modulus or strain of L4 between PPID+ and aged PPID- horses. No differences were found in serum PTH, ionised Ca++ , 25-hydroxyvitamin D, or OC concentrations between groups.

MAIN LIMITATIONS

Limited number of equids studied and variation in test results.

CONCLUSIONS

BMD of nonweight bearing bones can be decreased with PPID and could increase risk of developing pathological fractures.

Influence of feeding and other factors on adrenocorticotropin concentration and thyrotropin-releasing hormone stimulation test in horses and ponies

BACKGROUND

The basal (bACTH) and post-thyrotropin-releasing hormone stimulation concentration of adrenocorticotropin (pACTH) are recommended for diagnosis of pituitary pars intermedia dysfunction (PPID). Many factors influence bACTH (e.g., disease, age, month) and some affect the results only in autumn (e.g., breed, colour, sex). There are discrepancies about the impact of feeding on b/pACTH.

OBJECTIVES

To determine whether feeding, month, age, breed, colour, sex and body condition score affect b/pACTH.

STUDY DESIGN

Prospective crossover.

METHODS

Sixty-one animals were divided into groups: healthy, PPID, treated-PPID. The b/pACTH was measured three times (1 mg protirelin; blood collection after 10 min; mid-November to mid-July) after different feedings: fasting, hay, hay + grain. Friedman's test was applied to evaluate the influence of feeding on b/pACTH and linear mixed model to evaluate impact of further factors.

RESULTS

The b/pACTH was not significantly affected by feeding (p = 0.7/0.5). The bACTH was lowest in healthy (29.3 pg/mL, CI 9-49.5 pg/mL) and highest in PPID-group (58.9 pg/mL, CI 39.7-78.1 pg/mL). The pACTH was significantly lower in healthy (396.7 pg/mL, CI 283.2-510.1 pg/mL) compared to PPID (588.4 pg/mL, CI 480.7-696.2 pg/mL) and treated-PPID group (683.1 pg/mL, CI 585.9-780.4 pg/mL), highest in July (881.2 pg/mL, CI 626.3-1136.3 pg/mL) and higher in grey (723.5 pg/mL, CI 577.5-869.4 pg/mL) than other colours (338.7 pg/mL, CI 324.8-452.5 pg/mL). The size of effect for those variables was >0.5.

MAIN LIMITATIONS

Small number of animals, subsequent bACTH measurements were significantly lower in each horse.

CONCLUSIONS

There was no evidence that feeding influences the b/pACTH. There was evidence that pergolide affects the bACTH but it had little effect on pACTH. Further investigation of the impact of month and coat colour on b/pACTH is warranted to better interpret the results.

Dermatitis, cellulitis, and osteomyelitis caused by Aspergillus nidulans in a horse with pituitary pars intermedia dysfunction

Clinical and histologic examination of a 12-y-old client-owned Quarter Horse gelding with pituitary pars intermedia dysfunction revealed dermatitis, cellulitis, and osteomyelitis caused by Aspergillus nidulans, confirmed by a PCR assay. This novel presentation of a fungal disease in a horse was characterized by aggressive local invasion and failure to respond to all medical therapy attempted over a 1-y period. Treatments included systemic and topical antifungals, anti-inflammatories, and use of cellular matrices. Surgical excision was not attempted but should be strongly considered early in the disease process in similar cases if clean margins can be achieved. Postmortem findings were of locally aggressive disease with no dissemination.

Epidemiological investigation of insulin dysregulation in Shetland and Welsh ponies in Australia

BACKGROUND

Insulin dysregulation (ID) is central to equine metabolic syndrome. There are limited epidemiological studies investigating dynamic testing of ID in ponies.

OBJECTIVES

To evaluate prevalence and risk factors for ID through dynamic testing of hyperinsulinaemia (DHI) and insulin resistance (IR).

STUDY DESIGN

Cross-sectional.

METHODS

Sex, age, breed, height, cresty neck score (CNS), body condition score (BCS), laminitis, HMGA2:c.83G>A genotype and pituitary pars intermedia dysfunction (PPID) status were documented. Dynamic hyperinsulinaemia was diagnosed with an oral sugar test (OST) and IR with an insulin tolerance test (ITT). Owners completed surveys reporting activity, laminitis history and perception of body condition using a (1-9) visual analogue scale (VASo). Ordinal scores were converted to binary outcomes for CNS (≤2/5 or ≥3/5), BCS and VASo (≤6/9 or ≥7/9). Variables associated with insulin concentrations, glucose reduction after the ITT and laminitis were evaluated with mixed effects regression models accounting for random effects of farms.

RESULTS

Among 167 ponies tested, median (range) age was 9 (4-21) years and BCS was 6 (4-8). Prevalence (95% confidence interval [CI]) of ID was 61 (53-68)%. Factors associated with insulin concentrations (estimate [95% CI]; μIU/mL) 60 min post-OST were: age (1.07 [1.02-1.11]), CNS (≥3/5, 1.52 [1.04-2.23]) and VASo (≥7/9, 1.75 [1.09-2.79]); and 90 min post-OST were: age (1.08 [1.03-1.12]), CNS (≥3/5, 1.80 [1.22-2.64]), VASo (≥7/9, 2.49 [1.52-4.08]) and sex (male, 0.64 [0.45-0.91]). Factors associated with glucose reduction after the ITT (estimate [95% CI]; %) were: age (-1.34 [-2.01 to -0.67]), sex (female, -6.21 [-11.68 to -0.74]) and VASo (≥7/9, -1.74 [-18.89 to -4.78]). Factors associated with laminitis (odds ratio [95% CI]) were DHI (4.60 [1.68-12.58]), IR (3.66 [1.26-10.61]) and PPID (11.75 [1.54-89.40]).

MAIN LIMITATIONS

Single time-point sampling, laminitis definition and diet analysis.

CONCLUSIONS

Ageing, being female and owner-perceived obesity were associated with ID.

Evaluation of seasonal influences on adrenocorticotropic hormone response to the thyrotropin-releasing hormone stimulation test and its accuracy for diagnosis of pituitary pars intermedia dysfunction

Pituitary pars intermedia dysfunction (PPID) is an age-related neurodegenerative disorder, affecting >20 % of older horses. There is a need for improved endocrine tests for early disease detection, and the thyrotropin-releasing hormone (TRH) stimulation test has been recommended for diagnosis of early or mild cases. However, it is currently not recommended for year-round use due to marked seasonal variability. The aims of this cohort study were to evaluate effects of month and season on adrenocorticotropic hormone (ACTH) responses to TRH stimulation and to derive monthly cut-offs for PPID diagnosis. Sixty-three horses were assigned to control (n = 17), subclinical PPID (n = 21) and clinical PPID (n = 25) groups, based on a composite reference standard that combined clinical history and examination findings with endocrine test results. TRH stimulation tests were performed monthly for a 12-month period. Circannual changes were evaluated with one- and two-way repeated-measures analysis of variance and receiver operating characteristic curve analysis was used to derive cut-off values for basal and TRH-stimulated ACTH. TRH-stimulated ACTH concentrations were lowest in February-May and highest in August-October. Specificity of both basal and 30 min post-TRH ACTH was generally higher than sensitivity, and TRH stimulation had improved diagnostic accuracy compared to basal ACTH, although its sensitivity was not significantly greater year-round. TRH stimulation tests yielded considerably more positive results than basal ACTH in the subclinical group, but few additional positive results in clinical PPID cases. There were large differences between cut-offs that maximised sensitivity or specificity for TRH-stimulated ACTH, highlighting the importance of considering clinical presentation alongside test results in diagnostic decision-making.

Diagnosis of equine pituitary pars intermedia dysfunction

Equine pituitary pars intermedia dysfunction (PPID) is common in aged horses. The majority of horses respond well to treatment, but treatment is lifelong, meaning accurate diagnosis of PPID is important. Similar to any condition, there is no perfect laboratory test to diagnose PPID and accuracy is affected by the characteristics of the population in which the test is being evaluated. This review details the importance of consideration of clinical factors and diagnostic test accuracy. Basal adrenocorticotrophic hormone (ACTH) concentration is used most frequently in practice and has very good diagnostic accuracy when used in combination with clinical judgement and the correct application of diagnostic thresholds. The thyrotropin-releasing hormone stimulation test can be used in horses with equivocal test results following basal ACTH testing, or to evaluate subtle cases due to its improved accuracy.

Diagnosis of equine endocrinopathies: The value of measuring blood glucose during an oral glucose test

Blood glucose concentration is often measured during an oral glucose test (OGT), but is not thought to aid in diagnosing insulin dysregulation (ID) or pituitary pars intermedia dysfunction (PPID). The aim of this retrospective study was to investigate whether the change in blood glucose concentration during an OGT aligned with indicators of equine metabolic syndrome or PPID, including serum insulin and plasma ACTH concentrations, clinical observations, age, sex, breed type and the test dose. The cohort included 149 horses, miniature horses, and ponies that had undergone an in-feed OGT and clinical examination between 2015 and 2021. The animals were diagnosed as either metabolically healthy, insulin-dysregulated, having PPID or both endocrinopathies. The mean ± standard error increase in blood glucose during the OGT was 3.41 ± 0.21 mM, and this change showed a weak positive correlation with the increase in serum insulin concentration (r = 0.36; P 0.001), body condition score (BCS; r = 0.26; P = 0.002) and cresty neck score (CNS; r = 0.38; P 0.001). The median [interquartile range] increase in blood glucose for miniature horses (5.25 [2.98-6.5] mM), was more than twice that seen in full-sized horses (2.4 [1.33-3.45] mM; P = 0.03). In metabolically healthy animals the increase in blood glucose during an OGT (+2.2 [1-3.5] mM) was smaller (P 0.001) than in animals with ID (+3.8 [2.73-5.33] mM), or both endocrine diseases (+6.1 [3.6-6.85] mM). There was an effect of the dose of dextrose on the blood glucose response, with higher doses yielding larger responses (P 0.001). The variability in these data support that basal and post-prandial blood glucose responses to an OGT are not appropriate as stand-alone diagnostic markers of ID or PPID. However, the association between blood glucose and CNS supports the use of CNS when evaluating animals for ID.

Investigation of breed differences in plasma adrenocorticotropic hormone concentrations among healthy horses and ponies

Plasma adrenocorticotropic hormone (ACTH) concentration is commonly measured to diagnose pituitary pars intermedia dysfunction (PPID). Several intrinsic and extrinsic factors affect ACTH concentrations, including breed. The objective of this study was to prospectively compare plasma ACTH concentrations among different breeds of mature horses and ponies. Three breed groups comprised Thoroughbred horses (n = 127), Shetland ponies (n = 131) and ponies of non-Shetland breeds (n = 141). Enrolled animals did not show any signs of illness, lameness or clinical signs consistent with PPID. Blood samples were collected 6 months apart, around the autumn equinox and spring equinox, and plasma concentrations of ACTH were measured by chemiluminescent immunoassay. Pairwise breed comparisons within each season were performed on log transformed data using the Tukey test. Estimated mean differences in ACTH concentrations were expressed as fold difference with 95 % confidence intervals (CI). Reference intervals for each breed group per season were calculated using non-parametric methods. In autumn, higher ACTH concentrations were found among non-Shetland pony breeds compared with Thoroughbreds (1.55 fold higher; 95 % CI, 1.35-1.77; P < 0.001), and in Shetland ponies compared with Thoroughbreds (2.67 fold higher; 95 % CI, 2.33-3.08; P < 0.001) and non-Shetland pony breeds (1.73 fold higher; 95 % CI, 1.51-1.98; P < 0.001). In spring, no differences were identified among breed groups (all P > 0.05). Reference intervals were similar among breed groups in spring, but upper limits for ACTH concentrations were markedly different between Thoroughbred horses and pony breeds in autumn. These findings emphasise that breed should be accounted for when determining and interpreting reference intervals for ACTH concentrations among healthy horses and ponies in autumn.

Correlation of pituitary histomorphometry with dopamine and dopamine D2 receptor expression in horses with pituitary pars intermedia dysfunction

Pituitary pars intermedia dysfunction (PPID) is an endocrinopathy commonly affecting old horses. It is a spontaneously occurring, progressive disease that is still poorly understood. Previous studies have observed neurodegeneration of the dopaminergic inhibition of melanotrophs, which leads to decreased dopamine (DA) in the pars intermedia (PI) and increased pro-opiomelanocortin-derived peptides circulating in plasma. However, rats knockout for the dopamine D2 receptor (D2r) similarly develop PI hypertrophy and hyperplasia. Thus, based on the current pathophysiological theory of PPID, whether the decreased DA or the D2r dysfunction leads to PPID is still unclear. To test this, a total of 28 retrospective cases of horses with PPID were collected, graded and the expression of tyrosine hydroxylase (TH) and D2r in the PI were determined. The histological and immunohistochemical results demonstrated that horses with higher tumor histological grades had reduced TH expression with increased D2r immunoreactivity colocalized in the PI (p < 0.001, p < 0.05 respectively). This correlation supports the role of DA in the pathogenesis of continuous unregulated proliferation of neoplastic cells in PI and indicates the efficiency of D2r agonists as a treatment for PPID.

The effect of pergolide mesylate on adrenocorticotrophic hormone responses to exogenous thyrotropin releasing hormone in horses

Thyrotropin releasing hormone (TRH) stimulation testing is often used to support a diagnosis of pituitary pars intermedia dysfunction (PPID) in horses although it is unclear whether or not repeat TRH stimulation testing post-treatment is a valid means of assessing response to medical therapy. Laboratory submissions from 64 suspected equine PPID cases were examined including the initial pre-treatment TRH stimulation test and a follow up test within 100 days of starting medical therapy with pergolide. In a subset of cases, further follow-up tests were examined beyond 100 days of starting treatment. Results from tests conducted between 1 July and 30 November 30 were excluded. Significant improvements were seen in both the baseline and TRH-stimulated adrenocorticotrophic hormone (ACTH) concentrations within 100 days with no further improvements seen in the subset of cases examined thereafter. Although 88% (n=56/64) of all cases showed a decreased response to TRH post-treatment, only 24% (n=9/38) of horses with positive pre-treatment TRH stimulation tests normalised following treatment, with a further 34% (n=13/38) improving into an equivocal test outcome category. Most commonly (42%; n=16/38), horses with positive pre-treatment TRH stimulation tests remained positive following treatment, although 75% (n=12/16) of these showed a numerically lower post-treatment response to TRH. These results will help inform practitioners of expected changes in TRH stimulation test results when assessing response of horses with PPID to medical therapy with pergolide.

Use of the SGLT2 inhibitor canagliflozin for control of refractory equine hyperinsulinemia and laminitis

Background:

Hyperinsulinemia associated with pituitary pars intermedia dysfunction (PPID) and/or equine metabolic syndrome is well documented to put horses at high risk of laminitis. While dietary control of simple sugars and starch is the most effective therapy to control hyperinsulinemia, some horses fail to respond.

Case Descriptions:

Ten horses with hyperinsulinemia refractory to diet control, metformin, levothyroxine, and pergolide (if diagnosed with PPID) were treated with sodium-glucose cotransporter-2 inhibitor canagliflozin (Invokana^®). Nine horses were hyperglycemic (>5.5 mmol/l) or had a history of hyperglycemia. Before instituting therapy, renal function was assessed by determining serum creatinine and blood urea nitrogen concentrations. Canagliflozin was administered orally once a day, with food. Dipstick urinalysis was performed every 2 weeks to confirm glucosuria and screen for proteinuria. Owners were also instructed regarding clinical signs consistent with urinary tract infection. All horses responded with a substantial decrease in serum insulin concentrations to normal or near normal values. Laminitis pain resolved in all cases, with regression of fat deposits. Owner satisfaction with outcomes was 100%.

Conclusion:

Once daily administration of the SGLT2 inhibitor canagliflozin corrected hyperglycemia, reduced insulin to normal or near normal levels, and was 100% effective in reversing or reducing abnormal fat pads and eliminating laminitis pain in horses with refractory hyperinsulinemia and laminitis. The core aspects of therapy–diet control, exercise when possible, and adequate treatment of PPID–must also be maintained if using canagliflozin. Canagliflozin should be reserved for refractory cases. Further controlled trials to investigate canagliflozin pharmacokinetics, pharmacodynamics, efficacy, and safety are needed.

Impact of blue light therapy on plasma adrenocorticotropic hormone (ACTH) and hypertrichosis in horses with pituitary pars intermedia dysfunction

Blue light therapy can be used in horses to alter the natural photoperiod and inhibit winter hair coat growth. Seasonal increases in ACTH occur in the fall season but are exaggerated in horses with pituitary pars intermedia dysfunction (PPID). Additionally, PPID horses frequently present with hypertrichosis. Thus, blue light therapy was proposed as a potential management tool for hypertrichosis and for investigating the impact of photoperiod manipulation on ACTH. Eighteen PPID horses, aged 18 to 31 yr, from a university-owned research herd were selected and assigned to either the control group (n = 10) or the treatment (blue light therapy) group (n = 8) based on age and clinical history, which included the results of multiple endocrine tests. Consistent daylength of approximately 14.5 h was maintained for the treated horses from July 15 through approximately late October via the extension of natural daylength using wearable masks that provided short wavelength blue light (465 nm) to 1 eye. The control group was exposed to only the natural photoperiod during this time. All horses were housed on the same farm and remained on pasture for the duration of the study. On Day 0, thyrotropin-releasing hormone (TRH) stimulation tests were performed to confirm PPID status; there were no differences between the 2 groups in resting plasma ACTH or plasma ACTH at 10 min after TRH administration. To determine an effect of treatment on ACTH, blood was collected via jugular venipuncture for measurement of ACTH at sequential timepoints over a 16-h period in mid-October. Hair weights were also assessed throughout the study. No differences in resting plasma ACTH were observed between the 2 groups across the seasonal analysis (July and October) or during the 16-h testing. The PPID horses receiving blue light therapy had lighter hair weights compared to the PPID control horses. These results suggest that blue light therapy does not alter ACTH concentrations but could potentially be used as an additional management tool for hypertrichosis in PPID horses. Manipulation of the photoperiod using blue light therapy did not affect seasonal changes in ACTH in this study.

Endocrinopathic Laminitis

Endocrinopathic laminitis (EL) primarily occurs because of insulin dysregulation (ID) mediated through downstream effects of insulin on IGF-1R in lamellar tissues. There is likely contributing vascular and metabolic dysfunction within the lamellae, but EL is relatively non-inflammatory. EL is associated with lamellar stretching, proliferation, and failure, ultimately causing failure of the suspensory apparatus of the distal phalanx. Proper education regarding mitigating risk factors makes this a largely preventable cause of laminitis. Annual hoof evaluation plus screening geriatric horses for pituitary pars intermedia dysfunction and ID, and younger horses for ID, can significantly decrease the incidence of this devastating condition.

Markers of muscle atrophy and impact of treatment with pergolide in horses with pituitary pars intermedia dysfunction and muscle atrophy

Pituitary pars intermedia dysfunction (PPID) is a common endocrine disorder of aged horses, with muscle atrophy as one of the clinical signs. We sought to compare muscle mass and regulation of skeletal muscle proteolysis between horses with PPID and muscle atrophy to older horses without PPID, and to assess the impact of treatment with pergolide (dopaminergic agonist) on PPID horses. We hypothesized that PPID-associated muscle atrophy is a result of increased proteolysis, and that markers of muscle atrophy and proteolysis would improve over time with pergolide treatment. Markers of muscle atrophy, adiposity, insulin regulation, skeletal muscle composition, and proteolysis (muscle atrophy F- box/atrogin 1 [MAFbx1], muscle RING finger 1 [MuRF1], Bcl2/adenovirus EIV 19kD interacting protein 3 [Bnip3], and microtubule-associated light chain 3 [LC3]) were compared between PPID and control horses. PPID horses were treated for 12 weeks with either pergolide or placebo. Dose of pergolide was adjusted based upon monthly measurement of adrenocorticotropin, and markers of muscle atrophy, adiposity, insulin regulation, skeletal muscle composition, and proteolysis were compared after 12 weeks of treatment. Horses with PPID exhibited increased transcript abundance of MuRF1 (P= 0.04) compared to control. However, no difference was observed in transcript abundance of markers of proteolysis with treatment (P ≥ 0.25). Pergolide treated horses lost weight (P = 0.02) and improved fasting insulin (P = 0.02), while placebo treated horses gained weight and rump fat thickness (P = 0.02). Findings from this study suggest that treatment with pergolide may promote weight loss and improve insulin regulation in horses with PPID, but does not impact muscle mass or markers of muscle proteolysis.

Effects of pituitary pars intermedia dysfunction and Prascend (pergolide tablets) treatment on endocrine and immune function in horses

It remains unclear how pituitary pars intermedia dysfunction (PPID) and pergolide treatment (Prascend [pergolide tablets]) affect endocrine and immune function in horses. To evaluate these effects, blood was collected regularly from 28 university-owned horses (10 Non-PPID, 9 PPID control [PC], and 9 PPID treatment [PT]) over approximately 15 mo. Pergolide treatment was initiated after Day 0 collections. Analyses included ACTH, insulin, total cortisol, free cortisol, complete blood counts, plasma myeloperoxidase, and cytokine/receptor gene expression in basal whole blood and in vitro stimulations (PMA/ionomycin, heat-inactivated Rhodococcus equi, and heat-inactivated Escherichia coli) of whole blood and peripheral blood mononuclear cells (PBMCs). The results were analyzed using a linear mixed model (SAS 9.4) with significance set at P < 0.05. Significant group (P = 0.0014) and group-by-time (P = 0.0004) effects were observed in resting ACTH such that PT horses differed from Non-PPID horses only at Day 0. PT horses had significantly lower changes in ACTH responses to thyrotropin-releasing hormone stimulation tests than PC horses at non-fall time points only, mid-late February 2018 (P = 0.016) and early April 2018 (P = 0.0172). When PT and PC horses did not differ, they were combined before comparison to Non-PPID horses. No significant group or group-by-time effects were seen in resting insulin, total cortisol, or free cortisol; however, significant time effects were observed in these measures. PPID horses had lower absolute lymphocyte (P = 0.028) and red blood cell (P = 0.0203) counts than Non-PPID horses. In unstimulated whole blood, PPID horses had increased IL-8 expression compared with Non-PPID horses (P = 0.0102). In addition, PPID horses had decreased interferon γ production from PBMCs after stimulation with R. equi (P = 0.0063) and E. coli (P = 0.0057) and showed increased transforming growth factor β expression after E. coli stimulation (P = 0.0399). The main limitations of this study were a limited sample size and an inability to truly randomize the PPID horses into treatment groups. Resting ACTH is likely the best choice for determining successful responses to pergolide. Neither PPID nor pergolide appears to influence insulin, total cortisol, and free cortisol. As measured, systemic immune function was altered in PPID horses, and it is likely that these horses are indeed at increased risk of opportunistic infection. Despite reducing ACTH, pergolide treatment did not appear to influence immune function.

Effects of advanced age and pituitary pars intermedia dysfunction on components of the acute phase reaction in horses

Age, neurodegenerative disorders, and dysfunction of insulin secretion may be correlated with increased systemic concentrations of acute phase markers. Thus, the study aimed to determine the effect of age, pituitary pars intermedia dysfunction (PPID), and insulin dysregulation (ID) associated with PPID, on markers of the acute phase reaction. Twenty-nine mix-breed horses of both sexes were classified into groups: (1) healthy adult controls, (2) healthy non-PPID geriatric horses, (3) PPID ID+ horses, and (4) PPID ID- horses. Whole blood proinflammatory cytokine gene expression and serum concentrations of pro- and anti-inflammatory cytokines and acute phase proteins were measured. The data were analyzed using the Mann-Whitney U-test, and correlations between groups of data were assessed using Spearman's correlation coefficient. The tests were statistically significant if P < 0.05. No differences in the whole blood cytokine gene expression, serum cytokine concentrations, or acute phase proteins were noted between the groups. In the PPID ID group, there was a strong correlation between the ACTH concentration after the administration of thyrotropin-releasing hormone and the expression of IL-8 (r = 0.941; P = 0.0321). In the PPID ID+ group, there was a strong correlation between basal insulin concentrations and serum amyloid A (SAA; r = 0.936; P = 0.0083) as well as between postprandial insulin concentrations and SAA (r = 0.965; P = 0.001). These data suggest that neurodegeneration in horses moderately affects circulating markers of inflammation and that ID in horses with PPID influences acute phase inflammatory markers.

Influence of season and pituitary pars intermedia dysfunction on hair cortisol concentration in horses

Hair cortisol has been demonstrated to reflect hypothalamic-pituitary-adrenal axis activity (including Cushing's disease and stress) in several species. We hypothesized that hair cortisol concentrations are increased in horses with pituitary pars intermedia dysfunction (PPID) compared with healthy adult horses and that this difference is magnified in the fall, when circulating adrenocorticotropin (ACTH) is generally the highest. Cortisol from hair collected using clippers with a #40 blade from the neck was compared between PPID horses and control horses over several months in the fall (August-December) and 1 mo in spring (May). Cortisol from hair at several sampling sites (neck, jugular furrow, sternum, and submandibular) were compared between PPID (n = 6) and control (n = 8) horses in May. Relationships between hair cortisol and ACTH were assessed in the fall. Hair cortisol when measured by weight was higher in PPID vs control horses in October and November (P ≤ 0.01) but not December (P = 0.15), May (P > 0.7), or August-September (P = 0.18). When normalized for hair length, hair cortisol was higher in PPID vs control horses in November (P = 0.0006), but not October or December (P ≥ 0.06). Hair cortisol concentrations did not differ between PPID and control horses from any collection site in May (P > 0.7). There were no consistent relationships between ACTH and hair cortisol concentrations in October, November, or December (P ≥ 0.05). These findings suggest that PPID horses have increased hair cortisol accumulation in the fall compared with control horses. Additional work is needed to clarify whether assessing cortisol per weight or per hair length is most relevant in the horse.

Pharmacokinetics and pharmacodynamics of pergolide mesylate after oral administration in horses with pituitary pars intermedia dysfunction

Published information on the pharmacokinetic and pharmacodynamic properties of pergolide is limited. The aim of this study was to investigate the pharmacokinetic and pharmacodynamic properties of oral pergolide in horses with pituitary pars intermedia dysfunction (PPID). The study design was a nonrandomized clinical trial. Six horses with PPID diagnosed by thyrotropin-releasing hormone (TRH) stimulation tests received pergolide at 4 μg/kg for 18 d. Plasma samples for determination of pergolide and ACTH concentration were collected 0.5 h before and 2 and 12 h after each administration of pergolide. Maximum plasma concentrations after the first oral dose of pergolide (0.104-0.684 ng/mL; median 0.261 ng/mL; interquartile range [IQR] 0.184-0.416 ng/mL) were not significantly different to the maximum steady-state concentration at day 18 (0.197-0.628 ng/mL; median 0.274; IQR 0.232-0.458 ng/mL). Chronic administration was not associated with drug accumulation (R = 1.09) and pergolide concentration reached steady state within 3 d. Throughout, concentrations of pergolide fluctuated considerably, with median plasma peak concentrations more than four times higher than median trough concentrations. Plasma ACTH concentration reduced significantly within 12 h of administration with further reductions occurring up to 10 d after the initiation of treatment. Although there were parallel fluctuations in the concentrations of pergolide and ACTH, timing of ACTH measurement in relation to the administration of pergolide did not have a significant effect. Alterations in the response to TRH were identified at 8 d with no further change being identified at 18 d. A small number of horses were studied. Oral pergolide results in significant suppression of pars intermedia activity within hours. Pergolide and ACTH concentrations fluctuated in tandem although correlation was poor. Fluctuations in pergolide concentration were consistent with a terminal elimination half-life of less than 12 h. To reduce the level of fluctuation of ACTH, twice-daily dosing of pergolide may be more appropriate.

The oral glucose test predicts laminitis risk in ponies fed a diet high in nonstructural carbohydrates

The aim of this study was to investigate the relationship between laminitis development in ponies and insulin/glucose concentrations in response to the oral glucose test (OGT) and a dietary challenge high in nonstructural carbohydrates (NSCs). After undergoing an OGT (1 g dextrose/kg BW in feed), 37 ponies with 2-h serum insulin concentrations ranging from 22 to 1,133 μIU/mL were subjected to a diet challenge period (DCP), consuming 12 g NSC/kg BW/d for up to 18 d. Insulin and glucose responses were measured on day 2 of the DCP. Clinical laminitis was diagnosed by blinded experts and confirmed radiographically. Basal ACTH levels and clinical signs were assessed to investigate concurrent putative pituitary pars intermedia dysfunction (PPID). The diet induced Obel grade 1 or 2 laminitis in 14 ponies (38%). The ponies that developed laminitis had higher maximum concentrations of blood glucose (P = 0.04) and serum insulin (P = 0.02) in response to the diet. The geometric mean (95% CI) blood glucose concentration for laminitis cases was 14.9 (12.9-17.2) mM, compared to 10.7 (9.2-12.5) mM for ponies who did not develop laminitis. Similarly, the geometric mean (95% CI) for serum insulin was 396 (301-520) μIU/mL for laminitis cases, compared to 216 (148-316) μIU/mL for ponies who did not develop laminitis. Laminitis incidence was likewise associated with insulin concentrations measured during the OGT. Laminitis occurred at frequencies of 0% (0/7) if postdextrose insulin (μIU/mL) was <50; 35% (8/23) if insulin was 50 to 195; and 86% (6/7) if insulin was >195 μIU/mL. Basal ACTH concentrations were above seasonally accepted reference ranges in 16/37 ponies, and 8 of these animals (50%) developed laminitis. This included all 5 ponies in the study that had clinical signs of PPID (100%). In contrast, hyperinsulinemia and laminitis occurred in only 3/11 ponies (27%) with elevated ACTH concentrations and no clinical signs of PPID (P = 0.009). Thus, laminitis occurrence was associated with higher glucose and insulin responses to both the OGT and challenge diet, and the frequency of laminitis can be predicted based on insulin and glucose hyperresponsiveness to these oral carbohydrate challenges.

Pituitary pars intermedia dysfunction does not necessarily impair insulin sensitivity in old horses

Equine pituitary pars intermedia dysfunction (PPID) has been associated with reduced insulin sensitivity in comparison with younger adult horses; however, the difference in insulin sensitivity between horses with PPID and aged-matched controls has not been well characterized. The objective of the study was to determine if aged horses with PPID had reduced insulin sensitivity and alterations in the insulin-mediated signaling pathways in the skeletal muscle when compared with healthy aged horses. Isoglycemic hyperinsulinemic clamp procedures were conducted in 12 horses that were classified as either PPID (n = 6; age: 25.0 ± 2.5 yr; mean ± standard deviation) or non-PPID, aged-matched controls (control) (n = 6; age: 25.7 ± 2.0 yr). Blood samples were taken before and during the clamp procedures to measure plasma glucose, insulin, and amino acid concentrations, and 2 muscle biopsies were collected from the gluteus medius muscle, one in the basal state and the second at the end of the clamp procedure (insulin-stimulated state). Plasma insulin concentrations increased ∼9-fold during the clamp compared with basal conditions (P < 0.001) in both groups. During the last 30 min of the clamp, the rate of glucose infusion required to maintain isoglycemia in horses with PPID was similar to that in the control horses (P = 0.67). The plasma concentrations of most indispensible amino acids were lower in the insulin-stimulated state than the basal state (P < 0.05). PPID status did not have an effect on the activation of factors associated with protein synthesis and breakdown; however, factors associated with protein synthesis had increased phosphorylation in the insulin-stimulated state, compared with basal. The results from this study provide evidence that PPID is not always associated with impairments in insulin sensitivity.

Perianesthetic development of diaphragmatic hernia in a horse with equine pituitary pars intermedia dysfunction (PPID)

A 21-year-old Thoroughbred gelding with a history of equine pituitary pars intermedia dysfunction (PPID) presented with priapism of 2 days' duration. The horse received a caudal morphine epidural and then underwent corpus cavernosum lavage and phallectomy under general anesthesia. The patient's recovery featured multiple unsuccessful attempts to stand and his respiratory distress persisted for several hours until he acutely developed severe colic and was euthanized. Necropsy findings revealed a pituitary adenoma of the pars intermedia, bilateral adrenal cortical hyperplasia, and diaphragmatic herniation. This report suggests that horses with PPID may present a greater risk for diaphragmatic hernia under general anesthesia or during procedures placing stress on the diaphragm, including anesthetic recovery.

Circadian and circannual rhythms of cortisol, ACTH, and α-melanocyte-stimulating hormone in healthy horses

Cosinor analysis was used to evaluate whether pituitary and adrenal hormones exhibit circadian rhythmicity in horses. The effect of season and animal age on their respective rhythms was also determined. In addition, the usefulness of evaluating cortisol rhythmicity for the diagnosis of pituitary pars intermedia dysfunction (PPID) was assessed. Serum cortisol concentrations (P < 0.01), but not plasma ACTH or α-melanocyte-stimulating hormone (α-MSH), showed a significant circadian periodicity in horses. An effect of season on hormone concentration was observed with plasma ACTH and α-MSH concentration greater in the fall and cortisol concentration greater in the spring (P < 0.001). Age did not affect cortisol rhythm, but it did blunt the variation in cortisol concentration in horses, similar to what has been previously reported to occur in aged people and dogs. In addition, our results suggest that clinically and diagnostically normal, non-PPID-affected horses commonly have a loss of cortisol diurnal rhythm. Therefore, measurement of circadian rhythm is not an appropriate diagnostic test for PPID.

The prevalence of endocrinopathic laminitis among horses presented for laminitis at a first-opinion/referral equine hospital

Endocrinopathic causes of laminitis may be a common underlying causative pathogenesis in first-opinion or field cases presenting with laminitis, as opposed to laminitis produced in inflammatory research models. This study aimed to determine whether evidence of an underlying endocrinopathy was present in horses presented for laminitis to a first-opinion/referral veterinary teaching hospital. A second aim was to compare the signalment of horses and ponies with laminitis with the equine hospital population during the same period. All horses presenting for laminitis at Helsinki University Equine Teaching Hospital, Finland, over a 16-month period were examined for an underlying endocrinopathy. Horses presenting for laminitis were compared with the hospitalized population over the same period. There were 36 horses presented for laminitis, and evidence of endocrinopathy was present in 89%. Of the horses showing an underlying endocrinopathy, one-third had a diagnosis of pituitary pars intermedia dysfunction, and two-thirds showed basal hyperinsulinemia indicative of insulin resistance, without evidence of hirsutism. Phenotypic indicators of obesity were present in 95% of horses with basal hyperinsulinemia without hirsutism. Compared with the hospital population during the same period, horses with laminitis associated with an underlying endocrinopathy were significantly older and more likely to be pony breeds. Our data support that endocrine testing should be performed on all cases of laminitis that do not have a clear inflammatory or gastrointestinal origin.

Adrenocorticotropin concentration following administration of thyrotropin-releasing hormone in healthy horses and those with pituitary pars intermedia dysfunction and pituitary gland hyperplasia

OBJECTIVE

To compare the effect of thyrotropin-releasing hormone (TRH) administration on endogenous ACTH concentrations in healthy horses and those with pituitary pars inter-media hyperplasia and compare the test with the dexamethasone suppression test (DST).

DESIGN

Prospective case series.

ANIMALS

15 horses with clinical signs of pituitary pars intermedia dysfunction (PPID), 4 horses with equivocal signs of PPID, and 29 horses without signs of PPID.

PROCEDURES

ACTH concentrations prior to and after administration of TRH were measured 61 times in 48 horses. Results of the DST (cortisol response) were compared with those of the TRH test in 29 horses. Thirty-three horses (24 with no clinical signs of PPID, 5 with clinical signs of PPID, and 4 with equivocal clinical signs of PPID) were euthanized and necropsied and their pituitary glands evaluated.

RESULTS

ACTH concentrations increased in all horses, but magnitude and duration of increase were significantly higher in horses with PPID. Endogenous ACTH concentrations were influenced by season. The ACTH baseline concentrations and response to TRH were not correlated with results of the DST. Results of DST were abnormal only in clinically abnormal horses or those with pars intermedia hyperplasia, but were within reference range in 17 of 26 tests in these horses.

CONCLUSIONS AND CLINICAL RELEVANCE

The ACTH response to TRH is a useful test for diagnosis of pituitary gland hyperplasia, particularly in horses in which baseline ACTH concentrations are within reference range. The DST was specific but not sensitive and was inconsistent for individuals, and results often did not agree with the TRH test response.

Advantages and limitations of the equine disease, pituitary pars intermedia dysfunction as a model of spontaneous dopaminergic neurodegenerative disease

Parkinson's disease (PD) is a leading cause of neurologic disability in the aged population. Remarkable progress has been made in the past decade to understand the cellular and molecular events that occur in PD. However attempts to unravel the early, initiating factors in the pathogenesis of dopaminergic neurodegeneration and PD have been limited by the lack of a suitable animal model. Models in which there has been genetic or environmental manipulation are not of use in determining the natural cause of a disease. While a large scale prospective human study would be ideal, the relatively low prevalence of PD makes this approach economically and logistically infeasible. Equine pituitary pars intermedia dysfunction (PPID) is a spontaneous, progressive neuroendocrine disease that commonly affects aged horses and ponies. PPID results from neurodegeneration of the dopaminergic periventricular neurons that innervate the intermediate lobe of the pituitary. PPID is 10-20 times more prevalent than PD and may be readily diagnosed without a need for advanced imaging technology. Although the diseases are anatomically distinct, recent evidence suggests the pathogenesis of dopaminergic neuronal damage in PPID may have significant similarities to that of PD. In this review, the similarities and differences in the pathology of neurodegeneration in PPID and PD are compared. The potential utility of the horse as a model of spontaneous dopaminergic neurodegeneration is discussed.

Alpha-melanocyte stimulating hormone release in response to thyrotropin releasing hormone in healthy horses, horses with pituitary pars intermedia dysfunction and equine pars intermedia explants

Thyrotropin releasing hormone (TRH) stimulates an increase in plasma cortisol in horses with pars intermedia dysfunction (PPID, Cushing's disease). A similar phenomenon is observed in humans with Cushing's disease or Nelson's syndrome. The mechanism of the response in humans is not known, but an alteration in receptor expression, selectivity or responsiveness in abnormal corticotropes has been proposed. Horses with PPID, unlike humans, almost exclusively have adenomas of pars intermedia (PI) rather than pars distalis (PD) origin. Therefore, the mechanism responsible for the TRH response observed in horses likely differs. We proposed that TRH directly stimulates the PI in normal and PPID-affected horses to release proopiomelanocortin (POMC) derived peptides. Using alpha-melanocyte stimulating hormone (alpha-MSH) as a marker of a PI response and ACTH as a marker of a PD response, we were able to demonstrate a marked increase in plasma concentration of alpha-MSH and a modest, but significant increase in ACTH after TRH treatment in normal horses. The ability of TRH to directly stimulate release of POMC peptides was confirmed using PI and PD tissue explants. The presence of TRH receptor mRNA in PI tissue from both normal and PPID horses was confirmed using reverse transcriptase polymerase chain reaction. We conclude that TRH triggers the release of POMC-derived peptides from the PI through the direct stimulation of TRH receptors normally expressed on melanotropes. The increase in plasma cortisol following TRH in horses with PPID is likely attributable to the release of ACTH from the hyperplastic PI.

Pediatric Endocrinology

Endocrine and metabolic disorders affecting puppies and kittens from birth until 6 months of age may manifest as clinical problems related to growth or to water metabolism (polydipsia and polyuria). Most commonly,endocrine and metabolic disorders affect growth of the animal,and puppies are often presented to the veterinarian for assessment of delayed or aberrant growth. Other endocrine disorders of small animals,such as juvenile-onset diabetes insipidus or diabetes mellitus, affect water metabolism, resulting in excessive thirst and urination and resultant difficulty in house-breaking.

Agreement in histologic assessments of the pituitary pars intermedia in aged horses

OBJECTIVE

To evaluate concordance among veterinary pathologists in the assessment of histologic findings in the pars intermedia of pituitary gland sections from aged horses with mild signs suggestive of pituitary pars intermedia dysfunction (PPID). Sample Population-10 pituitary glands from aged horses.

PROCEDURE

7 pathologists were provided with signalment, clinical signs, and a single H&E-stained pituitary gland section from 10 aged horses with mild signs suggestive of PPID. Pathologists described histologic findings for each section and stated whether findings were consistent with PPID. Agreement among pathologists and with antemortem diagnostic test results was calculated.

RESULTS

Overall, only fair agreement was found among the pathologists as to which horses had histologic findings consistent with disease (mean +/- SE kappa value, 0.34 +/- 0.069). Interpretation of individual sections varied, with minimal agreement (4 or 5/7 pathologists) for 5 of 10 sections evaluated. Postmortem assessment was in agreement with an antemortem endocrine diagnostic test result 79% of the time.

CONCLUSIONS AND CLINICAL RELEVANCE

Validation of antemortem diagnostic testing for PPID in horses often relies on the results of postmortem histologic evaluation. The lack of consensus in histologic interpretation of pituitary glands from aged horses with mild clinical signs in our study indicates that postmortem histologic evaluation of pituitary glands is an inappropriate standard in validation of antemortem diagnostic tests for detection of early PPID. Caution should be used when interpreting diagnostic test results in horses in which early PPID is suspected.

Systemic and pituitary pars intermedia antioxidant capacity associated with pars intermedia oxidative stress and dysfunction in horses

OBJECTIVE

To determine whether a deficiency in systemic or local (pars intermedia) antioxidant capacity is associated with pituitary pars intermedia oxidative stress and pituitary pars intermedia dysfunction (PPID) in horses.

SAMPLE POPULATION

Blood samples from 20 horses with PPID and 20 healthy client-owned horses, archived paraffin-embedded adrenal gland and substantia nigra tissues from 20 horses, and pituitary gland tissue from 16 horses.

PROCEDURES

Total glutathione, superoxide dismutase, and glutathione peroxidase activities were determined in RBCs. Accumulation of a systemic marker of oxidative stress (3-nitrotyrosine) was assessed in plasma and formalin-fixed, paraffin-embedded adrenal gland and substantia nigra tissues. Local antioxidants (total and manganese superoxide dismutase, glutathione peroxidase, and total glutathione) were measured in pars intermedia tissues.

RESULTS

No significant differences existed in systemic antioxidant enzyme activity or accumulation of 3-nitrotyrosine between horses with PPID and control horses. In pituitary gland tissues, glutathione peroxidase activity was increased in horses with oxidative stress, whereas total glutathione concentration and superoxide dismutase activity remained unchanged. There was an age-associated decrease in manganese superoxide dismutase activity in the pars intermedia.

CONCLUSIONS AND CLINICAL RELEVANCE

There was no evidence of systemic accumulation of oxidative stress markers or deficiencies in antioxidant capacity in horses with PPID, suggesting that these are unlikely to be major predisposing factors in the development of PPID. Manganese superoxide dismutase activity in the pars intermedia decreased significantly with increasing age. Role of an age-associated decrease in antioxidant capacity for the pars intermedia in the development of PPID in horses warrants further investigation.

Brainstem and cranial nerve abnormalities: listeriosis, otitis media/interna, and pituitary abscess syndrome

This article reviews three disorders associated with multiple asymmetric cranial nerve deficits in ruminants: encephalitic listeriosis,otitis media/interna, and pituitary abscess syndrome. Emphasis is placed on encephalitic listeriosis, an infectious disease of the brainstem and cranial nerves caused by Listeria monocytogenes. The epidemiology, pathophysiology, clinical manifestations, diagnosis,and treatment of encephalitic listeriosis are reviewed, and differences between cattle and small ruminants are noted. Physical and neurologic examination findings that distinguish otitis media/interna and pituitary abscess syndrome from encephalitic listeriosis are highlighted.

Evaluation of suspected pituitary pars intermedia dysfunction in horses with laminitis

OBJECTIVE

To determine prevalence and clinical features of pituitary pars intermedia dysfunction (PPID) in horses with laminitis.

DESIGN

Case series.

ANIMALS

40 horses with laminitis.

PROCEDURES

Horses with laminitis that survived an initial episode of pain and were not receiving medications known to alter the hypothalamic-pituitary-adrenal axis were tested for PPID by evaluation of endogenous plasma ACTH concentration. Signalment, suspected cause, month of onset and duration of laminitis, Obel grade of lameness, pedal bone rotation, physical examination findings, results of endocrine function tests, treatment, outcome, and postmortem examination findings were recorded.

RESULTS

Prevalence of PPID as defined by a single high plasma ACTH concentration was 70%. Median age of horses suspected of having PPID (n = 28) was 15.5 years, and median age of horses without PPID (12) was 14.5 years. Laminitis occurred most frequently in horses with and without suspected PPID during September and May, respectively. Chronic laminitis was significantly more common in horses suspected of having PPID. In horses suspected of having PPID, the most common physical examination findings included abnormal body fat distribution, bulging supraorbital fossae, and hirsutism. Five horses suspected of having PPID had no clinical abnormalities other than laminitis. Seventeen horses suspected of having PPID that were treated with pergolide survived, and 3 horses that were not treated survived.

CONCLUSIONS AND CLINICAL RELEVANCE

Evidence of PPID is common among horses with laminitis in a primary-care ambulatory setting. Horses with laminitis may have PPID without other clinical signs commonly associated with the disease.

Molybdenum-associated Pituitary Endocrinopathy in Sheep Treated with Ammonium Tetrathiomolybdate

Ammonium tetrathiomolybdate (TTM) has hitherto been the treatment of choice for chronic copper poisoning in sheep, but the long-term consequences have not been evaluated. This study was based on a flock of copper-poisoned sheep which, after apparently successful treatment with TTM, became infertile and progressively unthrifty and eventually died 2-3 years later. The last five surviving animals were subjected to euthanasia and detailed study. Necropsy revealed marked wasting together with depletion of the pituitary and adrenal glands, testicular atrophy and ovarian cystic follicles. Histopathological examination revealed a non-inflammatory atrophy or degeneration of the adenohypophysis with loss of trophic cells; adrenocortical and testicular atrophy and ovarian degeneration. The regressive changes in the anterior lobe of the pituitary were confirmed by immunocytochemical labelling, which revealed a marked depletion of adrenocorticotrophic hormone (ACTH), follicle stimulating hormone (FSH) and luteinizing hormone (LH) in the affected pituitaries by comparison with healthy controls. Excess molybdenum (Mo) retention (P<0.02) was identified by inductively coupled plasma mass spectrometry (ICPMS) in the pituitaries and atomic absorption spectrometry (AAS) in the adrenals and brains of affected sheep. It was concluded that molybdenum introduced systemically as TTM is retained within the brain, pituitary and adrenal glands and is associated with a toxic endocrinopathy. It is postulated that Mo administered as thiomolybdate adversely affects the hypothalamo-adenohypophyseal system by interfering with trophic hormone release, leading to the cessation of reproductive activity and ultimately the failure of intermediary metabolism. Whether Mo exerts its effect centrally or directly on the pituitary was not established.

Dynamic Computed Tomography of the Pituitary Gland in Dogs with Pituitary-Dependent Hyperadrenocorticism

Dynamic computed tomography (CT) of the pituitary gland was performed in 55 dogs with pituitary-dependent hyperadrenocorticism (PDH) that underwent transsphenoidal hypophysectomy. On routine contrast-enhanced CT images, microadenomas of the pituitary gland often are indistinguishable from nontumorous pituitary tissue because of isoattenuation. Dynamic CT may allow visualization of these adenomas. The changes in the contrast-enhancement pattern of the pituitary during dynamic CT in 55 dogs with PDH were correlated with surgical and histopathologic findings. In 36 dogs, dynamic CT identified distinct contrast enhancement of the neurohypophysis (pituitary flush). In 24 dogs, this pituitary flush was displaced, which indicated the presence of an adenoma. This observation was confirmed surgically and histopathologically in 18 of the 24 dogs. In 19 dogs, there was a diffusely abnormal contrast-enhancement pattern. CT findings agreed with surgical findings in 13 of these dogs and with histopathologic findings in all 19 dogs. It is concluded that a dynamic series of scans should be included in the CT protocol of the pituitary gland in dogs with PDH because it allows for identification of an adenoma or a diffusely abnormal pituitary gland.

Spontaneous pituitary abnormalities and mammary hyperplasia in FVB/NCr mice: implications for mouse modeling

The FVB/N mouse strain is widely used in the generation of transgenic mouse models. We have observed that mammary glands of wild-type virgin female FVB/NCr mice frequently have the morphologic and histologic appearance of a gland during pregnancy. By 13 months of age, the mammary glands of more than 40% of the mice examined had lobuloalveolar hyperplasia that was characterized by the presence of secretory alveoli and distended ducts apparently containing secretory material. The prevalence of this phenotype further increased with age. The mammary phenotype was highly correlated with the presence of proliferative, prolactin-secreting lesions in the pituitary gland. In mice aged 18 to 23 months, hyperplasia of the pars distalis was seen in 11 of 21 mice (52%), and a further 4 of 21 mice (19%) had pituitary adenomas. Pituitary hyperplasia was already evident in some mice as young as nine months. The pituitary phenotype was also associated with high prevalence (4/6 mice) of spontaneous mammary tumors in aged multiparous, but not virgin FVB/NCr mice. This high prevalence of pituitary abnormalities and their effects on the mammary gland have important consequences for the interpretation of new phenotypes generated in transgenic models using this mouse substrain.

Mensuration of the pituitary gland from magnetic resonance images in 17 cats

The objective of this retrospective study was to estimate using magnetic resonance imaging the size range of the pituitary gland in cats who had no evidence of pituitary disease. The pituitary gland was measured from transverse and sagittal magnetic resonance postgadolinium T1-weighted images in 17 cats. The cats were 0.83 to 15 years of age and weighed between 2.9 and 6.5 kg. Linear pituitary measurements were performed on a dedicated workstation using electronic calipers. Mean (+/- standard deviation) pituitary gland length was 0.54 cm (+/- 0.06 cm) and mean width was 0.50 cm (+/- 0.08 cm). Mean pituitary gland height measured on sagittal images was 0.34 cm (+/- 0.05) and measured on transverse images was 0.32 cm (+/- 0.04 cm). Mean pituitary volume was 0.05 cm3 (+/- 0.01 cm3). There was no significant correlation between cat weight (kg) and pituitary volume or age and pituitary volume. The pituitary gland appearance varied on pre- and postcontrast T1-weighted images. On the precontrast images, the majority of pituitary glands had a mixed signal intensity. On postcontrast images, uniform pituitary gland enhancement was seen commonly.

Results of clinical examinations, laboratory tests, and ultrasonography in dogs with pituitary-dependent hyperadrenocorticism treated with trilostane

OBJECTIVE

To determine the efficacy of trilostane, a 3beta-hydroxysteroid dehydrogenase inhibitor, in dogs with pituitary-dependent hyperadrenocorticism (PDH).

ANIMALS

11 dogs with PDH.

PROCEDURE

The initial dose of trilostane was 30 mg, PO, q 24 h for dogs that weighed < 5 kg and 60 mg, PO, q 24 h for dogs that weighed > or = 5 kg. A CBC count, serum biochemical analyses, urinalysis, ACTH stimulation test, and ultrasonographic evaluation of the adrenal glands were performed in each dog 1, 3 to 4, 6 to 7, 12 to 16, and 24 to 28 weeks after initiation of treatment.

RESULTS

All dogs responded well to treatment. All had reductions in polyuria-polydipsia and panting and an increase in activity. Polyphagia decreased in 9 of 10 dogs, and 9 of 11 dogs had improvement of coat quality and skin condition. Concentration of cortisol after ACTH stimulation significantly decreased by 1 week after initiation of treatment. After treatment for 6 months, clinical signs resolved in 9 dogs. In the other 2 dogs, marked clinical improvement was reported for 1 dog, and moderate improvement was reported in the other dog. Ultrasonographically, there was a considerable change in the parenchyma and an increase in size of the adrenal glands. Adverse effects consisted of 1 dog with transient lethargy and 1 dog with anorexia.

CONCLUSIONS AND CLINICAL RELEVANCE

Trilostane is an efficacious and safe medication for treatment of dogs with PDH. Additional studies in a larger group of dogs and characterization of progressive changes in adrenal glands are needed.

[History of pituitary surgery in humans and animals: from experiments with dogs to treatment of patients]

At the end of the 19th century and the start of the 20th century experimental hypophysectomy was carried out on cats and dogs, by means of the lateral temporal approach, to investigate the physiological role of the pituitary gland because there was a debate as to whether the pituitary gland was essential for life. At the same time pioneering neurosurgeons such as Harvey Cushing used animal experiments to explore the different approaches to the neurocranium and the pituitary, thereby taking the first steps towards neurosurgery in humans. Eventually the transsphenoidal route was chosen for such an operation. Veterinary medicine has benefited from these developments in the medical field. For the past few decades, hypophysectomy has been used for the treatment of pituitary adenomas in dogs and cats that are kept as pets.

Medical treatment of canine pituitary-dependent hyperadrenocorticism (Cushing's disease)

Pituitary-dependent hyperadrenocorticism (Cushing's disease) is a relatively common endocrine disorder of middle- to old-age dogs. Three treatments commonly used in the management of pituitary-dependent Cushing's disease in dogs include mitotane, ketoconazole, and L-deprenyl. These medications are associated with the potential of different side effects and expense, but all can produce satisfactory results in dogs with this disease. The choice of treatment for a given dog depends on the severity of the dog's disease, as well as clinician and client preferences. This article reviews the indications and adverse effects associated with each of these three drugs, as well as the treatment protocols commonly used in treating dogs with hyperadrenocorticism.

Use of endogenous ACTH concentration and adrenal ultrasonography to distinguish the cause of canine hyperadrenocorticism

Twenty-nine dogs were diagnosed with hyperadrenocorticism (HAC). A single determination of endogenous plasma adrenocorticotropic hormone (ACTH) and adrenal ultrasonography were used in a prospective study to differentiate between pituitary-dependent HAC (PDH) and adrenal-dependent HAC (ADH). In 27 out of the 29 dogs (93 per cent), both endogenous plasma ACTH concentrations and adrenal ultrasonography indicated the same cause of HAC. Twenty-one of the 29 cases (72 per cent) were shown to be pituitary-dependent; all had plasma ACTH concentrations of greater than 28 pg/ml (reference range 13 to 46 pg/ml) and both adrenal glands were ultrasonographically of similar size and of normal shape. All 21 cases responded well to mitotane therapy. Six cases (21 per cent) were shown to be adrenal-dependent; all had plasma ACTH concentrations below the limit of the assay (<5 pg/ml) and the presence of an adrenal mass on ultrasonography. The sensitivity and specificity of adrenal ultrasonography and endogenous ACTH determinations to identify the cause of HAC were demonstrated to be 100 per cent and 95 per cent, respectively, for ADH. These discriminatory tests are more accurate than published figures for dexamethasone suppression testing.

Diagnosis and treatment of juvenile endocrine disorders in puppies and kittens

Endocrine and metabolic disorders affecting puppies and kittens from birth until 6 months of age may manifest as clinical problems related to growth, water metabolism (polydipsia or polyuria), or as episodic weakness. Endocrine and metabolic disorders that affect stature, such as pituitary or hypothyroid dwarfism, present to the veterinarian for assessment of delayed or aberrant growth. Conversely, juvenile-onset diabetes mellitus and diabetes insipidus cause excessive thirst, urination, and difficulty in house-breaking.

Combined pituitary hormone deficiency in german shepherd dogs with dwarfism

In German shepherd dogs pituitary dwarfism is known as an autosomal recessive inherited abnormality. To investigate whether the function of cells other than the somatotropes may also be impaired in this disease, the secretory capacity of the pituitary anterior lobe (AL) cells was studied by a combined pituitary AL stimulation test with four releasing hormones (4RH test) in four male and four female German shepherd dwarfs. In addition, the morphology of the pituitary was investigated by computed tomography. The physical features of the eight German shepherd dwarfs were primarily characterized by growth retardation and stagnant development of the hair coat. The results of the 4RH test confirmed the presence of hyposomatotropism. The basal plasma TSH and prolactin concentrations were also low and did not change upon stimulation. Basal plasma concentrations of LH were relatively low and responded only slightly to suprapituitary stimulation. With respect to the plasma FSH levels there was a clear gender difference. In the males plasma FSH concentrations remained below the detection limit throughout the 4RH test, whereas in the females the basal plasma FSH levels were slightly lower and there was only a small increase following suprapituitary stimulation, compared with the values in age-matched controls. In contrast, basal and stimulated plasma ACTH concentrations did not differ between the dwarfs and the controls. Computed tomography of the pituitary fossa revealed a normal sized pituitary with cysts in five dogs, an enlarged pituitary with cysts in two dogs, and a small pituitary gland without cysts in the remaining dog. The results of this study demonstrate that German shepherd dwarfs have a combined deficiency of GH, TSH, and prolactin together with impaired release of gonadotropins, whereas ACTH secretion is preserved. The combined pituitary hormone deficiency is associated with cyst formation and pituitary hypoplasia.

Frequency of pulmonary mineralization and hypoxemia in 21 dogs with pituitary-dependent hyperadrenocorticism

The purpose of this study was to determine the frequency of hypoxemia and pulmonary mineralization using 99mTc-methylene diphosphonate (99mTc-MDP) in dogs with pituitary-dependent hyperadrenocorticism (PDH). Twenty-one dogs with PDH were prospectively evaluated using thoracic radiography, arterial blood gas analysis, and bone phase and pulmonary perfusion scintigraphy (using 99mTc-macro-aggregated albumin [99mTc-MAA]). The radiographs and bone and perfusion studies were evaluated subjectively. An averaged quantitative count density ratio was calculated between the thorax and cranial thoraco-lumbar vertebrae from lateral thoracic 99mTc-MDP images. Thoracic:vertebral ratios were calculated using 99mTc-MDP studies from 21 control dogs. The thoracic:vertebral ratios were compared between the 2 groups (PDH and control). The mean age (+/-SD) of the 21 PDH dogs was 10.2 (+/-3) years, whereas the mean age of the control group was 9.8 (+/-3) years. Seven of the 21 dogs with PDH were hypoxemic (defined as an arterial partial pressure of oxygen [PaO2] < 80 mm Hg) with an average PaO2 (+/-SD) of 62 (+/-15) mm Hg. Of the 7 hypoxemic dogs, 2 were found to have pulmonary mineralization based on bone scintigraphic images. Pulmonary perfusion abnormalities were not identified using 99mTc-MAA in any of the 21 PDH dogs. Six PDH dogs had an abnormal interstitial pulmonary pattern and 5 of these dogs were hypoxemic. The average quantitative thoracic:vertebral ratio was not significantly different between the PDH and control dogs (0.5 +/- 0.4 versus 0.4 +/- 0.1, P = .16). Causes of hypoxemia other than pulmonary thromboembolism should be considered in dogs with PDH. Pulmonary mineralization may contribute to hypoxemia in dogs with PDH.