Case 6

In addition to the endoscopic examination, Roxy's cobalamine and folate concentrations were measured, and cobalamine deficiency was identified. Ancillary tests such as cobalamine and folate measurements may be performed in patients with intestinal disease and decreased concentrations of one or both may be a marker of concurrent small intestinal bacterial overgrowth. Cobalamine is important for cellular metabolism, and cobalamine deficiency is common in patients with malabsorptive diseases such as PLE. Supplementation with parenteral injections is often instituted using the following protocol: 25µg/kg given subcutaneously once a week for six weeks, then every two weeks for six weeks, and then once a month.

Roxy recovers well from her endoscopic examination, and her abdominal effusion is stable at this time. Treatment consisting of prednisone (1 mg/kg given orally b.i.d.), cobalamine injections, and a low-fat therapeutic diet is initiated, and she is scheduled for a follow-up in five to seven days.

At her follow-up visit, Roxy's owners report she is a little peppier and is eating well. She is, however, having accidents in the house and is drinking constantly. Her abdomen still appears a little distended, but she does not appear to have ascites. You suspect that Roxy’s polyuria and polydipsia are related to the prednisone, but just to be sure you recheck a urinalysis. Other than hyposthenuria, the results are normal. You also recheck a CBC and serum chemistry profile, and these are her results:

CBC

Patient values

Reference range

WBC (/µl)

17,820

4,000-15,500

-Neutrophils (/µl)

14,540

2,060-10,600

-Monocytes (/µl)

1,500

0-840

-Lymphocytes (/µl)

1,230

690-4,500

-Eosinophils (/µl)

550

0-1,200

Hct (%)

30

36-60

RBC morphology

Hypochromasia

Reticulocyte count

32,000

> 60,000

Serum chemistry profile

Patient values

Reference range

BUN (mg/dl)

23

6-31

Creatinine (mg/dl)

1.2

0.5-1.6

ALP (IU/L)

332

5-131

ALT (IU/L)

98

12-118

Albumin (g/dl)

2.4

2.7-4.4

Globulin (g/dl)

2.9

1.6-3.6

Glucose (mg/dl)

125

70-138

Sodium (mEq/L)

143

139-154

Potassium (mEq/L)

5.3

3.6-5.5

<< Back | Next Step >>