Transcript Méningoencéphalite d*origine inconnue

Dr. Andrea Finnen
DVM, DES, MSc, DACVIM (Neurology)
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Lipid soluble
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Protein bound – free portion important
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Interact with receptor IN cell
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Transcribe genes
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or protein
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Affect biological action
Effect
Site of action
Gluconeogenesis
 Hepatic glycogen
 Blood glucose
 Lipolysis
 Water excretion
 Gastric acid secretion
Catabolic
−ve feedback CRH
Block inflammatory response
Suppress immune system
Liver
Liver
Liver
Adipose tissue
Kidney
Stomach
Muscle, liver
Hypothalamus
Diffuse
Macro, lymphs
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Inhibit synthesis of inflammatory mediators
(prostaglandins, thromboxanes, leukotrienes)
Phospholipids
STEROIDS
Arachidonic Acid
Leukotrienes
Inflammation
Prostaglandins
Physiological Functions
NSAIDS
Prostaglandins
Inflammation
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Inhibit synthesis of inflammatory mediators
(prostaglandins, thromboxanes, leukotrienes)
Stabilize lysosomal membranes - rupture
and release of proteolytic enzymes
Attenuates fever by Il-1, reduces
vasodilation
Pain relief via anti-inflammatory actions
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permeability of capilliaries
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migration WBC into tissues
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Suppresses immune system by Tcell
lymphocytes and Tcell antibody production
Prevent fibrin deposition and connective
tissue synthesis
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PU/PD
PP, weight gain
Potbelly
Panting
Lethargy
Muscle
atrophy/weakness
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Common
Alopecia
Thin skin
Comedones
Bruising
Hyperpigmentation
Calcinosis cutis
Pyoderma
Seborrhea
2° demodex
Dermatologic
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Proteinuria
urine glucose
Recurrent UTI
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Diabetes mellitus
Euthyroid sick
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Renal/endocrine
 TT4, T3, TSH
Hyperglycemia
Hyperlipidemia
Hypercholesterolemia
ALP
Lymphopenia
Neutrophila
Eosinopenia
Hypokalemia
Hyperlactatemia
Blood work
abnormalities
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Vomiting
Diarrhea
Gastric ulceration
Colonic perforation
Urinary tract infection *
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30x more potent than
cortisol
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7x more potent than
Prednisone
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2x mineralocorticoid effects
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Greater penetration into
CSF
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4x more potent than
cortisol
Minimal mineralocorticoid
effects
Prednisolone in cats better
absorbed
Biologic effect 12-36hr
Biologic effect ≤48hr
Dexamethasone
Prednisone
Prednisone
0.5-1mg/kg/day
Prednisone
1-2mg/kg/day DOG
up to 4mg/kg/day CAT
Dexamethasone
0.075-0.15mg/kg/day
Dexamethasone
up to 0.3mg/kg/day
Anti-Inflammatory
Immunosuppressive
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Many neurological diseases have an
inflammatory or immune etiology
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Sometimes steroids are the only treatment
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If you think it’s inflammatory and it’s not…
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Think about what you are treating before Rx Diagnosis is key!
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Degenerative myelopathy (DM)
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FCEM
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Coonhound paralysis
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Trigeminal neuritis
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Ischemic infarct (stroke)
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Bengal polyneuropathy
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Steroid responsive meningitis-arteritis (SRMA)
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Meningoencephalitis of unknown etiology (MUE)
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Intracranial neoplasia
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IVDD Type I and II
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Cervical spondylomyelopathy (Wobblers)
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COMS + syringomyelia (SM)
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Hydrocephalus
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Steroid responsive meningitis-arteritis (SRMA)
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Meningoencephalitis of unknown etiology (MUE)
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Intracranial neoplasia
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IVDD Type I and II
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Cervical spondylomyelopathy (Wobblers)
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COMS + syringomyelia (SM)
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Hydrocephalus
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Head trauma
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Spinal trauma
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Infectious encephalitis/abscess
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Lumbosacral disease
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Myasthenia Gravis
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Signalment + clinical signs
Imaging – MRI preferred for CNS
+/-CSF
+/- biopsy, culture
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But……client have only $100 to spend…..
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4 yo FS Miniature poodle
Presenting complaint: walking funny
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Hind end ataxia (grade 2)
Delayed paw placement both HL
Back pain at TL junction
Appetite decreased
Lethargic, not moving around much
Top 2 differentials:
◦ IVDD
◦ Meningomyelitis
◦ +/- Others (trauma, infectious, neoplasia, FCEM, etc)
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Inflammatory
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IVDD
Other spinal cord/nerve compression
CSF over-production
Unknown dx
Immune
◦ Definitively diagnosed
◦ Hard to justify high dose steroids if no definitive dx!
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“Evaluation of the Success of Medical Management for
Presumptive Thoracolumbar IVDD in Dogs”
Levine, VS 2007
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Conclusion:
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◦ “…glucocorticoids may negatively impact success and QOL.”
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Discussion:
◦ “…possible that glucocorticoids have a negative impact on dogs
with medically managed presumptive disk herniation.”
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“Evaluation of the Success of Medical Management for
Presumptive Cervical IVDD in Dogs”
Levine, VS 2007
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Conclusions:
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Discussion:
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◦ “NSAIDs should be considered as part of the therapeutic regimen.”
◦ “…glucocorticoid administration does not appear to benefit these
dogs..”
◦ “…glucocorticoids were less likely to have a successful outcome
but this association was also not statistically significant.”
◦ NSAIDs seem to be associated with success in dogs with
presumptive cervical disk herniation..”
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“Recurrence rate of presumed thoracolumbar disc disease
in ambulatory dogs with spinal hyperpathia treated with
anti-inflammatory drugs: 78 cases (1997-2000).”
Mann et al., JVECC 2007
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Conclusions:
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◦ “Dogs treated with NSAIDs or MPSS were less likely to experience
recurrence than dogs treated with corticosteroids other than MPSS.”
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Discussion:
◦ “…impossible to determine whether any of the drugs used are
necessary for recovery of the initial episodes of presumed IVDD…”
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“Adverse effects and outcome associated with
dexamethasone administration in dogs with acute
thoracolumbar intervertebral disk herniation: 161 cases
(2000-2006).”
Levine, JAVMA 2008
Conclusions:
◦ “…treatment with dexamethasone before surgery is associated
with more adverse effects, compared with treatment with
glucocorticoids other than dexamethasone or no treatment with
glucocorticoids…”
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DOSE 1-30mg/kg!!!!!
3.4x more likely to develop AE
66% non treatment had AE too
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CVT XV Chapter 233 Canine IVDH
◦ Medical therapy:
 2-4 weeks cage rest and analgesia with NSAID and opioids
+/- drugs for neuropathic pain
◦ “The use of corticoids such as Dexamethasone is
strongly discouraged for acute SCI from IVDH.”
◦ “..glucocorticoid therapy was negatively associated with
improved functional outcome.” (Levine, 2007)
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Inhibit platelet aggregation
Aspirin has irreversible action!
Risk of gastric ulceration and GI effects
Can lead to renal damage
Need 48-72 hour wash-out
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Ideally – MRI +
decompressive surgery
Dexamethasone 0.10.15mg/kg/day for 35 days
+/- Prednisone antiinflammatory tapering
for 1 week
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No diagnosis?
Dexamethasone 0.1mg/kg/day x 1 week then
0.05mg/kg/day x 1 week
Recheck – better?
STOP or switch to Prednisone for longer
maintenance
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Steroids are not all bad!
Think about what you are treating
Use appropriate doses
Follow up and D/C when possible
Don’t use steroids with NSAIDS!