A Feisty Ferret – The Final Chapter

Bandit returned 7 days later for a post-operative examination. His owner reported that Bandit’s recovery was smooth and rapid and that there had been no complications observed at home. Bandit’s surgical incision was healing very well and there were no sign of infection. At the time of this visit I was able to discuss Bandit’s adrenal pathology report with his owner. As it turns out Bandit was doubly lucky: first, his adrenal was affected with an adenoma, a benign type of cancer that was extremely unlikely to spread throughout the body. Additionally, the report confirmed that his surgery had removed the entire gland and associated cancer, thereby greatly reducing the risk of a local recurrence of the cancer. Bandit was seen once more 3 weeks later at which time his owner reported that Bandit’s aggressive behavior had disappeared and that he was no longer biting the other ferrets or his owner. His incision was fully healed and his surgery was considered a complete success. As I discuss in my detailed blog about adrenal disease, surgical intervention is not always an option for ferrets with adrenal disease. Typically speaking surgery is not recommended in old ferrets, particularly those with poorly controlled or severe concurrent diseases such as insulinoma or age related degenerative disease. Bandit however represented those patients at the other end of the spectrum: He was relatively young, outwardly very healthy, had a tumor on the left gland (not the right or both glands) and had no abnormalities or other diseases detected on screening exams and blood tests. In cases like these, surgical intervention can potentially cure adrenal disease indefinitely. At the time of writing this blog Bandit continues to do well at home with no aggressive behavior and an excellent coat of fur. His owner is pleased as am I and the entire staff at Whitestone Vet Care and the Animal Medical Hospital and Bird Clinic in Hempstad, New York.

Thanks for reading and stay tuned for more important information on exotic pet health.

Dr. Starkey

A Feisty Ferret – Bandit’s Story Part II

Bandit was admitted to Whitestone Veterinary Care for an ultrasound evaluation of his abdominal organs and his adrenal glands prior to his owner and I reaching a final decision on whether to perform adrenal surgery or not. Our consulting, board certified veterinary internist, Dr. Judy Pawlusiow performed the ultrasound examination and confirmed Bandit’s adrenal disease. Dr. Pawlusiow detected an enlarged and irregular left adrenal gland which was approximately 2 times larger than normal and appeared to be irregular in shape and consistency based on the ultrasound images. Bandit did have some good luck in that the remainder of the ultrasound examination was unremarkable. His right adrenal gland was found to be normal, as were his kidneys, liver, spleen, prostate, and intestines.

Given Bandit’s good general health and normal complete blood count and chemistry panel results, it was decided that his best chance for a complete cure was a left adrenalectomy (surgical removal of the left adrenal gland). The surgery was performed later that day. Given the challenging nature of performing an adrenalectomy in ferrets Dr. Wyler and I set aside 3 hours for the delicate procedure, and both scrubbed in on the case. Dr. Wyler took the lead in the surgery while I assisted with the intricate process of isolating and removing the gland. I also served as Bandit’s anesthesiologist, directing our licensed veterinary technician in the critical process of maintaining Bandit at a safe depth of general anesthesia and providing cardiovascular support.

Whenever an abdominal surgery is performed on an animal the veterinarian should examine all internal organs and attempt to diagnose any concurrent diseases. In the case of ferrets this is particularly important owing to their propensity to develop conditions like the pancreatic disease known as insulinoma, and internal cancers such as lymphoma. Given this fact Bandit’s internal organs were examined as soon as the surgery began. Luckily for him this visual inspection confirmed the ultrasound findings and failed to detect any disease other than the enlarged left adrenal gland. With this step completed we were able to proceed with the removal of Bandit’s left adrenal gland.

The adrenal glands are located deep within the abdominal cavity, less than an inch in front of the kidneys. The glands are supplied by large blood vessels and sit within 1 inch of the largest artery and vein in the body. In ferrets the adrenal gland sits encased within a layer of fat, as such great care is required to isolate the glands without damaging their blood supply which is often buried in the layer of fat as well. Dr. Wyler and I employed a variety of techniques to isolate the left adrenal gland, including radiosurgery and the use of small surgical steel hemoclips to safely occlude the blood vessels supplying the adrenal glands. Once the gland was isolated and its blood supplies safely occluded the diseased gland was removed and placed in a preserving solution such that it could be sent to a pathologist for analysis.

With the gland removed Bandit’s abdominal cavity was closed in three separate layers using advanced suture material. Due to the intensive care and close attention paid to Bandit during the anesthesia he recovered rapidly and uneventfully from the surgery. Because of his exceptional recovery Bandit was sent home to the care of his owner late that evening. He I was given detailed instructions in the care of Bandit in the first days during the postoperative period and was encouraged to call us at any hour during the night should you be concerned about that Bandit’s health. Bandit continued to do extremely well at home and recovered without incident.

Check in next week to see how Bandit does at his follow-up visits, to learn the results of the pathologist’s analysis of his adrenal gland and to determine if any changes in his feisty behavior occurred as a result of the adrenal surgery.

Thanks for reading,

Cheers,

Dr. Simon Starkey

 

A Feisty Ferret – Bandit’s Story

Bandit had just turned 5 years old when he was rescued by his current owner from a friend who could no longer take care of him. He was thin, had lost a large amount of fur over his tail and lower back and seemed a little weak. With lots of TLC by his new owner, and a visit to the vet Bandit bounced back. He gained strength and weight and regrew some fur. However his new owner notice that Bandit was particularly aggressive with the other two ferrets in the household. He would often jump on their backs and bite at their necks. The owner also reported that Bandit bit him during rough play.

I evaluated Bandit at Whitestone Vet Care and discussed the possibility of adrenal disease with his owner. Given the aggression and fur loss it was decided that the next best step would be to perform an adrenal panel to evaluate Bandit’s reproductive hormone levels. The lab work returned it demonstrated that Bandit a two and a half fold increase in androstenedione – a hormone which is similar to testosterone. This finding explained Bandit’s aggression and allowed us to diagnose him with adrenal disease. Medical and surgical options were discussed with Bandit’s owner. Given his excellent health and relatively young age the owner decided to perform surgery on Bandit as this option can lead to a complete clinical cure, especially if only the left gland isaffected.

In order to prepare for surgery an ultrasound examination was performed on Bandit’s abdomen. This allowed us to evaluate his adrenal glands directly and to visualize his liver, kidneys, spleen, bladder, prostate and intestines, which were found to be normal. Fortunately Bandit the ultrasound identified a normal right adrenal gland and moderately enlarged left adrenal gland. The left gland was free of major blood vessels and did not appear so large as to present surgical difficulties. Bandit was sent home later that day and a left adrenalectomy was scheduled forthe following week.

Read my blog next week to see how Bandit’s surgery turns out and to monitor his post op progress!

Cheers,
Dr. Starkey

Insulinoma

Most long-term ferret owners have heard about insulinoma; some may have experienced the disease first hand in one or more of their furry friends. However, for those seasoned ferret owners who haven’t heard of the condition and for new ferret owners this article is a must.

What is insulinoma?

Insulinoma is an endocrine disease that occurs quite frequently in ferrets. Most ferrets are 5 or more years of age when the disease is diagnosed. To a certain degree insulinoma is related to diabetes. Both conditions are caused by disease of the pancreas. In diabetes the pancreas produces little or no insulin, and as such blood sugar (glucose) levels are very high. With insulinoma the situation is reversed. One or more small tumors on the pancreas produce too much insulin. This leads to a significant drop in glucose levels and several symptoms, described below:

• Lethargy and weakness – while these signs are non-specific, they are by far and away the most common symptoms seen in ferrets with insulinoma. The weakness may wax and wane, however as the disease progresses it will be more apparent and may occur 100% of the time.
• Pawing at the mouth and increased salivation – it is not known why this occurs in ferrets with insulinoma, but has been speculated that ferrets with insulioma feel nauseous and paw at their mouth salivate as a response to the nausea.
• Vomiting – This symptom is not as common as the other symptoms mentioned above, however it can occur with insulimoma.
• Seizures (fits) – While seizures are not common with insulioma, they do occur. Seizures are particularly likely to occur with severe insulinoma, or in those cases in which diagnosis and treatment by a qualified veterinarian is delayed.

If you notice any of these signs in your ferret you should seek help from a qualified exotic pet veterinarian. If you suspect insulinoma inform the staff at your vet’s office. They will likely ask that you bring the ferret to the clinic on an empty stomach (after a 2-3 hour fast). By doing so blood tests can be performed at the time of your appointment and a diagnosis can be reached rapidly.

How is insulinoma treated?

Insulinoma may be treated medically or surgically. The decision to choose medical management over surgical management is made on the basis of the ferret’s age, general health and ability to withstand surgery. The aim of surgery is to remove the mass or masses within the pancreas which are causing an increase in blood insulin levels and leading to a reduction in blood glucose levels. At times your veterinarian may discover that your ferret has more than on mass, and that it is not possible to surgically remove all of them. Should this happen, he or she will likely remove any large mass and as many small masses as they feel is safe. In these instances the ferret will need to be managed medically after surgery.

Medical management can be preformed alone, or after surgical intervention fails to remove all of the insulin secreting mass within the pancreas. Medical management usually consists of treating the affected ferret with a liquid medication known as prednisolone. The aim of this medication is to increase blood sugar levels and counteract the symptoms of insulinoma. Medical therapy does not treat the pancreatic tumors that are responsible for the disease, rather it treats the symptoms. This is critical as low blood sugar can be fatal if not controlled. Many ferrets live several years on their medication. Close follow up is required with your veterinarian to ensure the appropriate dose of medication is being given. Your vet will often wish to recheck blood sugar values fairly frequently until levels are stable. You ferret should always be evaluated 2-3 hours after eating and having its morning dose of medication. This takes out variability caused by food and medication from the equation when your vet evaluates your ferret’s progress. Whether medical or surgical management is chosen it is important to stop giving your ferret sugary treats and supplements. This may seem counter productive, since insulinoma causes disease by decreasing blood sugar. However, giving your ferret sugary treats causes the pancreas to secrete even more insulin and this can cause a sudden and severe drop in blood sugar.

With time most ferrets require more prednisolone as the disease progresses. At a certain point the amount of medication may be difficult to administer. At this point, your vet may suggest adding another medicine know as diazoxide. This medication is quite expensive and is often reserved for cases where prednisolone is not working as well as it should.

In conclusion, insulinoma is caused by one or more tumors in the pancreas. These tumors secrete too much insulin and cause blood glucose levels to fall to dangerously low levels. The disease is common in older ferrets and diagnosis is relatively straightforward. The disease can be managed medically or surgically, but either option will require close cooperation with your exotic pet vet and relatively frequent follow-up until the blood sugar levels are stable.

Ferret Adrenal Disease

What do the adrenal glands do?

The adrenal glands are responsible for many important functions. One key
function of the adrenal glands is to produce adrenaline (epinephrine).
Adrenaline helps the body respond to life-threatening situations and
is the key driver of the fight or flight response. The glands also
produce an important hormone known as cortisol. This hormone assists
in the regulation of blood sugar, it is an immune regulator, and it
assists in the metabolism of protein, fat and carbohydrates. Finally,
the adrenal gland also produces relatively small amounts of
reproductive hormones and their precursors.

What is adrenal disease?

When used to describe disease in ferrets adrenal disease refers to
hyperadrenocorticism. This big term simply means an overactive adrenal gland. An overactive adrenal gland usually produces excessive
amounts of cortisol in humans and dogs and this condition is know as
Cushing’s disease (or syndrome).

Do ferrets get a different type of adrenal disease?

Yes, the type of adrenal disease in ferrets is different to that
commonly seen in people and dogs. In ferrets it is the reproductive
hormones that are overproduced with overactive adrenal glands. The glands may be overactive due to hypertrophy, benign cancer or a malignant form of cancer. Without a surgical biopsy or gland removal and pathology determining which of the three causes of adrenal disease a ferret has is difficult to impossible.

What are the clinical signs (symptoms) of adrenal disease in ferrets?

The increased amounts of circulating reproductive hormones lead to one or more
of the following clinical signs in ferrets:

-Hair loss: This usually starts at the tail and often extends to
involve the back, stomach and ultimately most of the pet’s body. Some
ferrets initially lose fur only over the crown of their heads and look
a bit like little Friar Tucks. These pets may go on to lose fur over
their entire body as well.

-Itching: Approximately 30% of ferrets with adrenal disease will have
itchy skin. They may have little scabs and scratches on their bodies
from itching so much. Some ferrets will also show a yellow
discoloration of the skin accompanied by waxy-type exudates.

-Swelling of vulva: The majority (over 70%) of female ferrets with
adrenal disease will have an enlarged vulva secondary to the increased
reproductive hormones produced by over active adrenal glands.

-Anemia: Female ferrets may develop anemia. Typically it takes a
licensed veterinarian to diagnose anemia, however you may suspect it
if your ferret’s gums appear pale or if she is weaker than usual.

-Aggression: Aggression and increased sexual activity can be seen in
some ferrets with adrenal disease. Typically aggression is more common
in males, but can be seen in female ferrets as well.

-Urinary problems: Owing to increased testosterone levels male ferrets
can suffer from an enlarged prostate which can make urination
difficult or impossible. This rapidly becomes a life-threatening
situation and warrants emergency veterinary care.

How is adrenal disease diagnosed?

While the symptoms of adrenal disease in ferrets are fairly
characteristic it is important to allow your veterinarian to perform
additional diagnostic tests to help confirm the diagnosis and
determine your pet’s overall health. In any middle aged or older
ferret, be it showing signs of illness or not, your veterinarian will
likely suggest a complete blood count (CBC) and chemistry panel. These
tests don’t diagnose specific diseases, however they give an overall
picture of health by assessing liver and kidney health as well as
monitoring for anemia and signs of infection. There are two tests
available to specifically diagnose adrenal disease itself:

-Ferret adrenal panel: This test involves your veterinarian obtaining
a blood sample and sending it to the laboratory for endocrine testing.
Three common reproductive hormones are studied and if one or more are
elevated then a diagnosis of adrenal disease can be made.

-Abdominal or adrenal ultrasound: In this test a skilled veterinarian
(often a specialist) performs an ultrasound examination on the
affected ferret. The abdominal ultrasound is more comprehensive than
an adrenal ultrasound in that all abdominal organs are evaluated
(liver, kidney, spleen, bowel, bladder, prostate) in addition to the
adrenal glands. If an adrenal ultrasound is offered then only the
adrenal glands are evaluated. This test will likely be slightly less
expensive than a full abdominal ultrasound, but may or may not be an
option depending upon your veterinarian’s policies.

How is adrenal disease treated?

Broadly speaking there are two main ways to treat ferret adrenal
disease, medical or surgical management. The decision as to which
treatment path to follow is one made between the veterinarian and the
pet owner taking the following factors into consideration: The age and
sex of the ferret, the nature of the individual ferrets disease and
symptoms, presence of additional diseases, affected gland(s) (left,
right or both), owner’s desire for cure versus control, risks of
surgery, possible complications during and after surgery, willingness
to tolerate possible recurrence or disease of opposite gland if
surgery is performed.

-Surgery: Generally speaking the prognosis for left-sided adrenal
gland removal is good and the chances of medium to long-term cure are
good. Right-sided disease is complicated by the close proximity of the right
adrenal gland to the largest vein in the body (the vena cava) and the
liver. As such, right-sided or bilateral adrenal disease carries a
larger risk of intra- and post-operative complications as well as a
reduced likelihood of cure. If right gland is affected the surgeon may
only be able to partially remove the gland. This may slow the progress
of the disease, but is unlikely to lead to a cure.

-Medical management: There are several types of medical management
available. The medication offered to you will likely vary with your
veterinarians experience and comfort level with one or more of the
available treatment options. It is important to note that medical
management will help reduce and potentially eliminate some of the
potentially life-threatening secondary symptoms of adrenal disease
(such as anemia or urinary blockage) but it is generally not believed to be effective in slowing or stopping tumor growth in those ferrets affected by adrenal gland cancer.

Lupron (leuprolide) : Lupron has been a mainstay of medical management for several
years. This agent is generally effective in controlling clinical
signs when given to ferrets by injection once a month. Lupron helps to reduce the hormone induced aspects of adrenal disease-such as fur loss, estrogen induced anemia and prostate disease. Lupron is essentially a synthetic hormone, and over time the ferret’s body may recognize this substance as foreign and create antibodies against it, thereby reducing its efficacy.

Deslorelin: This drug is similar to lupron, although it is available in a longer term implant. The drug is not currently licensed in the USA and you will need to ask your ferret veterinarian if he or she is able to import the drug from Australia.

Melatonin: The use of oral melatonin has been studied in ferrets and the drug has proven effective in treating the clinical signs and hormonal changes seen with this disease. One problem with its use however is the lack of regulation of melatonin manufacture in the US. As such it can be difficult to be certain that the ferret is gaining the benefit it should from this drug. As an alternative, a melatonin implant is available to veterinarians in the US. This product is being actively investigated by Dr. Matthew Johnson of Colorado State University, and initial reports are very promising as to this products ability to improve fur loss and improve the hormone status of ferrets with adrenal disease.

In conclusion, the treatment of adrenal disease requires a commitment on the owner’s behalf and teamwork between the owner and their veterinarian.

I wish you and your furred friends all the best.

Stay warm, stay safe and Happy New Year!

-Dr. Simon Starkey

Is your ferret DIM?

No, I don’t mean slow or silly. DIM stands for disseminated idiopathic myofasciitis, a very serious, but thankfully relatively rare disease of ferrets. So what do all those big words mean? Basically this term means a widespread inflammation of muscle and adjacent tissue of unknown cause. DIM emerged as a disease of concern to ferret owners and veterinarians in late 2003. The disease occurs predominantly in young adult ferrets, typically striking animals between 6 and 12 months of age.

Affected ferrets almost always have a fever, are weak/lethargic and demonstrate pain or difficulty moving. About half of affected ferrets will have difficulty eating or swallowing and some will have abnormal stools. Routine blood tests may help support the diagnosis by demonstrating a characteristic increase in white blood cells and an anemia.

While the symptoms and blood tests may support a diagnosis of DIM, a true diagnosis can only be achieved by taking muscle biopsies. In a 2007 journal article examining the condition in 17 ferrets, all 17 animals had damage to the muscle of the esophagus as well as the heart. Eleven of the 17 animals had damage to muscles of the hind legs and/or lower back muscles. From a diagnostic perspective, taking a biopsy from the legs or lower back is much easier and safer than taking a sample from the esophagus. However it is important to keep in mind that in up to a third of cases with DIM, these tests will fail to accurately diagnose the condition. In these cases a tentative diagnosis will likely be reached by your ferret vet based on the symptoms and blood test results.

Sadly, despite significant research, a cause for DIM has yet to be identified. With no known cause many different types of treatment have been attempted for ferrets with DIM. Treatments have ranged from various antibiotics, anti-inflammatory drugs and steroids to more advanced therapeutic attempts such as trials of interferon and/or cyclophosphamide. Unfortunately no treatment regimen has proven effective against the condition and sadly death or euthanasia is almost guaranteed for any ferret with an accurate diagnosis of DIM.

It is important to keep in mind that other diseases can cause similar symptoms and blood results as DIM. As such your veterinarian will discuss other diagnostic options in an attempt to find the true cause of your ferret’s symptoms. Occasionally treatable conditions, such as toxoplasmosis, may cause similar signs in ferrets. As such working with your vet to achieve a definitive diagnosis can be a worthwhile endeavor.

As always, if you are concerned about your ferret’s health contact a ferret savvy veterinarian. Remember very few vet schools actively teach ferret medicine and surgery and very few graduate vets take the time to study these wonderful pets.

Best,

Dr. Simon Starkey

Rabbit GI stasis

Many of my rabbit savvy clients are very familiar with gastrointestinal (GI) stasis and its
common causes. They are also aware that GI stasis is not a disease per se; rather it is a common symptom of many rabbit diseases. In today’s post I will briefly discus several common causes of stasis.

Dental disease:

Perhaps one of the most common causes of stasis is dental disease. For this reason it is critical that you allow your veterinarian to perform a thorough physical examination, including a detailed dental exam, on your rabbit at least once a year. As your rabbit ages or if s/he has had dental disease in the past it is possible that your vet will advise that your rabbit’s teeth be examined more frequently. Additionally, any rabbit experiencing GI stasis should have a dental exam as part of the work up. There are many different types of dental disease, from the growth of relatively minor molar points (or spurs), through severe dental abscesses and potentially compromised jaw bones. It is important to note that certain types of dental disease can only be detected with radiographs (X-rays) and/or a sedated oral examination.

Gastrointestinal disease:

Many types of gastrointestinal disease can contribute to anorexia and stasis in rabbits, when this occurs the stasis is known as primary GI stasis. One of the most common causes of primary GI stasis is a poor quality diet. Rabbits have a large fiber requirement, and the bulk of their diet should consist of high quality grass hay. In younger (and in some geriatric rabbits) alfalfa hay is recommended as it is higher in protein and calories as well as calcium. GI stasis is likely to occur in rabbits fed only pellets, or worse yet those fed diets high in sugar and starch (as occurs with rabbits fed oats and/or cereal). Other types of gastrointestinal disease can cause stasis and these diseases will likely require blood tests, radiographs and various fecal tests to accurately diagnose.

Kidney and bladder disease:

Kidney and/or bladder disease are perhaps the third most common cause of GI stasis in rabbits. It is believed that the pain and possible toxin buildup in the case of kidney disease lead to anorexia and secondary stasis. Diagnosis may be straight forward in the case of bladder stones which can be readily palpated at times. However, generally speaking a diagnosis of stasis secondary to kidney or bladder disease will require a detailed physical exam, complete blood work, radiographs and a urinalysis. Depending on the underlying case many of these rabbits will recover their appetite and have resolution of their urinary system disease with appropriate veterinary care.

Reproductive disease:

The vast majority of rabbit owners know the importance of having female rabbits spayed. It has been reported that up to 80% of unspayed female rabbits will develop uterine disease in their lifetime. Sadly, most of these cases will involve the development of potentially fatal uterine cancer or aneurysms. The first symptoms noticed by owners will involve the visualization of blood in the urine or visible on the rabbit’s back end. However, an equally common initial symptom is GI stasis secondary to the uterine pathology. A tentative diagnosis may be achieved based on the pet’s history and symptoms, however a detailed physical exam, radiographs and potentially exploratory surgery (which may be curative if a spay is performed) may be required.

Toxicoses:

It is uncommon for well cared for rabbits to gain access to toxins. However, after practicing in New York City for several years I have seen many cases of GI stasis secondary to low-grade, chronic lead intoxication. These pets invariably live, or have lived, in buildings built before 1978. This was the year in which the sale of lead paint was banned in the United States. Many rabbits with lead poisoning are ‘free-range’ rabbits. They spend their day out of an enclosure and have the run of the house. Owners may or may not be aware of their rabbits chewing at baseboards, door frames or walls. When lead poisoning is suspected many owners will state that their home is lead free, even if it was built before 1978. These owners often erroneously believe that renovations and fresh paint means that the lead based paint has all been removed. This is almost never the case; more often than not the renovations simply cover deeper layers of lead based paint.

Lead toxicosis appears differently in rabbits than in cats and dogs, and it is unlikely that a non-rabbit savy vet will suspect this condition. In dogs and cats symptoms are often pronounced, and many times include overt neurological disease. It appears that rabbits are more sensitive to low levels of lead in the blood, perhaps because of their complicated gastrointestinal system. In my experience, lead poisoned rabbits often demonstrate GI stasis, weight loss and anorexia of several days to weeks duration. The symptoms may wax and wane, but no other cause of GI stasis can be found. Lead levels are often in the high normal to low toxic range for dogs. With appropriate treatment the vast majority of these patients make a full recovery.

Conclusion:

GI stasis can vary from relatively simple condition for your rabbit vet to diagnose and treat, through one of any number of more complicated and serious medical conditions. You should always seek help from an experienced rabbit vet as soon as your rabbit has showed decreased appetite, or anorexia of 12-hours or more. Owners may not always notice their rabbit’s appetite, and as such decreased fecal production may be the first clue to GI stasis. Once this is noticed a veterinarian should be contacted immediately.

Good luck with your furred friends and good health to you all.

Dr. Simon Starkey