Pacific Rimism and misdiagnosis, take a look
  • lindsaytlindsayt
    Posts: 3449
    Pacific Rimism in Japanese Dogs
    An informal case study in the lethal misdiagnosis of Hyper-kalemia and Addison’s disease in Nihon Ken

    Hi all, I wanted to write up some of what I have come to know about this recently. I believe it is essential that all Nihon Ken owners, or anybody with related Asian spitz breeds like Jindo, etc, read, understand and share this information, especially to the Veterinary community.

    Following our Christmas dinner (and scraps from the relatives), my spayed 2.5 year old Shiba Inu female Beebe began to have some GI upset/gastroenteritis/colitis symptoms, mainly mucous diarrhea. This is not a new thing for her. To refresh, she was diagnosed last year with an immune deficiency and has been on interferons, allergy injections, and has required treatment for demodex, papilloma virus warts, and histiocytomas. She suffers from environmental and food allergies, and thus we made the transition to a home prepared raw diet for 6 months now to help with her GI issues. It works well, except when she eats grain and table scraps, and for the fact that she is not a healthy dog to begin with.

    Her most recent bought of diarrhea went on for 2 days, but it wasn’t severe to cause me to panic. I made her NPO and then fed her a bland diet of rice and chicken which resolved the diarrhea. On top of the GI disturbance, she also seemed to just not be herself, seemed more tired, had some trembling episodes during the night, and appeared to be developing some rear limb weakness in conjunction with hesitance when rising, getting on the couch or jumping into the backseat of the auto. She occasionally regurgitates her food (prior to starting raw). These symptoms are suggestive of Addison’s, which was our initial diagnosis, and are symptoms sometime seen with conditions like hip dysplasia, LP, hypothyroid, mega-esophagus, cauda equina, colitis, and pancreatitis. I took her in to my Vet to do bloodwork and x-rays.

    Of note, the spun serum had blood stranding and a pinkish hue, even though it was allowed the standard time to clot and set prior to being spun. This suggested cellular lysis (hemolysis). When this happens, electrolytes in the cells can be released, giving falsely elevated electrolyte levels, and in certain breeds, it can appear that the electrolytes are at lethal levels as their cells are naturally more prone to this condition, and contain higher levels of K naturally which is not a detriment to the animal.

    These were her aberrant labs, which Dr. told me was scary to see.

    K: 8.1, reference range 4.0-5.7
    Repeat K level the following day was 8.4. We performed an EKG which was normal.
    As a human nurse for 5 years and an animal nurse for 13-ish years, I can tell you that I have never known an animal with K that elevated, and if it was a human they would be dead in an ICU. Hyper-kalemia (elevated K), can result in fatal heart arrhythmias if not treated. K can be elevated in renal failure, adrenal insufficiency, and hemolysis, secondary to leakage of cellular material in platelets and RBCs during the clotting process and is influenced by lag time in blood collection. In Addison’s (hypo-adrenocorticism), K is elevated and sodium (Na) is reduced (hyponatremia). Her Na/K ratio was also low (18, with a reference range of 27-40). Following this, the definitive diagnostic rule-out is an ACTH stimulation test. Her sodium was normal, so I was encouraged to have her undergo an ACTH stim test as the pieces didn’t fit into the larger picture. All other significant labs were normal, including glucose, and renal/liver values (which are often abnormal in Addison’s).

    In addition to the abnormal labs, the blood cells themselves exhibited slight hypochromasia (most commonly related to iron deficiency anemia in dogs, vitamin deficiency, or celiac disease) and poikilocytosis (a misshapen and distorted RBC seen as a result of hemolysis, immune mediated injury, or by a congenital process).

    Unlike the Vet in the instance below, my Vet had heard of Pseudo-hyperkalemia in Akita, and wondered if it wasn’t the same for my Shibas, given that Addison’s is NOT known in Shibas and the generally unknown instance of Pseudo-hyperkalemia can easily be mistaken for it. I decided to phone some breeders, this is what they had to say:

    This paragraph on Pacific Rimism is listed further down in this article.
    I have seen a number of Shibas over the years with elevated potassium levels and this is entirely NORMAL for Shibas, as well as a number of other Asian breeds. A vet in Seattle actually treated a 6 month old Shiba puppy for Addison’s with only the elevated potassium levels. The dog came in with a gastrointestinal problem and vomiting. What was probably just a bug, was treated totally improperly and led to this dog's demise. I am absolutely dumbfounded at the number of vets over the years that have no knowledge of Pacific Rimism. I really feel that the information should be given in written form to the new Shiba owners to give to their Vets along with the health record. I am sure that some vets would see this as insulting, but it has cost me entirely too much time and effort over the years to educate the uneducated.


    “What is Pacific Rimism?
    Dog breeds originating in the Pacific Rim, such as the Akita and Shiba inu, commonly have elevated potassium levels on blood tests. This can be very confusing when a patient has symptoms that suggest Addison's disease. These patients will have normal ACTH Stimulation test results if they do not have Addison's disease.”

    Brad had also given me similar information from his Akita book, which stated that this syndrome can be easily mistaken for the difficult to diagnose Addison’s disease, and has been reported occuring in all of our Nihon Ken breeds.

    The Vet feels it is likely this syndrome, so the next step for Beebe is an ACTH stim test just to be sure. I am obviously hoping that it is normal. I am so thankful to the knowledgeable people who pointed me in the right direction as had we undergone steroid treatment for Addison’s when it is likely not, the result could be lethal. Here is the Dogster page and journal entries for the Shiba pup who died from misdiagnosis:

    I hope this information is useful, I apologize if any of it was not accurate, please let me know. 12/29/09
    Lindsay, Beebe and IkeHokusei Kashinoki Hokkaido and Shiba Inu
  • aykayk
    Posts: 1979
    Here is the citation to the original article about it, the abstract, and my summary about the body of the article.

    Fujise, Hiroshi; Higa, Kazunari; Nakayama, Takahiro; Wada, Kayoko; Ochiai, Hideharu and Yuichi Tanabe. Incidence of Dogs Possessing Red Blood Cells with High K in Japan and East Asia. The Journal of veterinary medical science. 59( 6): 495-497. (Jun 1997)

    ABSTRACT: The phenotype of high K (HK) red blood cells, which is an autosomal recessive, was found in dog groups from 10 of 13 breeds or populations in Japan. The incidence of HK was 26 to 38% in the San-in-Shiba, Shinshu-Shiba and Akita breeds, and the gene frequencies of HK ranged from 0.513 to 0.612. The highest incidence (42%) was found in the Jindo breed from Korea, and the gene frequency was 0.652. Two other groups from Korea also possessed this HK variation. However, although HK cells were not found in dogs from Taiwan, Mongolia and Sakhalin, Russian, the HK phenotype is clearly distributed now throughout Japan and Korea.

    COMMENTS: Very interesting article for the researcher and layman. It gives evidence on the flow of dogs from Korea to Japan. The following quotes are what I consider crucial conclusions that every Jindo owner should be aware of::

    "There are a couple of clinical problems related with high K (potassium) cells or hyperkalemia. The first is pseudohyperkalemia where cellular K may leak out from red blood cells into the serum during separation procedures confusing diagnosis. The second possibility is life-threatening hyperkalemia resulting from transfusion. In this instance, the availability of fresh blood as well as stored blood is critical
    because K may move from plasma when the recipient is acidotic or the hemolysis may result from improper transfusion."

    "HK cells also exhibit high sensitivity to onion extracts and aromatic sulfide and have a tendency to hemolyze."
    Post edited by ayk at 2009-12-29 19:56:23
  • BradA1878BradA1878
    Posts: 12224
    Thanx for sharing Lindsay. Jen and I had not heard of and never dealt with this issue - when you brought it to our attention, and after we found that info in our Akita book, we did more research and found a lot of the same info above. Having 10 Nihonken I am surprised - and very happy - we had not heard of or experienced this already.

    Something all of us spitzy owners should keep in mind and help spread the word to vets - mos def, Lindsay. Good call.

    Good luck with Beebe, keep us posted as thing progress. I hope all is ok.

    Post edited by BradA1878 at 2009-12-29 20:23:43
  • tjbart17tjbart17
    Posts: 4055
    Wow thanks Leslie. When Koda got neutered, his Potassium levels were elevated but the vet said it was common in Asian breeds. He did still have Anemia, but we later found out that it was because of a Papilloma Virus most likely. He did get PV pretty bad, and had to be quarantined. He too has some of the same issues as Beebe with diet and diarrhea. Not that I think this is all the same situation, but it's just wierd that it has some of the same events.

    So, for a layman like me what does this mean for Beebe? Is she ok?
    Post edited by Unknown User at -0001-11-30 00:00:00
  • lindsaytlindsayt
    Posts: 3449
    I'm really glad you contributed, Ann. I was hoping you would put some rates of occurance and add your article, I now remember you had once mentioned this on the forum. It is the only study I have seen about it and I will print it off for my Vets to read. Thanks!

    Brad-I'm really suprised that this is the first time I have dealt with this as well as this appears to be inherited and of clinical significance.

    Tara-I was interested in the cellular abnormality aspect, and I wonder if Koda were to have his blood drawn (as he had an anemia problem), if he doesn't also have similar cellular structures that make him prone to anemia (more than just a dietary deficiency).

    I'm thinking Beebe should be totally fine if it is really this syndrome. Rather have to deal with this than Addison's.Hokusei Kashinoki Hokkaido and Shiba Inu
    Post edited by Unknown User at -0001-11-30 00:00:00
  • aykayk
    Posts: 1979
    On a shiba e-list, I remember someone saying that vets only need to adjust how they take the sample and the high K false reading doesn't become an issue. I don't remember what that adjustment was though. :-p Maybe some vets are already unknowingly using a procedure that minimizes false positives?

    The PV aspect is new to me. I assume it's not the juvenile mouth warts but something different?
    I do recall some instances of rescue Jindos not having very good digestion (vomiting, diarherra, etc) and it was vaguely chalked up to stress and gastrointestinal inflammation. It would take like 6 months to a year to clear up.
    Post edited by Unknown User at -0001-11-30 00:00:00
  • tjbart17tjbart17
    Posts: 4055
    Lindsay, I emailed Koda's vet your article. My gut has always told me that Koda's blood tests are normal for him, but I had heard some scary possibilities like autoimmune disease (possibly from rabies shot?), kidney disorder, and megasophogus, among a few others that I can not remember. My heart has always told me to trust the breed and his bloodlines as being healthy, but it gets scary when people are telling you that there potassium levels should not be that high and he's anemic.

    I even switched vets (from one I have adored for 15 years) to one who owns Jindos and has more experience with Asian breeds. a woman from the Akita Inu rescue told me about her. She's the one who told me that his blood levels are quite common for an Asian breed, but she never said Pacific Rimism to me. It really does make sense given some of his symptoms which I must say he seems to be growing out of. *fingers crossed*

    When I said PV, I did mean Canine Papilloma Virus, mouth warts. Koda had it for a month. I'll start a thread on that. I've been holding out, but I do think that it's something that should be on here. When Koda got it, I ran to my computer for advice from the forum but it seemed like no one had ever experienced it with their dogs. It was terrible, and I felt terrible for him. There was a lot of guilt on my part during that whole ordeal.
    Post edited by Unknown User at -0001-11-30 00:00:00
  • lindsaytlindsayt
    Posts: 3449
    Ann, about handling the blood, Brad had pointed that out, so we tried it differently the second time around on the repeat labs. The first time I drew the blood with a vaccutainer and larger bore needle. I let it have approximately 20 minutes time to clot before spinning it down in a standard (dinosaur) centrifuge. The serum was pink so I knew the cells were lysed. The second time, I tried again with a vaccutainer, but spun the serum down immediately, and had pretty much the same results (much pinker serum-it should normally be pale, and K was higher.) I want to try a newer method involving less blood and a mini cetrifuge that spins much faster and with greater force (if that's the right word to use). The serums on those tubes have been clearer on average with less cell damage, so I wonder if that is the way to get a more accurate result?

    I wonder if their cells, which seem to contain more K for some reason, are just inherintly more fragile from some congenital immune mediated cause/auto immune disorder and thus this makes the breeds more prone to experience sub clinical anemia and HyperK? It would really be interesting to see more studies on it. I'm planning to submit a formal write up to the NSCA and for publication. Maybe they already have good research on this that I don't know anything about.

    Tara, glad you are passing it along. I'm glad Koda is growing out of his troubles. We often won't have all the answers we want about our pets, especially with the rare breeds, and this is frustrating when they have health issues.

    Anyways, this is rather tedious and I don't want to make mountains out of molehills, but I did want to pass it along.Hokusei Kashinoki Hokkaido and Shiba Inu
    Post edited by Unknown User at -0001-11-30 00:00:00
  • Tara, Sage had a papilloma too as a youngster. Our vet said he got it from his mother, and that it could pop up again but that all I needed to do was supplement him with vitamin C, which I did. It did shrink and vanish and has not reappeared. There was no quarantining or anything. Did Koda have this severely? Sage only had one.
    Post edited by Unknown User at -0001-11-30 00:00:00
  • OK. I have been reading this thread and I have been wondering: Is there any advantage for a dog to have slightly elevated K levels? Would this help their survival in any way?
    Post edited by Unknown User at -0001-11-30 00:00:00
  • tjbart17tjbart17
    Posts: 4055
    Koda's mom never had them. It was a dog park thing, and there were lots and they were big. I'll start a thread.
    Post edited by Unknown User at -0001-11-30 00:00:00
  • Juno (kai) also has shown high K at her blood draw (end of 2017 I think) alarming our vet. The initial draw was sent out to a lab for a comprehensive annual senior bloodwork panel and upon receiving the results our vet recognized that only a VERY sick dog would have levels that high, so she had the lab run from the same draw a second time in case there was a lab error, but of course it was the same again.

    I remembered this post and was able to point our vet to Pseudohyperkalemia, which she then researched in her books and vet web resources. We drew her blood again and spun it quickly without giving the cells time to leak K and Juno's range was shown to be perfect. This saved the vet and I a lot of work and worry and expense and risk of a dangerous misdiagnosis.

    I am putting together a pdf for the Kai Society for owners to take to their vets about any Kai-relevant health items, and including basics of Pacific Rim-ism. I wanted to thank you guys @lindsayt and @ayk for bringing this up and researching it and sharing it way back in 2009 and Brad @brada1878 for keeping this info available and running.

    viva la NKF! ;)

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