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HOD

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I saw a 7 year old FS lab X 8/5/09 for non-weight bearing lameness RFL 2 day duration. Past medical hx is generalized demodicosis 2002, anal gland abscess 2004, whipworms and HWDz treated with immiticide 2008, inflammatory mammary carcinoma with regional LN metastasis 6/2009 surgically excised.
Current PE findings include red eyes, severely swollen and hot carpus with all joints swollen and hot. Tongue is lavender pink with purple center, small cracks. Thoracic rads show nodular densities in the cranial lung lobes, increased interstitial pattern caudal left lobe, and smooth periosteal reaction involving the entire length of the radius/ulna and metacarpals (did not image the hind legs).
The patient has been on piroxicam and pepcid rxed by the DVM who removed the mammary neoplasia.
My assessmentis that Liver Qi stagnation /Blood deficiency (demodicosis, parasites) with Qi/Blood stasis and Phlegm in the Chong Mai and Liver channel (mammary cancer)and now Lung and bones.
I started with Hoxsey and Boneset at 0.5 ml/10 lb div BID and change to a home-prepared diet, which the dog has responded well to. However, the owner called today to say the dog is acutely worse on the front leg, and the swelling and heat have progressed proximally to include the shoulder.
Can I add Si Miao San (+Dang Gui?) to the H&B? Also, as pulmonary lesions are the source of the HOD,do I need to treat Lung Phlegm Heat concurrently? And lastly, would Shen Tong Zhu Yu Tang be a choice for the appendicular stasis, or not with the inflammation? Maybe XFZYT or Qing Ying Tang?

by naturevet

August 24, 2009

"Can I add Si Miao San (+Dang Gui?) to the H&B? Also, as pulmonary lesions are the source of the HOD,do I need to treat Lung Phlegm Heat concurrently? And lastly, would Shen Tong Zhu Yu Tang be a choice for the appendicular stasis, or not with the inflammation? Maybe XFZYT or Qing Ying Tang?"

My first thought is to get the dog onto an anti-inflammatory (low carb minimally processed) food. I prefer raw and don't believe protein levels are the problem in these dogs, but rather that it is the pro-inflammatory effect of a processed starch-based diet. Hopefully that has been addressed.

Regarding the formulas:
STZYT is helpful when there is a Wind invasion component, as evidenced by a pulse improvement when BL 40 or BL 13 is sedated.
QYT is helpful for autoimmune conditions and vaccine-induced pathology. Did this condition come on within two weeks of a vaccine?

Overall the tongue suggests central stasis and heat, and seems to reflect the lung lesions, so XFZYT is an excellent consideration, except it moves blood peripherally. If the pulse was deep, that's okay, but if it was superficial, it's not. The other option in that case is to use Chai Hu Jia Long Gu Mu Li Tang to resolve the stasis in the upper body, and harmonize the Shao Yang. The relapsing nature of the disease is consistent with a Shao Yang pathogen. Did you find any TB or GB points to be active and improve the pulse? If so, I'd start there and continue the Hoxsey. It's also not a bad 'autoimmune' formula, in the event vaccines appear involved.

Hope that helps!

Steve

by

August 26, 2009

Dear Steve,
Here is an update from my exam today. More history info-the dog has already been changed to a cooked diet with less that 25% carbs coming from beans and peas only, with 40% protein and 40-50% vegetables, all cooked, an antioxidant supplement containing silymarin. There have been no vaccinations since 2006.
Today, the swelling in three of the limbs has improved by 90%, with the swelling and heat now severe and localized in the right front leg only between the carpus and elbow. The dog drags the leg but can place the limb when running. Additionally, the left eye is now red, with flare and corneal edema. Vision, PLR all normal. I did not measure pressures. Serum chemistry and CBC are pending, the ALT was mildly elevated 2 weeks ago). Tongue is large, purple dry center with thin cracks and a thin white coat, red dry edges. Pulses are thin, very rapid and deep, feels like deep hen-pecking (quality?). Heat at both SP6/9, all GB points not swollen or warm.
The pulmonary nodules seen 3 weeks ago radiographically have disappeared. The periosteal reaction on the distal left radius/ulna/metacarpals is slightly less, but there is a marked increase on the reaction at the distal right ulna which does not cross the joint. (Is there a way I can post the radiograph image on this forum?)
Assessment:Liver Heat (red (left)eye, red dry tongue edges), Damp Heat (active SP6/9, cellulitis, periosteitis, conjunctiviitis, uveitis). Damp Heat may have damaged Qi (deep pulses).May also have lIver Yin deficiency with upward flaring of Fire (red eyes, thin rapid pulses, red dry tongue edges). Qi deficiency (loss of function)-BlX with Damp Heat right foreleg (bone stasis and osteitis).
I have added some raw organ meats, cooked salmon to the diet, along with more dandelion and beet greens. I have discontinued piroxicam and pepcid. I am continuing the Hoxsey & Boneset formula at 2 cc BID (wt=77#).
I was going to add LDXGT since the left red eye and tongue indicate Liver Heat with some Blood deficiency and Qi stagnation, but as the pulses are deep, I am using SMS 2 gm BID withXFZYT 1 gm BID instead. I had thought of Qing Ying Tang due to the severe Heat, but did not since the primary site of inflammation is now the bones of the right foreleg. Your ideas?
Thank you,
Jodi

by naturevet

August 27, 2009

Hi Jodi,

You've come so far, that it's hard to imagine the dog won't get better with just what you're doing now. That being said, when I see Stasis, Heat, Dryness, deep wiry pulses and inflammation in multiple locations, I think of Qing Ying Tang. It also addresses deep-seated problems (i.e. relapsing problems), which is the main risk for this dog going forward. So that's where I'd go with it. If the pulse was superficial, I'd think more of LDXGT.

Now if the SMS and XFZYT have been on board a while, and are responsible for part of the dog's recovery, you may not need to do anything different. In a crude way, they approximate what QYT would do, assuming the latter is beneficial.

Continued good luck!

Steve

by

September 1, 2009

Hi Steve-
I saw Tyra again today for a recheck :(
The leg is even more swollen and starting to ooze through the skin due to hydrostatic pressure from the severe edema. Appetite still good, tolerating the addition of raw organ meat well but has lost 5 lb. Radiographically, the periosteal reaction extends proximally to midshaft. It is hard to tell if there is cortical destruction since the reactive tissue superimposes over the bone. T=103.3. Serum electrophoresis shows a polyclonal gammopathy. The owners have declined fungal serology or biopsy. The left eye has a completely opaque cornea from edema and scleritis, is not hard but slightly buphthalmic and not painful. Tongue is purple, dry center with small cracks, redder and wet edges. The pulse is deep, wiry, rapid, slightly improved with needling at right ST36 and GB39. Heat over BL18-22. Slight edema left SP6/9.
I think there is Liver Heat and Qi stagnation. I think some of the GB points are reactive, but also SP9/6 indicate Damp (Heat). There is local Blood stagnation and Damp Heat in the distal forelimb. I can not definitively rule out a Toxic Heat pathogen, i.e. bacterial, fungal agent.
My gut feeling is that, Western-wise, it looks like a bone tumor, local Qi-Bl-Phlegm-Toxic Heat in the FLF, and that the corneal edema/uveitis is related due to Blood Heat. Pulses are wiry from stagnation, although might be GB/TH obstruction. Pulses are deep and improve with needling ST36 due to damaged Qi.
I increased the dose of SMS to 3 gm BID, and substituted QYT with E Zhu and San Leng added for the XFZYT. Hoxsey and Boneset at 2 cc BID to guide to the bones, and Neo-Poly-Dex topically for the eye. May add cephalexin in case osteomyelitis in a couple days if the Spleen tolerates all this cold stuff. I was torn between the modified QYT and CHJLGMLT-we'll see how it goes. It's either success or E&D next week.
Do you ever needle Ting points on these to drain? Is there a risk of moving the Blood Heat with San Leng and E Zhu?

by naturevet

September 1, 2009

I don't usually needle Ting points in dogs and cats, but more for practical (point location, needle retention) reasons than because I feel it would be hazardous. Some people needle the tip of the ears and tail to vent excess heat.

Hopefully the Qing Ying Tang will kick in.

Steve

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