Question Details
Lymphoma With Cranial Nerve Involvement In A Dog
by Dr. Krisi Erwin - March 25, 2021    View Case Report
Hello,

Sampson was a patient of mine for about 1 year prior to the owner moving away. I treated him for back injury and muscles spasms using laser therapy, acupuncture, and herbs (Benefits the hips and knees and Bu Gan Tang). He did very well. Starting in the fall, they began seeing someone in NC where they had moved for continued pain management but also because he started with diarrhea and weight loss. There was not much relief for those clinical signs. They moved back to VA in December and I resumed his care. On my second visit with them, I found that the L submandibular LN was big (~2cm in diameter) and axillary LN were palpable as well. I did an aspirate but only got a small sample because he was very resistant to it. It came back suspicious for LSA. I sent him to internal medicine and oncology for consultation and they confirmed LSA but felt it was only in the lymph nodes at that time. Abdominal ultrasound and chest x-rays seemed normal. The owner has opted for Pred and whatever I can do to support Sampson as he was becoming increasingly afraid of going into the specialists offices and because of cost issues (she's currently unemployed). At the end of December, they started Prednisone 10mg in am and 5mg in pm tapered down over several weeks to 5mg per day.

Based on my exam, he does not seem to have much in the way of heat signs. Diarrhea is cleared up now on Quiet Digestion by Health Concerns changed over to Liu Jun Zi Tang for maintenance. He has lost weight - was 44lbs, down to 35lbs and back up to 37lbs. I started him on XFZYT with added San Leng and E Zhu, mushrooms, and omega 3 FA's along with the LJZT. In mid January, his pulse seemed sl. wiry, it had been more superficial and bounding prior to herbs. His tongue was lavender and reddish. He seemed to be in remission from January until about 2 weeks ago.

When I saw him 2 weeks ago (~3/10), I noticed he had facial sagging on the right and a Horner's. He was also having increasing troubles with muscle bunching and pain. My exam notes say this:
TCVM: Tongue : lavender red
Pulse: soft and more normal feeling
Active point: tender over hips and at BL 20
I started him back on the Bu Gan Tang as he had done really well with that in the past for muscle spasms.

I saw him today (3/24) for a recheck because he has started to have more vision issues on the right side. Per the history, it seems like depth perception more so than blindness. On exam he has a good dazzle and PLR. No palpebral reflex- his 3rd eyelid goes up on tapping near the medial canthus but he cannot blink. The pupil is a normal size. Fundus looks normal to me. Facial sagging seems improved but he drools a lot out of the right side when eating and the owner reports he drops food out of that side of his mouth. When licking a peanut butter bowl, he seems to have good use of his tongue. Exam is otherwise pretty good- he has gained 2 lbs. Chest and abdomen check out ok on exam. The left submandibular LN is a bit more plump than it was 2 weeks ago. The rest of the LN feel normal to me. I feel his muscle spasms are much improved. The owner reports he is more lethargic at home, will go into another room and put himself to bed. Mildly PU/PD, eating fine but not over the top. Not much in re: to panting or seeming hot. Stools are good. He has lost muscle over the right side of his face. The owner feels the facial sagging comes and goes. He was super BAR and ridiculous here visiting with me today and his overall desire to still want to be here seems excellent. Pulse today seemed deeper, maybe sl wiry but not fast. Stronger on the left than the right.

I told her today that I am concerned he is out of remission. I increased his Pred back up to 10mg PO SID. I had to think on the fly how to modify his herbs- I did not feel like he was a Si Miao or Hoxsey guy. I dispensed CHJLGMLT just to start and asked her to keep up with the LJZT, XFZYT with San Leng and E Zhu, mushrooms, Bu Gan Tang, fish oil, and he is on melatonin (b/c of Pred side effects). She has also started him on a hemp product.

I will see him for a recheck in 2 weeks, sooner if he has a problem. He gets AP monthly to help with his back/hip/knee pain and I will treat him then.

I guess I just wanted to see if I was on the right track or if I should change him to something different? The owner is less panicked now than she was during the diagnosis time in December. She is trying to stay in the moment with him and just enjoying whatever time she has. I will reach out to oncology, too, to see if there are any other options that she might be more comfortable revisiting but I suspect she will stay the course with herbs and Pred for as long as he can go. I told her dogs can live in partial remission for quite some time but I am concerned about brain issues if it's starting to spread. He has no mentation issues now. No circling, head pressing, confusion, etc.

Thank you for your time and help on this case! He's a great guy- I'd love to keep him cooking along for as long as he wants to be here!!

Sincerely,
Krisi
Replies
by naturevet
March 25, 2021
Hi Krisi,

The facial nerve paralysis could be tied to lymphoma just in the sense that, from a Chinese medical point of view, they often share the same underlying diagnosis - which is Shao Yang disharmony. Bell's Palsy and Horner's Syndrome are known to sometimes be concomitant, without an obvious explanation.

My favourite formula for the palsy is Chai Ge Jie Ji Tang, which Kan Essentials sells as Modified Bupleurum and Kudzu Combination. It expels Wind pathogens while harmonizing the Shao Yang, and tackles from a biomedical point of view acute CNS inflammation. At its core is Xiao Chai Hu Tang, which can be useful in lymphoma, so I would probably try this first, and keep the rest of your protocol the same given the success you've seen thus far.

Let us know how it goes. Other signs that can indicate a Shao Yang disharmony include:

  • Early spring onset of problems

  • Increased thirst (due to trapping of heat in the Yang Ming by an exuberant Shao Yang)

  • Prior response to BH&K. Shao Yang disharmony is a constitutional tendency that can keep rearing its head unless continuously or periodically prophylatically treated

  • Onset of symptoms after evidence of a Wei Qi (which includes Tai Yang) invasion. The success of Quiet Digestion points to a Wind Damp invasion of the Wei Qi as the cause of the diarrhea


This is an interesting case. Let us know what happens with the lymph nodes while taking the above formula. Resolution of the palsy can take a while, but you should see first improvements within the first couple of weeks on the neuro exam if you're on the right track.

Hope that helps!

Steve



by Dr. Krisi Erwin
March 30, 2021
Hello! Thank you so much. I will need to order the Chai Ge Jie Ji Tang so am hoping the CHJLGMLT will fill that space for now? I heard back from oncology that CCNU may be a reasonable add on now that there is likely CNS involvement. I suspect the owner will want to just do herbs but it's nice to be integrative when we can. Thank you again!

Sincerely,
Krisi
by naturevet
March 30, 2021
Hi Krisi,

Yes, start with the CHJLGMLT. Switch over once you have it on hand. Herbs can integrate well with CCNU, too, so there would be no need to discontinue the herbs if you go that route. On the contrary, usually herbs enhance chemotherapy outcomes, in my experience anyway

Good luck!

Steve
by Dr. Krisi Erwin
April 16, 2021
Hello! Here is my update for Sampson from his visit yesterday:

I saw him yesterday 7 days post CCNU. Started Clavamox on Day 5. No V/D. Eating like a champ. Happy. o reports that they wouldn't know he has cancer based on his energy level and overall happiness. I will try to attach his CBC for you to see but it is low normal but no bands and everything is within normal limits. Exam-wise, all LNs feel normal. The changes to his palpebral reflex are unchanged but I do think there is less sagging in general to the right side of his face. He has gained 3lbs- on one hand, this is excellent as he was losing weight for several months despite eating well but on the other I think it's too many ice cream dates with his family as well. I think he's at the max weight he should be so I discussed that with them yesterday. He is still on 10mg Pred in am and 5mg in pm. I will recheck a Vetscreen/CBC prior to the next CCNU dose. I'm guessing I should leave the Pred alone for now?

Re: herbs, he got significant diarrhea after only a few days of the CHJLGMLT so I had her stop it and then we started the new herb when it came in. I just noticed the bottle says Jia Wei Chai Ge Jie Ji Tang. He has been tolerating it well with no diarrhea but I wanted to make sure I didn't make a mistake. I wrote up the dispense in the chart but my staff filled it without me seeing it. He has been taking it and feeling very well on it. I just want to make sure we haven't made a big mistake. Looking now, I think we just searched the Bupleurum and Kudzu and ordered the tablets and missed the difference in the Pin Yin name. How much of a difference does this make? We can order the powdered CGJJT instead. I'm sorry about that!! He is still on the other herbs as listed previously (sans the CHJLGMLT). I may also have had rose colored glasses for him but I thought musculoskeletally he was feeling a lot better with less spasming in the TL-lumbar paraspinals and his gracilis muscles were no longer like little rocks. I'm wondering if that is because of the effect of the Jia Wei Chai Ge Jie Ji Tang. If he continues to feel so much better, should I stop the Bu Gan Tang?

Fingers crossed he will keep doing so well!!

Krisi
by naturevet
April 16, 2021
Hi Krisi,

How great that your dog is doing well. I wouldn't take anything - drug or herb - out of the mix that is supporting his current progress. For now, just enjoy seeing him gain strength. If new problems appear, remember that these are indicators of the 'roots' of his pathology, and will signal a need to change strategy if and when they appear. For now, I'd go with what you're using, including the pred, Jia Wei... and the Bu Gan Tang.

Jia Wei Chai Ge Jie Ji Tang is actually what I had in mind for him. I added some herbs when I created the "Jia Wei" version of the formula for Kan, but it has CGJJT at its core, so all is fine with respect to using it in your patient. Jia Wei means 'added flavours' or 'added herbs', so that is the only change to CGJJT that was made to create the formula. Things were added, not taken away.

Note that the formula is used to treat diarrhea, with its content of Ge Gen, but it does what we need in terms of battling cancer and also subsiding CNS inflammation, so the diarrhea in response to CHJLGMLT in a way tells us even more clearly that CGJJT is a good idea.

Hope that helps! Enjoy the improvements you're seeing in this very complex and difficult case! When these dogs get better, it makes it all worth it, doesn't it?

Steve
by Dr. Krisi Erwin
April 16, 2021
Yes! It's so worth it! Thanks for clarifying about the JI Wei version, that helps a lot! I'll continue to keep everyone posted with how he does. Fingers crossed it's for awhile. I wish you all could meet him- he's such a happy, PB eating machine. Be well everyone!

Krisi
by Dr. Krisi Erwin
May 26, 2021
Hello! I wanted to give an update on Sampson. He just had his 3rd dose of CCNU. When I saw him last week for acupuncture and bloodwork (pre-3rd dose), his facial nerve paralysis was almost undetectable when he first came in. There was much less drooling and an easier time eating all of his peanut butter. After eating for the treatment, the sagging was more evident. His weight is stable. Mentation seems good- maybe a bit more distant with me during tx than is typical for him. Hair coat is starting to feel a bit more dry and not as silky shiny as it has always been. Muscles are MUCH more comfortable (cheers for the Jia Wei formula I think?) LN are all normal. We will pull blood soon for his post CBC. He has very mild increase in Alk Phos (mid 200's). Labs are otherwise good. The post CBC after the 2nd treatment showed a very mild neutrophilia but all the rest of the indicators were normal? He is still on 10mg Pred and and 5mg pm. He is somewhat heat intolerant and I lent them a circulating water cooling bed to use in the house and discussed a Kool Collar for walks. They just celebrated his 5 month post-diagnosis with footlong hot dogs in their hometown. He is still the Jia Wei 1 PO BID, Bu Gan Tang 2 PO BID, modified XFZYT 3/4 tsp BID, LJZT 2 PO BID. Not sure if I should change anything or leave well enough alone?
by naturevet
May 29, 2021
Hi Krisi,

You could leave well enough alone, but there may be something more you can do to address those lingering Heat and dryness signs, as well as the neutrophilia and slightly high ALP, both of which may be side effects of the pred. It's nice that he is not neutropenic from the CCNU at least!

If you felt like it, you could try changing out Bu Gan Tang for Zhi Bai Di Huang Wan. The Huang Bai in there will counter some of the pred side effects, and the formula is decidedly more cooling than Bu Gan Tang, while still supporting the bone marrow. Clearing some of the Heat and countering some of the pred side effects may help with the hair coat becoming more soft and shiny again.

Hope that helps you out. You're doing an amazing job with very complicated cases. That must be really gratifying for you!

Steve
by Dr. Krisi Erwin
May 29, 2021
Ok! I can do that and the client will be happy to do so as well. I'll report back. I really appreciate you taking the time to help all of this. I would be a bit lost trying to parse through all of it by myself and it is great to keep Sampson going for as long as he wants to be here!!

Sincerely,
Krisi
by Dr. Krisi Erwin
June 22, 2021
Hello again! Just an update on Sampson. He had his CCNU on 6/11 after very normal vetscreen/CBC. We decided to skip the CBC this time and plan to do his next vetscreen/CBC the week of 6/28 pre next CCNU dose. Starting on 6/17, he had soft stools that the owner reports looked black and tar like but they are about normal now. No vomiting. Super high appetite (probably from the prednisone). Demeanor 6/17-20 was stand offish and prone to be sleeping in a. closet or under the bed. He didn't seem to want to be bothered or touched. The owner couldn't get a rectal temperature (he wouldn't let her) until 6/21 and it was normal. She also reports that he has started with a gagging/coughing thing when he is laying down and when she touches the area where his ribs meet his belly, he sometimes yelps like in pain. It is not consistent when that happens. During his lowest moments she felt his head felt hot to the touch and he just seemed hot.

Of course, this all happened going into the weekend and I did not check the work phone Saturday or Sunday. She tried calling the local emergency clinics and none of them could see him (all of the emergency places in Northern Virginia region have been crazy backed up and having to turn people away) and just said to not come in unless his temperature went up above 103.

So, she is giving me daily updates now. I offered to check him and told her I am a bit worried re: the possibility of GI ulcer b/c of the steroids. I'm not sure if these signs would have been due to the CCNU or not. She wanted to hold off until her next scheduled recheck on Monday for now. I discussed that I could call in Sucralfate for him and I need to check that he is on Omeprazole.

I guess (knowing that you have an impeccable crystal ball), what would you do? His next dose would be 7/2 but I would rather maybe skip at least 1 week to make sure he is still on the up and up? Rechecking his bloodwork next week I think would still be good. If the owner wants to do another CCNU dose, should we decrease it? We are now 6 months since confirmation of his diagnosis so I know it's just a matter of time for the lymphoma to cause more trouble.

He is taking the Liu Jun Zi Tang, Modified XFZYT, Jia Wei Chai Ge Jie Ji Tang. We also started him on the Zhi Bai Di Huang Wan and stopped the Bu Gan Tang about 2 weeks ago. He looked really good when I saw him the day before CCNU. I wasn't due to recheck him again until next week.

I appreciate any insight you have. As of last night's update, he is much more like himself now.
by naturevet
June 23, 2021
Hi Krisi

We might get more protection from ulceration due to CCNU/pred treatment by switching him to Xiao Chai Hu Tang plus Yi Guan Jian, although ZBDHW does protect against colitis. This change may help address the gagging/coughing symptom, too. Rather than continuing the CGJJT, you could stop it if you feel his pulse is no longer superficial and broad. If it still is broad and superficial, then don't worry about using XCHT. Maybe just make the switch to YGJ, though. Pred may not be the only cause of ulceration here. Alkylating agents like CCNU can cause it, too. Since the ulcer happened around his last CCNU treatment, that may be the explanation

Steve
by Dr. Krisi Erwin
June 23, 2021
Thanks a million! I tried to get her in this week for a recheck but I think she is wanting to wait until her appt next week. Clinically he is acting better- stools more normal in consistency and color. Facial paralysis is getting worse. I have been corresponding with an oncologist on VIN as well to help make sure I don't miss anything with the conventional drugs and she would be surprised if this was a sepsis/neutropenia event from the CCNU but admits anything is possible. I am wondering if I'm losing that partial remission that he has been in. If that's the case, is there any benefit to increasing any herb doses or frequencies? I double checked with her and the current meds are:

AM:
5mg Melatonin
10mg Prednisone
Omega 3 FA
Jia Wei Chai Ge Jie Ji Tang 1 tab
Concentrated Zhi Bai Di Huang Wan (had to drop ship from Jing Tang to get it to her more quickly) 2 capsules
Modified Xue Fu Zhu Yu Tang powder 3/4 tsp
6 mushroom blend 1/4 tsp

PM:
5mg Melatonin
5mg Prednisone
Omega 3 FA
Jia Wei Chai Ge Jie Ji Tang 1 tab
Concentrated Zhi Bai Di Huang Wan (had to drop ship from Jing Tang to get it to her more quickly) 2 capsules
Modified Xue Fu Zhu Yu Tang powder 3/4 tsp
6 mushroom blend 1/4 tsp

I did ask her to increase the Prednisone tonight to 10mg until I get a plan as the coughing/gagging and change in facial nerve is making me worry that it's a lost of remission more so than a drug issue at this point? I know right now, I'm shooting in the dark until I can get another exam on board.

He weighs 38-39lbs

Sincerely,
Krisi
by naturevet
June 26, 2021
Hi again,

I'd be tempted to see how he does on the XCHT + YGJ combination, vs. the CGJJT + ZBDHW Combination. Dogs on CGJJT often eventually need to switch to XCHT. YGJ protects against ulcers.

It's possible you're seeing some muscular tightness and contracture from the facial nerve paralysis. Adding about 15g of Mu Gua to YGJ may help relax those muscles.

Also, some facial nerve paralysis patients eventually need to switch to a 'wind invasion' approach, for which cough can be a symptom. We've accidentally found Du Huo Ji Sheng Tang to have some benefits in chronic GI inflammation. If the pulse is superficial and sinks inward with stimulation of BL 40, that is the approach that is needed, though. I guess let me know what you find after you see the dog

Steve
by Dr. Krisi Erwin
July 1, 2021
Ok. So my colleague Jane saw Sampson yesterday. He is leaning toward more generalized lymphadenopathy and she felt he was seeming more Qi deficient. Here are her notes:

LN: both prescapular LN are prominent, (R>L) and R submandibular is enlarged also. Axillary are normal. Popliteal are enlarged bilat, and inguinal on L side is enlarged. No palsy noted on left side of the face, right is still present/mild/no change.

Pulses are a bit wiry, stronger on the L.
Tongue is soft, wet, pale pink like a Qi deficient tongue

He is not tolerating the higher prednisone (very hot, restless, panting, PU/PD, food crazed) and the dose hasn't made a difference. I'm having her back it down to 10mg in am and 5mg in pm for now until I revamp the plan. His bloodwork was perfect outside of an Alk Phos that is now in the 500's, likely from the Pred but may be another indication for the change to XCHT? I appreciate any insight if your opinions have changed at all with this information.

RE: needling, I've been avoiding BL 40 since his popliteal were one of the first nodes to show in the beginning. Is that something I don't need to have worried about?

Thanks again!

Krisi
by naturevet
July 2, 2021
Hi Krisi,

I don't generally avoid needling points near tumors. Using an acupuncture needle there poses no more risk than a fine needle aspirate of the lump, which we all do at the drop of a hat.

This phase of lymphoma is harder to get a good handle on. I do sense that Xiao Chai Hu Tang is the correct root formula. The hard part is knowing what cooling herbs to add. You could consider adding Qing Dai. I've also used Xia Ku Cao. Or both! For XKC, I've used 30g per 100g. You could try 20g of each if you're going to add both. I would continue using the YGJ in either case

I guess give that a go. Other possibilities are Hoxsey and Si Miao San, which can be used in addition if needed, but I'd see what happens with the modified XCHT first, especially given the neuro complications, which are more the province of XCHT

Hopefully this helps!

Steve
by Dr. Krisi Erwin
July 5, 2021
I'm on it! I have Xiao Chai Hu Tang, Yi Guan Jian, Si Miao San, and Hoxsey on hand. I will need to order the Qing Dai and Jia Ku Cao. I will start plain XCHT and the Yi Guan Jian now and get the others on order. I'll report back!!

Thank you!
Krisi
by Dr. Krisi Erwin
July 5, 2021
Ok, hi again. I wanted to share with you that Sampson's mom told me today that he has had an increase in muscle spasming and soreness in his rear end and spine since stopping the Bu Gan Tang. Is it ok to restart that with the XCHT and Yi Guan Jian?
by naturevet
July 5, 2021
For sure. If you don't feel the YGJ has done anything for you, you can use the Bu Gan Tang as your Yin tonic. We were using it in case of ulcers, but if those have been ruled out, then you can go back to Bu Gan Tang. Or use them together. Or add Mu Gua to Yi Guan Jian to cover the spasms, if the GI seems to have improved.

S
by Dr. Krisi Erwin
July 6, 2021
Ok! I will play around and report back. Thanks!!!
by Dr. Krisi Erwin
July 22, 2021
Hi everyone,

I wanted to let you know that I euthanized Sampson today. He celebrated 7 months post diagnosis yesterday. The long term prednisone (and I suspect other changes re: lymphoma spreading) finally tipped the scales to the side of poor quality of life. He was really a very happy dog up until the last couple of weeks when he started to have PU/PD, severely increased appetite, excessive heat and restlessness (despite steadily decreasing Pred doses and changing herbs) as well as changes coughing/gagging when laying down and diarrhea (making me feel that lymph nodes were enlarged/intestines were getting affected). On presentation tonight, his peripheral LN and facial changes were not markedly different but he had a much more rounded abdomen with likely hepatomegaly. Breathing was heavy/rapid but not in distress. He just seemed hot and mentally checked out. He wasn't his usual self in terms of being engaged. Given the changes the owners came in ready for PTS instead of doing acupuncture again today.

As an FYI re: what I had done herbally, I tapered off the Jia Wei Chai Ge Jie Ji Tang to switch to the Xiao Chai Hu Tang. I decreased the Zhi Bai Di Huang Wan to a lower dose and added in Bu Gan Tang again. He was more comfortable with less muscle bunching back on the Bu Gan Tang. I continued the modified XFZYT. I had a note to add the other cooling herbs to the XCHT if needed but there wasn't quite enough time I don't think. I supposed I could have tried Hoxsey if they wanted to keep going but I think they made a fair decision for him.

Thank you so very much for your help. I think we benefited Sampson and gave his family the best possible run with him given the current situation. Please be well and I hope his case can help others!!

Sincerely,
Krisi
by naturevet
July 23, 2021
Hi Krisi,

Sorry to hear about Sampson, but congratulations on the quality of life you gave him along with its extension. That is one thing that is not always true about conventional treatment.

I have found that when lymphoma patients enter that 'hot PU/PD' stage, they are more unstable and likely to deteriorate, so the outcome is not really surprising. That's why I started experimenting with Xia Ku Cao and the like. I know Erin Bannink has a new webinar on XCHT in lymphoma. It would be good to look that up and see what she is doing. I think the link is available in the header of A Time to Heal's website

Steve
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