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
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