Question Details
Pruritic Ears Mania Poor Digestion In A Dog
by fdzenitsky - October 12, 2021    View Case Report
Hello Steve et al!

Oliver, a 5YO NM (neutered at 11 weeks old) terrier mix, first presented April 2020 with chronic non-seasonal allergies, 2 years duration, and recurrent severely inflamed ear canals w/ pinpoint red rash, ceruminous debris, yeast 3+, cocci 1+, some self trauma, severe atopy, responsive to Apoquel and steroids (injectable work best). Weaned off Apoquel, worse, depomedrol injections, much better, oral steroids not as effective and prednisolone works better than hydrocortisone. Bloodwork not exciting, including endocrine. He is extremely manic, reminds me of ADHD. We started elimination diet trials using fresh, organic food, raw goat milk/cow kefir fast, novel proteins - little response to any diet changes including fermentable carbs, but the ears look better.

August 2020, very pruritic, obsessive scratching, inflamed scabby ears, high anxiety, skin looks normal on legs and trunk. In October, he's on prednisolone, still itchy - dorsal, lateral, face, ears look normal, extremely excitable, OCD pica, very thin. After devouring your skin lectures (AHVMA conf.), I attempt to assess Oliver from a TCM perspective: worse on real food diet > leaky gut central even w/o GI signs, manic "brain-skin-gut axis", persistent wide spread skin inflam, pruritic (anxiety sets off), nocturnal itching, good response to suppressive meds, wears off when d/c, seasonality: 2018 Apr-Oct, 2019 April on Apoquel, then June-Sept Apoquel, 2020 March-Apr Apoquel, then it all persists into October. Assessment: Immune dysregulation w/ Shao Yang disharmony. I'm so excited I think I nailed it. I start him on CHSWT and nettle leaf tincture. 2 weeks later, pruritus not improved. He improves for a few days w/ a fecal transplant. I change formula to CHJLGMLT (Yang energy trapped outside, mania, P-superficial). In December, no improvement, persistent itch but skin and ears look normal. He is obsessively pawing at his muzzle and lateral trunk, trying to eat mulch, rocks. T-lav, pale, dry, coated, P-deeper, forceful.

February 2021: On exam, pinnae have mild erythema, hyperplasia, lichenification; the chin is red with alopecia and follicular cysts extending to the commissures. He also rubs around the eyes and is paw licking, but skin looks normal and paws are cool. T is pale, frothy, P is easily felt superficial, bounding, but also strong deeper. In general, he is highly excitable and anxious. Itchiness increases when he is excited - ie when owner comes home, when friends come over, when he is excited about eating. He has a voracious appetite, fairly low thirst drive, normal stools, no GI symptoms, but a poor body condition. Often he will initially improve with a new real food diet, then relapse, although with the recent new diet of no grains, a mix of veggies, and either beans/salmon/cooked meat the owner has seen a sustained improvement (from regular itchiness level of 4 on scale of 1-5 to average itchiness level 2 (subjective measure of what she perceives but nonetheless there has been a notable difference). Currently, I have him on ION Biome, Fourleaf Rover Gut Guard, D3, and 2gm of methylprednisolone per day (he's 37 lbs. and this steroid is working better than 5mg of prednisolone). The change in his itchiness happened upon removing grains, cooking more of the foods, and including the digestive enzymes, etc., so he is not as Hot as he was when I saw him last.

March, his picture has shifted somewhat. Pruitus/anxiety markedly reduced w/ diet mods, supplements (SB probiotics, ION Biome, enzymes), skin is normal (ears almost), but I observed him rubbing his muzzle and lateral trunk when over excited. Mod. halitosis. The T is pale, a bit lavender; P is deep, forceful or wiry w/ excitement. I put him on Chai Hu Si Wu Tang and SMS. Symptoms spiked after a few days and owner d/c both formulas, and his symptoms calmed down. In May, he’s down to 27 lbs., emaciated, restarted the herbs for over 2 weeks and he is significantly more itchy and has mucousy stools. In June, T is pale, thin, lav center, P is slippery superficial and wiry deeper. The only abnormal blood test is persistently low AST and TRI, and elevated TLI. B12 and folate normal. My assessment was Blood and Yin deficiency. I put him on Yi Guan Jian for a month, no better or worse. I was so sure the YGJ would benefit him, now I am at a loss of where to go next.

Current symptoms: Itchiness/inflammation in ears. Ears are less visibly red but still has persistent itchiness. Nose seems pretty dry and will sometimes crack and bleed a little; Pica - eats woodchips (this gets much worse when he is excited or anxious); Difficulty gaining weight (due to poor digestion?) Symptoms appear to worsen with certain foods (grains, certain raw foods, etc.). Issues with digesting raw foods, seems to improve when meats/vegetables are lightly cooked. Symptoms appear to worsen somewhat with environment - ie, he seems to improve when at owner’s mom’s house for a few days (not sure if there is an issue with air quality in the apartment? He has gained some weight, now 30.4 lbs.

Still on 2mg medrol per day in the mornings which keeps his symptoms (itchiness/inflammation, specifically with his ears) at a manageable level. Itchiness/inflammation is heightened with excitement / anxiousness, also in the morning when medrol has worn off and he is excited to eat breakfast.
T is pale, but not as pale and with lavender center and mild longitudinal cracks, P is easily felt w/ light pressure, quick, forceful, not compressible and deeper is wiry.

Whew! What do you make of this guy? Thanks as always!
Replies
by naturevet
October 12, 2021
Hi Franchesca,

That is quite a history! It seems you have made some slow progress, now, or am I reading it wrong?

I think you are on the right track with your Shao Yang approach. You mention mucousy stools when the 'herbs were restarted' but you didn't specific if that was with CHSWT alone, or CHSWT + SMS

If the dog is still slowly prone to reacquiring allergies, the CHSWT just may not be sufficient to heal the mucosa, stop the leaky gut, and correct the microbiome (which is an issue, given the response to the fecal oral transplant). A good formula to use in tandem with CHSWT that also helps the microbiome is Bu Zhong Yi Qi Tang. This formula favours assimilation, which is apparently a concern, and is commonly indicated when there is a deep wiry pulse. Given that SMS has a draining effect on Qi and its addition made the dog immediately worse, BZYQT is worth a look, since it has a raising effect on Qi.

Lastly, BZYQT is a strong adaptogen, helping to cut down on severe stress responses. All things considered, it seems a good fit. I'd try it with the CHSWT and see where it gets you

Steve
by fdzenitsky
October 18, 2021
Hi Steve,

We think the SMS caused the mucousy stools. I like BZYQT for this guy and thought I'd finish with it. From your Derm lectures at AHVMA and CIVT, I have in my notes that Astragalus formulas are used last (after XCHT) OR in clear Immune deficiency cases. We don't want to stimulate the immune system if too inflamed, correct? I didn't think of using them in tandem, but if you find that reasonable, I'm going for it. Do you recommend full BID doses of each?

Thanks!
Franchesca
by naturevet
October 19, 2021
Hi there,

Any skin patient we use BZYQT in will naturally have some inflammation, since at a minimum we are treating bacterial or yeast overgrowth. Thus, some itch and redness does not preclude it's use, but you're right - we would use it with great caution in a severely inflamed animal.

Using it in tandem with the XCHT here would help guard against any resurgence in inflammation from the Astragalus, and the two can, indeed, be used in tandem, instead of sequentially. You could test the waters with half doses of BZYQT and full doses of XCHT, and if well tolerated, bump up the dose of BZYQT to get its full effect.

Good luck with the case!

Steve
by fdzenitsky
October 19, 2021
Steve, would this patient also benefit from Suan Zao Ren Tang? Not a formula I typically think of for skin cases, but it nourishes the Blood and calms the Shen, clears Heat and relieves irritability. Suan Zao Ren nourishes Liver Blood and calms Heart Shen, Chuan Xiong regulates Liver Blood, Fu Ling sedates the Mind, Zhi Mu nourishes Yin and clears deficiency Heat, and Gan Cao clears Heat and harmonizes. If you think it would be helpful, how would I modify his therapy? Or, just keep it in mind for later? Before you brought up SZR for my Autism/Seizure patient, my plan was to put this guy on CHSWT and BZYQT.

thanks again!
Franchesca
by naturevet
October 20, 2021
Hi there,

It's possible, but I'd pursue the CHSWT + BZYQT combination first. Suan Zao Ren is really more for psychogenic itch (when the itch is chiefly from patient being 'hot and bothered'). When there is a medical explanation for the itch, I'm not sure if it is useful. Let's keep it waiting in the wings as a Plan B. Or that's what I would do, anyway

Steve
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