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Eosinophilic Stomatitis In A Dog

by jk176 - November 27, 2021 View Case Report

Dozer is a 4 year, 10 month old mn, 46 lb Terrier mix
Sorry for the long history, but it may be helpful:

8/17/17 - owner noted loose hind limb gait, radiographs - severe bilateral hip dysplasia, staged bilateral FHO surgery was performed

3/2019 presented for teeth chattering, oral/inflamed plaque noted right right caudal soft palate
biopsy - severe, chronic, active, lymphoplasmacytic, suppurative, and eosinophilic ulcerative stomatitis
treated with prednisone

3/14/19- owner noted behavioral change (aggression) PP, lesions resolved on 4/16/19
lesions recurred 5/13/19 resumed prednisone and tapered more slowly
8/16/19 - lesions resolved
11/9/19 lesions recurred - resumed prednisone - PU/PD/PP recurred- slowly tapered off prednisone

3/20/20 - lesions not seen on exam
6/6/20 - lesions recurred - started cyclosporine and prednisone
9/18/20 - lesions resolved discontinued prednisone, continued cyclosporine decreased from SID to EOD
12/8/20 - lesions recurred - restarted prednisone

1/16/21 - tongue pink/pulse weak/slippery - lesions resolved, off prednisone 1 week at this point
started Evergreen Si Miao San powder 3/4 tsp am, 1 tsp pm, increased cyclosporine to SID again
4/10/21 - teeth chattering occasionally, oral lesions recurred
restarted prednisone
4/30/21 lesions resolved - tongue dark red, pulse weak - can't palpate well
6/3/21 lesions not seen on exam - decreased cyclosporine to EOD
7/22/21 lesions recurred, resumed prednisone
Recent visit:
11/26/21 off prednisone x 5 days, on cyclosporine SID, on Si Miao San 1 tsp SID
increased teeth chattering more often at night and after stretching, paws over ears, rubs head, much more friendly to house guests, follows owner everywhere, still will nip if startled, normal thirst, excellent appetite, first bm formed, second a little soft with greenish material
tongue - lavender, slight phlegm, small cracks evenly distributed, tip sl. red, pulses as usual - difficult to palpate, thin/thready to sl. decreased tone, sl. fast
feet/ears neutral, body warm
oral lesions recurred
The prednisone is effective, but the side effects are not tolerable - indicating damp heat?

A - damp heat, liver blood deficiency, +/-spleen qi deficiency

Should I continue Si miao san - and see how he does on the full dose?
Should I add Dang gui - the pulses seem to indicate blood and or qi deficiency?
What do you think about adding in Hoxey-like combo?

Thank you in advance,
Jennifer

by naturevet

December 1, 2021

Hi there!

A bit of a tough case, but I'm wondering about Yi Guan Jian + Xiao Chai Hu Tang, coupled perhaps with diet change and probiotics. First, though, we can talk about the simplest thing you can try, which is to use Long Dan Xie Gan Tang to reduce your pred dose and mitigate the side effects.

Responsiveness to pred can indicate Blood deficiency and Shao Yang disharmony, both of which can occur together. Meanwhile, worsening on pred can indicate Damp Heat. If all this is true, one way to treat all three simultaneously is to use Long Dan Xie Gan Tang (the NPHC version, especially). Reference texts describe the formula as opening the Shao Yang (i.e., Triple Burner) and draining Damp. It contains Bupleurum to help open the Shao Yang, Ze Xie to draind Damp, and has Rehmannia and Dang Gui to address Blood and Yin.

LDXGT is famous for dealing with aggression, so if nothing else, it might help the dog feel normal while pred is in use, and lower the required dose of the drug to boot. Again, it's probably the simplest thing to try, but may not be curative.

Otherwise, to pursue a cure, as you noted, the weak pulse suggests deficiency as the current layer of the onion that we have to peel, if we are to take the case in stages. Regarding the core of the onion, the timing of the aggravations suggests we have a relative Yang Ming excess, aggravated by a Yang Ming Blood and Yin deficiency and compounded by a Shao Yang disharmony that keeps Yang trapped in the Yang Ming tissues of the Stomach (and mouth) and Large Intestine. In short, all that Yang bottled up in the Stomach/Mouth with no Yin to balance it creates the Heat of the stomatitis. Thus, if we tonify the dog for now, my guess is the pulse will get stronger and deeper, revealing Shao Yang disharmony as the core of the problem.

If we were to translate this into biomedical terms, it would be a failure of inflammation to resolve due to endothelial dysfunction, with that inflammation being caused by immune dysregulation, usually from a leaky gut.

If this is correct, then the sequence of formulas might be Yi Guan Jian to improve lesion blood flow and promote their active resolution, followed by Minor Bupleurum to address the underlying immune and leaky gut issues. Both formulas might help leaky gut, actually.

If that approach resolves the lesions, then a real food but not raw diet with probiotics might prevent the problem in the future. Animals responsive to Minor Bupleurum appear to need some fermentable carbohydrates in their diet to feed their gut flora and correct the dysbiosis which causes a leaky gut, propionate deficiency, and resultant immune dysregulation.

Sorry if that all seems bewildering. Bottom line: if you start with LDXGT + low dose pred for now, and it improves the situation but does not resolve it, the YGJ + XCHT/MB + diet change probably will, based on how things have gone to date

Hope that is how things actually play out!

Steve

by jk176

January 13, 2022

Should I continue treating Dozer with Yi Guan Jian and add in Xiao Chai Hu Tang? - I posted an update on how he is doing today as well.

Thank you,
Jennifer

by naturevet

January 13, 2022

Hi Jennifer!

Sounds like you're getting somewhere! YGJ seems to be holding the situation. Since the pulse feels weak to you, you could try something related that is still a tonic, but is a more robust anti-inflammatory, like Zhi Bai Di Huang Wan or Qing Ying Tang.

Alternatively, if you feel the darkening of the tongue reflects more Stasis than Heat, you could start Minor Bupleurum, say one dose daily?

Thank you for updating us on this case. Stomatitis is challenging, so it's great to hear back from people how their cases are doing and on what.

Happy New Year!

Steve

by jk176

January 15, 2022

Hi Steve,

Thanks for getting back to me so quickly. Zhi Bai Di Huang seems like a good fit to me. I will start him on this. Should I use the full dose and keep him on YGJ at the full dose?

Happy New Year to you and stay warm!
Jennifer

by naturevet

January 15, 2022

Sure you can, Jennifer. If things go well, you can switch to the new formula, or alternate them, in order to reduce the amount of herbs the owner has to give

Cheers,

Steve

by jk176

January 22, 2022

Hi Steve,

So... Since the last time I saw Dozer on January 13 of 2022, he has vomited 3 times. They have been solitary episodes several days apart. Todays episode was vomiting of food and slime 1.5 hours after he ate. He ate this and held it down, but was quiet today.

He started Yi Guan Jian around Christmas time. He just started Zhi Bai Di Huang Wan 2 days ago. 2 episodes occurred before starting ZBDHW. He is coming in for a recheck next week. I told Dozer's dad to stop the herbs until I see him.

I know there could be many other causes of the vomiting, but if it is due to the YGJ is this because there is stronger damp component to his issue? I will let you know exam findings when I have them.

You mention in your book that Xiao Yao San is more anti-inflammatory than YGJ. Is this something to try or is it too close to the original formula?

He is on prednisone 5 mg once daily along with the cyclosporine and is tolerating it. I think restarting the prednisone back in November had the biggest impact on resolving the oral inflammation, but I would like to get him off it and use Chinese herbal medicine for a cure.

What other formulas should I consider and specific active points or points to stimulate when I see him next?

Much appreciated,
Jennifer

by naturevet

January 26, 2022

Hi Jennifer,

If there is no urgency to the situation, I'd recommend seeing him first before you make big changes.

If his pulse feels slippery on the tonics, you'll know he's Damp and in need of something like San Ren Tang, or Wei Ling Tang if he's a Cold dog (with sometimes a wiry deep pulse responding to tonification of ST 36). I guess with stomatitis, though, it might be Si Miao San that you would resort to.

If his pulse feels deep and toned, and responds to GB 34, then you'll know it's time to introduce the Xiao Chai Hu Tang. At that point, you can stop the ZBDHW, since XCHT will now be the herb you're relying upon to address the inflammation, through its immune modulating properties. It has Ban Xia in it to deal with any Phlegm caused by the Yi Guan Jian, and YGJ is often needed in the end to clear the Heat from the Yang Ming after XCHT has done its work. So there is a natural synergy there that you might as well keep in play, unless the dog proves intolerant of YGJ and is normal only on XCHT.

Hopefully this helps you out!

Steve

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