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Seizures Bruxism Recurrent E Coli Uti And Dysphagia

by bfellisdvm - November 7, 2022 View Case Report

Skyway is a 2.5 Yr 40 lb FS spaniel mix with chronic history of inflammatory conditions. She is currently eating Fromm whitefish diet along with cooked vegetables. This is an interesting and long drawn out case so I will do my best to hit the highlights without leaving too much out.
Her early history involved multiple events of vomiting and diarrhea and other inflammatory events. She had some issues out of the gate with a saw horse stance/base wide with a hypomobile neck. She seemed “blind” she had to be carried places. Learning seemed delayed. Her first seizure was at around 10 months of age. Her seizures typically occur between 5&7am. She was started on Keppra because of severity of seizure. On keppra, she would have break through seizures with Gran Mal activity (3-5 minutes) with prolonged pre and post Ictal phases and zonisamide was added and caused toxic hepatitis. Seizures persisted and she was started on Phenobarbital with keppra. She then developed toxic epidermal necrolysis which resolved with discontinuation. A neurologist recommend increasing dose to 1500 mg bid. Bruxism occurs with or without seizures but patient is conscious. The mother of this dog has seizures controlled with phenobarbital and a litter mate died due to seizures…so there’s that. The neurologist had also recommended to try prednisone to rule out inflammatory conditions and that has seemed to help ..at low doses of 2.5 -5 mg of prednisone per day. Her seizures have been reduced to one every 4-5 weeks.
On presentation today, she is calm laying sternal in exam room and did not demonstrate bruxism as she has done in the past (per records) Her tongue is dark purple to red and WET.
Her pulse is surprisingly full and toned. She has active points in the T/L region (BL 19-BL 22) as well as at GB 20 and GB 30. Acupuncture at with sedation at GV3 softened the pulse. I tonified ST 37 & LI 11 and GB 20. Not sure I achieved a moderate pulse (I.e. ‘the happy Canadian’) but tonifying the Yang Ming and Shao Yang while sedating the Tai Yang produced a marked softening of her pulse and a calm, alert disposition that the owners were happy to see.
My diagnosis is Shao Yang disharmony with Kidney Yin/Qi/Jing deficiency as seizures b/w 5 & 7 am would be when Qi is highest in Large Intestine and Kidney Qi is at its lowest. My plan is to start Chai Hu Jia Long Gu Mu Li Tang at 1/2 tsp bid to tonify Shao Yang and allow Yang energy to descend and return to mix with deficient Kidney Yin. After a couple of weeks, I would add Tian Wang Bu Xin to tonify Kidney Yin and Heart Blood. We are also working to increase amount of whole food in diet. Any thoughts or changes to my plan would be greatly appreciated! My concern is returning the Yang energy to deficient Kidney Jing. Will that make symptoms worse? Thank you as always
Cheers,
Brett

by bfellis

November 8, 2022

Also, I forgot to mention failures of previous herbs prescribed based on clinical signs described by a colleague versus pulse diagnosis with with response to acupuncture
Long Dan Xie Gan Tang was prescribed for Heat signs in the upper Jiao /head-no response noted.
Si Miao San for Damp Heat in lower Jiao -chronic UTI with dysuria and anal sacculitis..noted response or improvement of Heat signs
Dang Gui Shao Yao San for UTI -cause diarrhea at any dose

It is now clear that the internal Heat is due to a Shao Yang Disharmony and the Shao Yang needs tonified to pump the Yang from the exterior to the interior.
Or at least that’s where I hope this is going!
Brett

by naturevet

November 9, 2022

Hi Brett!

That is an interesting case and I like your thinking. I'm basically leaning the same way myself, although my temptation is to try Si Miao San plus Xiao Chai Hu Tang out of the gate, and to be very careful in introducing Yin tonics given the response to even a weak Blood tonic like Dang Gui Shao Yao San.

The tongue appearance and history fit Damp Heat well, as does a tendency to seizures in the morning, when Dampness is highest. At the same time, though, you saw the pulse respond well to your Yang internalizing treatment, implying a Shao Yang formula is needed. Chai Hu Jia Long Gu Mu Li Tang seems a great choice for that.

The only thing that gives me pause is the seizuring at 5 to 7 am. Yang is in the Yang Ming at that point. If it is having any bearing on the seizures, then SMS may take care of it (since SMS cools the Yang Ming). Alternatively, though, if the Yang Ming excess is being passed (via internal connections) to the Heart, then entrapment of Yang in the Yang Ming is potentially part of the problem, which makes Xiao Chai Hu Tang a better choice than CHJLGMLT. The response to acupuncture suggests this is not the issue, but we have to remember the Shao Yang gate can stick both ways. It may be when you did your acupuncture, Yang was trapped on the outside, and that early in the wee hours, the Yang is trapped on the inside and generating seizures.

My temptation would be to step into the formulas, one at a time, and use either SMS + XCHT or CHJLGMLT + SMS. We can be more certain of SMS, just because it was used to good effect before. If it helped the pulse a lot, maybe it's a pure Damp Heat case, in which case the next step is a real food diet.

If SMS only helped a little, then I'd look at a Shao Yang formula next. CHJLGMLT is committed to Yang internalization. If SMS doesn't aid, then a Shao Yang disharmony is the likely cause of the seizures, with too much Yang in the Yang Ming somehow causing them. In that case, then, I wouldn't use CHJLGMLT, but instead XCHT, which address both types of Shao Yang disharmony, both of which might be present in this dog at different times of the day.

Only once I'd stripped the excess and seen what actually helps would I then turn to correcting the deficiency. Low dose pred acts as a Blood/Yin tonic, so you actually may already be addressing that. If the XCHT worked, then Yi Guan Jian (which hydrates and cools the Yang Ming) might be the best choice, but I'd figure that out later and deal with the excess for now.

Hopefully this makes sense to you. It makes my head spin, and I wrote it!

Steve

by bfellisdvm

November 10, 2022

Perfect sense and thank you for the clarity! I’m still trying to wrap my head around “where is Yang, where is not Yang, where is not Yin, where is Yin?”
That’s what led me to Kidney Yin/Jing Deficiency since it opposite of LI, so I somehow rationalized that Yin/ Jing deficiency was the cause, but in a young animal an excess or pathogen should be in the forefront I would surmise ?
I’m not sure any response was seen with Si Miao San previously but that was like a year ago and it would make sense to start safe and then add XCHT if no improvements seen in a couple of weeks. Would you go 1:1 SMS:XCHT …this is probably best understood after observing response alone to SMS. I’ll let you know how she responds and go from there. Any help with the “where’s s Yang, where is Yang not “would be greatly appreciated. I feel like that area needs some polishing.
Thank you!!!

Brett

by naturevet

November 10, 2022

Hi Brett,

You'd mentioned SMS was helpful in the past for bladder issues, suggesting the animal suffers from Dampness. If so, SMS may help again now.

It's the big pulse that tells us we shouldn't start by tonifying this dog. Young dogs generally need tonics, but the pulse overrules and dogma. If it's big, then the deficiency has led to a secondary excess that must be addressed. Otherwise, your tonics will tonify the excess (i.e., the pathogenic Qi), in which case the animal will worsen.

In the mornings: Yang Ming and Tai Yin are at 'high tide', meaning their opposites (Tai Yang and Jue Yin) are at low tide

In the early afternoon, Yang is in Tai Yang and Yin is internalizing through the Shao Yin. That means the opposite of Tai Yang (i.e., the Yang Ming) is at low tide.

In the evenings, Jue Yin is at high tide and its opposite (Tai Yin) is at low tide. Yang is internalizing via the Shao Yang.

In the very wee hours, Jue Yin is maximal and Yang has entered the Yang Ming. Tai Yang and Tai Yin are at low tide. A couple of hours later, Yin moves out to the Tai Yin layer, and the whole cycle starts anew

Lastly, if you do pair SMS and XCHT, use full doses of each to start with

Steve

by bfellisdvm

November 17, 2022

Si Miao San used before did not help bruxism or UTI signs , sorry for the confusion in my original post. He is just starting the Si Miao San again today (miscommunication on my part that he was indeed supposed to do this) and will see how she responds. The other big issue with Skylar is her severe aggression towards her food-she is on Fromm Whitefish recipe with green beans and sardines added. Skylar seems to have dysphagia and the owner has to feed her by hand or she gets very frustrated and bruxism increases. She does not bite owner while he hand feeds, it occurs more often in the process before feeding or after feeding. This only occurs with her food..not treats or toys or any other resources. The food “aggression” is worse on Prednisolone (2.5mg sid) but any taper in this dose results in increased seizure activity within 2-3 days. On prednisolone, her seizures have gone from every 2-3 weeks to 5-6 weeks and are less in severity and duration. We are concerned about a prefrontal cortex lesion, but MRI Is not possible due to financial restraints. She literally can become “unhinged” during feeding and will attack anyone near her food. I’ll let you know how SMS goes alone, I was going to try this alone for 10-14 days. If no effects noticed, should I continue SMS w/XCH or just try CHJLGMLT alone? 2 days after her first AP treatment , the owners did note a marked improvement in behavior with a decrease in bruxism and meal aggression that lasted 3 days or so Im thinking the CHJLGMLT will be my 1st choice if Damp Heat is not part of her clinical syndrome?

by bfellisdvm

November 17, 2022

Si Miao San used before did not help bruxism or UTI signs , sorry for the confusion in my original post. He is just starting the Si Miao San again today (miscommunication on my part that he was indeed supposed to do this) and will see how she responds. The other big issue with Skylar is her severe aggression towards her food-she is on Fromm Whitefish recipe with green beans and sardines added. Skylar seems to have dysphagia and the owner has to feed her by hand or she gets very frustrated and bruxism increases. She does not bite owner while he hand feeds, it occurs more often in the process before feeding or after feeding. This only occurs with her food..not treats or toys or any other resources. The food “aggression” is worse on Prednisolone (2.5mg sid) but any taper in this dose results in increased seizure activity within 2-3 days. On prednisolone, her seizures have gone from every 2-3 weeks to 5-6 weeks and are less in severity and duration. We are concerned about a prefrontal cortex lesion, but MRI Is not possible due to financial restraints. She literally can become “unhinged” during feeding and will attack anyone near her food. I’ll let you know how SMS goes alone, I was going to try this alone for 10-14 days. If no effects noticed, should I continue SMS w/XCH or just try CHJLGMLT alone? 2 days after her first AP treatment , the owners did note a marked improvement in behavior with a decrease in bruxism and meal aggression that lasted 3 days or so Im thinking the CHJLGMLT will be my 1st choice if Damp Heat is not part of her clinical syndrome? If no change with SMS, is there any way to assess if the Yang Ming is transferring excess or entrapped Yang to the Heart? Would any Luo connecting points be helpful to assess if this is the case? Which would lend more to a XCH treatment versus CHJLGMLT?
As with all good science… more and more questions! ??????????

by naturevet

November 19, 2022

Hi Brett,

If your acupuncture made a big difference, then I'd go ahead and just institute the formula that mimics those points, which is CHJLGMLT, like you originally suggested. You did see the pulse improve with tonification of ST points. Normally if there is Yang Ming excess, you'd see the pulse improve with sedation of ST points.

If there is no particular reason to expect SMS to work based on past experience, and if LDXGT didn't help, then you can probably stop SMS if there isn't some sort of prompt improvement.

As to alternate explanations for the morning seizures, the response to low dose pred can signal ST Yin deficiency. In other words, we want the Yang in the Stomach, as the acupuncture points show. But if there is reduced Yin in the Stomach to hold the Yang, seizures can occur. You can counter this tendency (if that is what is going on) by adding in Yi Guan Jian.

The Gold Standard Herb formula known as Halscion has CHJLGMLT and YGJ in it, making it a ready to use formula for you if you prefer. Vets can set up wholesale accounts with them, or if you don't want to stock the formula yourself, people can buy it directly online. Just a thought if your herb inventory is low

Hope that helps!

Steve

by bfellisdvm

November 20, 2022

I do have a good supply of NP for both herbs. I’m thinking of just adding 20gm YGJ to 100gm CHJLMGLT? Or go full dose of each herb? Thanks for your time and expertise!

by bfellisdvm

November 20, 2022

I do have a good supply of NP for both herbs. I’m thinking of just adding 20gm YGJ to 100gm CHJLMGLT? Or go full dose of each herb? Thanks for your time and expertise!

by naturevet

November 20, 2022

I often go 2 parts CHJLGMLT to 1 part YGJ

S

by bfellis

November 30, 2022

No response to SMS. Started CHJLGMLT W/YGJ at 2:1 (2gm former 1gm later). I’ll keep ya posted

Brett

by naturevet

November 30, 2022

Fingers crossed!!

by bfellis

December 9, 2022

Skylar started CHJLGMLT and YGJ on 11/26/22. Tongue is lavender and wet, but less wet than last time. Color improves to pink and moist with treatment.
Pulse is superficial, softer yet still toned under a thick cowhide. Ge Mai pulse
Softens with Tonification of GV3 and GV20. Bruxism started and I sedated ST 37 and bruxism stopped. Also sedated GB 30 and LU 5 (presented today for coughing) and pulse damn near went to sleep. No coughing in exam room. I advised to humidify air since heaters have been turned on and continue herbs. I’ll keep you posted on progress. Still too early to know about seizure control as she has them every 5-6 weeks. Todays exam was at 10:30am est

by naturevet

December 12, 2022

That's awesome information, Brett! Really helpful if we need to change gears somehow

Steve

by bfellis

December 14, 2022

Skylar had her first seizure in the evening around 5:30 pm. Could this indicate the formula is driving the pathogen out? This would be the time of excess Yang in the kidney? Is that even a thing? She is otherwise doing well and this seizure was grand Mal as are the morning seizures. Owner gives intranasal midazolam to stop clusters and that seems to work. Any thoughts on continuing with herbs or what this could mean as far as a 12 hour shift in seizure activity. Interestingly, I had another seizure patient that mostly has morning seizures, which I will be asking about as soon as I get time to input, had her seizure about the same time and same day as Skylar.
Thanks for your time!!

Brett

by naturevet

December 14, 2022

Hi Brett,

Evening seizures are often due to Yin having descended (through the Shao Yin, accounting for this happening due to Kidney high tide), yet Yang still being on the surface.

That kind of scenario is treated with Tian Ma Gou Teng Yin. I'd maybe add it to what you're doing.

Morning seizures (during Tai Yin high tide) are often due to Damp, calling potentially for Ban Xia Bai Zhu Tian Ma Tang

Steve

by bfellisdvm

December 17, 2022

Ok ???? I’ll add TMGTY. Thank you

Brett

by bfellisdvm

December 17, 2022

Ok ???? I’ll add TMGTY. Thank you

Brett

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