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Seizures In A Dog

by ajerger - October 25, 2023 View Case Report

Lily is a 4.5 yr old Lab, with a history of seizures since January 2020. The seizures started after she had been spayed and concurrently diagnosed with hip dysplasia.
Adopted from a breeder ~ 3months old.
Past Diet: Canned and Kibble,
Vaccine: Had all required vaccines on time per owner.

Hx from prior vet:
Seizures began 2/2020 multiple seizures and patient was placed on Phenobarbital.
Seizures averaged 1-3 per month
Hip dysplasia diagnosed March 2020, owner noted difficulty running, Adequan injections seemed to help.

Farmers Dog food started December 2020.

May 2021- Owner said she was having adverse reactions to Phenobarbital, at one point she needed to be hospitalized, for “drunk” like behavior and could not stand/walk. Patient was weaned off of phenobarbital and patient improved dramatically. She was much better after stopping phenobarbital and was put on Keppra 2,200mg TID and Zonisamide BID
( side note- the owner notes urine leakage almost every day, he says once he started the keppra he noted that, if there is a day or dose he misses the keppra, she does not leak urine per the owner)

She had 1-2 seizures per month until 5/2022.

May 2022- She was overfed one evening and was given avocado, she vomitied multiple times and had ~9 seizures which was stabilized at an ER.

Recently they have have increased in frequency but the intensity has lessened at bit, but just today she has had 4 small seizures between 5-7:30pm.

The days she has seizures she becomes very quiet, lethargic and often drools.

The seizures used to be in the early mornings but now have been in the later part of the day.

The only other history is that she has a very sensitive stomach, many times the days she has seizures she has had soft stool or diarrhea. The owner has made a correlation between Gi upset and seizures.

Currently, she is on a home made diet. Supplements, Probiotics..etc..

Another side note- 2 weeks ago she presented with a limber tail, could not move the tail and she was very painful just caudal to the base of the tail and it seemed to be slightly swollen. She was given metacam orally, which helped but she had a seizure after the second dose so that was discontinued. Her tail is now normal. Apparently this happened a couple of years ago, same presentation, resolved with anti inflammatories.

Physical exam:

70lbs,
(I can needle her and she is the calmest, most quiet demeanor, does not move at all)
She sleeps during acupuncture and physical exam
She initially had a smell around her anus for months and recently this has gone away, but today I smelled it again. Smells like maybe anal sac ? But not as potent. )

Pulse:
- [ ] superficial to mid depth
- [ ] Resists compression
- [ ] Highly toned
- [ ] Normal to slight increase in diameter
- [ ] Moderate finger lift
- [ ] Normal rate and rhythm

Tongue: Dark pink to Red

Labs: non regenerative anemia, very slight. Cause unknown, everything else is normal.

Acupuncture: pulse seems to moderate with GB34, GB20 and LI 4. I sedated SP 9 and maybe a slight change in pulse.

Herbs:
- [ ] Chai hu jig long gu mu Li Tang (1/2 tsp BID)
- [ ] Dang gui and Peony support
I had her on Spleen support but stopped since she is warm-hot.

8 parameters:
Internal
Excess ( seizures)
Deficient ( soft/loose stools, leaking urine?, hind limb weakness, flaccid tail)
Hot
Some dampness- perianal odor, some improvement with diet.

Western Diagnosis- Epilepsy

TCM- Shao yang disharmony?

Despite my current treatment plan, she remains warm to hot and persistent seizures

Not sure where to go from here…

Thanks so much…..

by ajerger

October 27, 2023

One more thing...Last few weeks she has been coughing/hacking as if she 'has something in her throat sounds slightly moist per the owner. nothing comes up....
Thank you again!

by naturevet

November 2, 2023

Hi there!

Another challenging case, I see.

I'm wondering if this is a case of Damp Heat, leading to Phlegm Obstructing the Orifices of the Heart; and to Upward Disturbance of Wind Phlegm. The pathogenesis would be Spleen deficiency (evidenced by digestive weakness) leading to Dampness accumulation and Damp Heat. Damp Heat is the only cause of Wei Syndrome referenced in the classics, and Si Miao San the only treatment they cite. Sometimes SMS cases have a big pulse like you palpated.

Simultaneously, Dampness and Phlegm has moved into the upper burner, obscuring the orifices of the Heart and creating that disconnection and lassitude you're seeing. That's why vomiting seemed to bring on an attack.

May aggravations and onset are consistent with Dampness and Phlegm causing the problem.

All that being said, the pulse also fits a Shao Yang disharmony, as does the January onset of the problem, and the response to your points. If you try to disperse however, using Minor Bupleurum derivatives, you could make things worse.

I can remember one of the first seizure cases I treated years ago was started with Long Dan Xie Gan Tang, and then once the excess was stripped away, was finished with Ban Xia Bai Zhu Tian Ma Tang. It may worsen the incontinence, however, and could be excessively sedating if we are wrong.

My temptation would be to try Si Miao San and BXBZTMT together, to see what happens. I'd give full doses of each, and see if the interval between seizures can start to increase and/or the severity of the seizures decrease

Hopefully that helps you out! Let us know how it goes!

Steve

by ajerger

December 19, 2023

Update:
Patient initially had a 3 week span of no seizures since adding the Ban Xia, with good energy. She is on highest doses of SMS and Ban Xia Bai Zhu Tian Ma Tang. ( 72lbs 8ml's divided BID SMS, Ban XIa -1.25tsp BID), Keppra Extended release 1000mg TID( 31mg/kg) and Zonisamide 270mg BID 8.4mg/kg), CBD twice daily.
Recently she has reverted back to having seizures more often (some less intense) but often still intense and lasting from 30 sec - 2 minutes. I had mentioned previously that she had been leaking urine and that is now more often as well as excessive licking of vulva. Her appetite has also increased dramatically, she is ravenous. Stools are good, no vomiting. The perianal odor is gone.
Her last labs on 11/1/23 her ALK spiked to 1414( 23-212), and baseline cortisol was 1.3 ( 1-5) ( we are going to go ahead and stim her today or tomorrow. Her HCT is always on the low end or just below normal, and her total t4 is 0.9 (1-4).
Should I discontinue the Ban Xia and Start Long Dan Xie Gan Tang? Thanks so much!

by naturevet

December 21, 2023

Hi there!

It's not clear to me that the anti-Damp approach produced any real meaningful change, since you haven't been able to get back to the once a month or less seizure frequency.

I'd wonder, then, about the Shao Yang approach. Shao Yang disharmony fits:
- a fall aggravation
- burgeoning Stomach Heat (from dryness) as we drain and dry Damp (which may not actually be there if seizures haven't markedly improved)
- a Heart Kidney disconnect, resulting in incontinence

To explore that, I'd probably suggest trying Minor Bupleurum with Tian Ma Gou Teng Yin. I'd do full doses of each of those two. If you see things start to improve, then you'll know you're on the right track, and that the seizures are arising from Shao Yang disharmony, compounded by Yin deficiency.

I'd look for the incontinence to improve, but you might have to add a Yin tonic or something like Sang Piao Xiao San (or HRUI Formula) for that to resolve completely. I wouldn't add any Blood or Yin tonics yet, though, until the ALP is back down. XCHT has the capacity to achieve that for you.

Hopefully this nets you more obvious improvements in such a challenging case!

Steve

by ajerger

January 24, 2024

Hi there,
Lily's Incontinence is worse on the Tian Ma Gou Teng Yin/SMS and Minor Blupleurum. Seizure frequency is the same. Appetite is Revenous, no polydipsia, just urinary incontinence, formed stools, no vomiting.

Energy levels are good, I have been tracking her heart rate at home is 60's -70's. I attribute this to the high doses of Keppra and zonisamide?

Her ACTH stim pre was 1.2 ( 1-5ug/dl) and post was 7.8 ( 8-17ug/dl), she is currently on Adrenal Support.

Pulse: somewhat superficial, toned, resists compression, somewhat full, normal rhythm and rate.
Tongue : Dark pink to red, somewhat wide.
My thoughts were that she may have a hormonal/endocrine component to her presentation (onset after spay) and low cortisol with little stimulation. I am stuck on what herbal formulas to choose with so much to consider.
Thanks in advance!

by naturevet

February 2, 2024

Well, we can try adding in a Yin tonic. Besides internalizing, the only other thing all the three formulas that are aggravating Lily do is dry (or at least offer no Yin support) The tongue suggests Heat. That pulse can be seen with Empty Fire. Zhi Bai Di Huang Wan is a possibility, or even Tian Wang Bu Xin Dan, which has more adaptogens to help with the adrenals.

It would be rare for a seizure dog not to have Yin deficiency, so maybe that is the next thing to address

by ajerger

April 24, 2024

Hi there!
Update: We have gone 22 days without a seizure, then she had one, Same intensity, sometimes urinates or defecates during seizure. She is currently on:
1. Xiao Chai Hu tang: 1 1/4 tsp BID
2. Tian Wang Bu Xin Dan 1 1/4 tsp BID
3. Si Miao San 1 1/4 tsp BID
4.Tian ma gou ten yin 1 1/4 tsp BID
5. Keppra 1000mg TID
6. Zonisamide 270mg BID
7. CBD BID
8. Incurin ( estrogen) 1.5mg/day
9, Prednisolone 1.25mg/day
73lbs good condition
She is still leaking but I do think it was/is the Keppra. The owner remembered the incontinence started with the addition of this drug before any herbal formulas were started. He also notes that on occasion he will find a keppra pill on the floor and noted the leaking was significantly less.
The patient appears hot, moving onto the floor more often, she has a decent amount of very odorous gas daily, very smelly light yellow urine without infection, eating home made diet, not drinking a lot of water.
Pulses: mid depth, toned, normal diameter, slight finger lift, normal rhythm and rate
Tongue: dark pink to red
Active points: GB 34, GB 20 and spleen channel
What else can I do? Does my assessment make sense?

by naturevet

April 27, 2024

Okay, here is an idea. The pulse tells us that we don't particularly need tonification, but neither do we need internalization. It suggests we need a moving effect. Normally in a seizure case, we'd suspect Shao Yang as being obstructed, calling for that moving effect, but you're already using XCHT.

How else can we move something in the interior, without 'dispersing and exteriorizing' to the point that we cause seizures? It occurs to me that you may have a Jue Yin excess here. In that instance, instead of Yang being stuck (which is Shao Yang disharmony), you have Yin being stuck, which is Jue Yin excess.

Essentially we are talking about Yin being balled up in the lower abdomen, unable to internalize Yang, which bounces up into the stomach and head to cause seizures, a red tongue and a big appetite. Meanwhile there is pressure in the lower abdomen creating a predisposition to incontinence. Yin tonics can prove beneficial, because Jue Yin excess arises from Yin deficiency. Yin deficiency often arises from Damp Heat.

Based on all of that, I'd wonder about trying:
- Wu Mei Wan (the treatment for Jue Yin excess, available from Evergreen)
- Xiao Chai Hu Tang (because the two conditions can occur together - Shao Yang and Jue Yin)
- Si Miao San (for the Cushing's symptoms and Damp Heat damaging the Jue Yin)
- Tian Ma Gou Teng Yin (which addresses Yang rising from Yin deficiency, which is what we are talking about)
If you see incontinence reduced despite Keppra, then I think we are on to something.

Lastly, remember that to assess seizure progress, you divide the number of days since the last seizure by the number of seizures on the day of the breakthrough. That gives you seizure free interval. So, if this last episode was one seizure after 22 days, then the interval is 22. If the last time (just as an example) she had two seizures in three weeks, that is an interval of just 11 or so. You're looking for the interval to slowly go up with time as evidence you're undoing the pathology. It's rare for dogs to suddenly stop seizing, but if you're on the right track, the interval will continue to rise

Hopefully this helps you out!

Steve

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