Question Details
Profound Weakness In A Dog
by equinesportsmed - January 31, 2024    View Case Report
Oh boy, this one is a doozy, Steve! I am missing some key lab work, but still feel like there is a possibility that all these effects are due to misdiagnosis and drug side effects.

Riley FS mixed breed, 11 yrs old
Riley has been healthy other than going blind 3 years ago— adapted well and continued good quality of life.

Early October 2023: Sudden onset of “shivering” when in bed with owner, and polydipsia. Took to urgent care clinic mid-October, had mild fever (103.4) but seemed to be NSF, wondered if she had UTI, when vet, as afterthought when walking out the door thought to check anal glands. Had monstrous abscess— huge and deep, took two rounds of antibiotics to clear up. Urgent care clinic also noted (I don’t have these records!) something that made them say— get her checked out for Cushings. To clarify— no clinical signs of Cushings, other than PU/PD.
So, the following week, O went to regular vet to follow up on cleaning up anal sacculitis. She had only been on AB for a few days, but the polydipsia had mostly resolved. RV did low dose dex suppression test (10/13/23), which showed baseline cortisol of 6.5 (1.0-6.0 ref range) and response — 4 hr 8.6, 8 hr 6.2. So, not supressed. But the dog was still ill with anal infection at that time. (To my mind, without clinical supporting signs of Cushings, they should have waited and retested I believe this may have been a medical error that precipitated everything else that happened.) RV sent dog home on more antibiotics, and Trilostane 60 mg SID.

Over the next few weeks, the anal lesion resolved, but the dog began having tremors and possibly occasional psychomotor seizures. O was convinced it was due to the medication. Dog was rechecked on 11/14, at which point they did a ACTH stim test, which was 5.8 baseline and 11.8 post-stim. Which convinced the vet he was on the right track, and told client not to worry about the tremors and neuro signs. (Why did he use a different test, rather than comparing test before treatment?). Dog continued to worsen through December, at which point the owners brought her back because they were concerned about tremors, weak hind end, lethargy, and inappetence. CBD/Chem done at that date showed:

Lymphocytes 0.69
Eosinophils 0
ALP 1207 (don’t know the October value)
ALT 151
Lipase 5700
Amylase >2500

Neuro signs worsened over six weeks. Owners requested stopping the Trilostane, vet refused, but added Keppra TID, saying she had seizures because of brain tumor, should really euthanize, but at least medicate them. Dog had terrible response to Keppra— very bad GI signs, vomiting all the time. Vet insisted she stay on it, and also added phenoxybenzamine to control blood pressure, which was measured at 192 systolic at a stressful time. They stopped giving the Trilostane in early January, still no symptoms of Cushings.

Since that time, dog has had episodic dehydration, is too weak to rise, only eats a little if hand-fed, tremors all the time. Owners insisted on stopping the Keppra, no change. Took to ER for fluids, they said (based upon history of Cushings diagnosis) that her tremors were from brain tumor and they should put the dog down. Gave a steroid shot, which was followed up by 20 mg/SID pred from home vet. No improvement whatsoever, is getting worse on pred. Owner is desperate, seeing dog waste away in front of her eyes.

According to owner, there are no changes in mentation, normal withdrawal reflex in hind legs, no evidence of inflammation in spine, too weak to reposition body while lying down, can not rise or support body while standing. Pulse was rapid and superficial. Tongue medium pink.
The only treatment I could think of was Chai Hu Jia Long Gu Mu Li Tang, which is consistent with presentation and season of onset. Sent home on TID, and instructions to wean off the prednisone.

It feels like this is not a Cushings dog, but she is definitely sick now!! Waiting to see if there is a response from high dose CHJLGMLT.
by naturevet
February 2, 2024
Hi there

It sounds like there is a real mix of roots and branches here. We always have to start with the branches and meet the patient where they are at, so the question is what do you prioritize? I find the answer to two questions allows us to at least sketch the basic 'Tai Ji' symbol of a body, so we can at least not aggravate them further and instead given them something with attributes that should at least be supportive.

The questions are: Hot or Cold?; and Excess or Deficient? Certainly the dog seems deficient, so we will likely need a tonic. I'm going to guess you answer Cold because the lack of any definitive Heat signs, the shivering at night, and the fact that Cold Draining treatments like Keppra and Vetoryl have damaged the dog. Yet there was thirst, and there is currently a rapid superficial pulse. So Heat might be there. Or normal bodily Yang might just be trapped in the upper burner by a Cold pathogen invasion.

From a conventional point of view, it looks like there is an out of control pancreatitis. Does the dog have EPI?

Given it's poor condition, if it doesn't respond to CHJLGMLT, then tonification should be the next thing to try. I would probably try something like Li Zhong Wan (which you may have to make up on your own). It deals with these Cold pathogen invasions of the Shao Yin which can produce the cryptic Hot above, Cold below symptoms. The formula contains Ren Shen to rescue the Source Qi, Bai Zhu to tonify the Spleen, Gan Jiang to warm the Middle Burner and Gan Cao. The formula is an adaptogen, so if the excess cortisol output was somehow exhausting the dog (e.g,, from stress), then it should help to temper that. It should support the Spleen, which is the organ most in need of tonification. It should give the dog a power boost.

Maybe start assembling the ingredients for that if you can't find it pre-made. As well, consider getting the dog on a digestive enzyme for dogs with pancreatic insufficiency, in case it's pancreas is wiped out. Once you've pruned some branches (i.e, the supreme deficiency), it should become apparent what the root cause is. The root is probably responsible for the pancreatic decline and tremors.

Note that Internal wind's are not the only cause of tremors. The others include the sinews being dried out (calling for Blood tonics and herbs like Mu Gua); and uneven flow along the meridians to the tremoring area. Most famous would be Qi stagnation in a Shao Yang Addison's dog causing tremors.

Hopefully this helps you out! Too bad they called you in so late as it doesn't leave you a lot of wiggle room for experimentation. Hopefully there's still time to turn this ship around

by equinesportsmed
February 4, 2024
Thanks! I am still finding that the CC system doesn't notify me when you reply, so I missed this for several days. Wonder if there is some way to reset that?

Interestingly, the next morning after I saw the dog, she happily ate an entire pound of the raw food complete diet I sent home with her, and owner ordered more. Real food? Couple of doses of Chau Hu BBB? Owner has not reported back any further details of her condition, but I did mail her some CBD and some Vitamin D on the advice of a colleague on our holistic vet FB group. Sounds like a good call re pancreatitis... let's see how she did over the weekend!
by equinesportsmed
February 8, 2024
She continued to weaken and died yesterday, I believe. I had a conversation with owner on Monday, where I offered to make the Li Zhong Wan, but was clear to her that given her advanced state of debilitation, it was not possible to predict whether she had enough Qi left to respond. No idea whether euthanized or died naturally, but she told me the high dose CBD I sent her made her more comfortable. Sad, sad, sad.
by naturevet
February 8, 2024
Hi there, I'm sorry to hear the news, but not surprised. It's tough to be called in when decline is so advanced. There is very little wiggle room to figure these cases out, if they can be figured out at all. Hopefully the next case that crosses your path is one that isn't so far gone
Reply to this question.
You must be logged in to reply