Bear with me....the case is complicated and I need help to sort it out!
12 yo FS Mini Schnauzer
always a grumpy reserved dog and difficult to work with at the vet. Not able to handle her much let alone palpate or do acupuncture. She is only able to be handled when she is feeling very sick. (Liver/Metal)
Problem list: PD>PU, UTI, Gall Bladder disease (possible mucocele developing), poor appetite in the morning, intermittent vomiting, hind end weaknes are the primary concerns now
- Seizures- Liver Blood deficiency, Damp accumulation – and Liver Yang rising? Seizures are controlled with current western epileptic drugs
- UI- Kidney Yang, Yin deficiency or Damp/Damp Heat (renal values normal). UI was happening almost always when she was sleeping or very relaxed during the day. If she was taken out on schedule to pee during the day, generally no dribbling at all. She can hold urine all night.
USG is 1.010. Heart and Kidney disconnect given Incurin response now makes sense.
She has a UTI now that is resistant to several abx including amoxi/clav. UPC is 2.6. In January she had a UTI as well but appeared to respond to 7 days of amoxi.
o Also of importance, I think…Incurin (estriol) has resolved the UI. She is not leaking anymore but due to the UTI and other problems going on with her right now, she is guzzling water and has to go out frequently including during the night to urinate.
- Hypothyroid-
found on bloodwork when she came in for UI. Did not come in with overt signs of hypothyroidism but we elected to treat in the event low thyroid function could be affecting other things.
- Proteinuria –
mild. UPC was 1.0 when she didn’t have overt UTI and now it is 2.6 with a UTI.
- KCS- Yin or Blood deficiency?
Was diagnosed at ophtho after treating her for hyphema/uveitis summer of 2023. Her symptoms were mild mucoid discharge and faint corneal pigmentation. No hyperemia.
- Hx of episodic UTI- Heat/Damp, possibly Yin deficiency?
o Clinical signs are consistently PU/PD and one time hematuria (in January 2024). Responded to amoxi. Right now, it is PU/PD. Drinking so much water she is vomiting it up. Labwork done last week shows ALT 316, ALP 663, GGT 23, Cholesterol 440, Triglycerides 567, Amylase 1141, cPL normal, T4 normal, CBC normal. Diagnostic ultrasound shows a GB that is filled with sludge and trending toward a mucocele.
o I do think there is a connection to the small intestine. She had an episode of gastritis in January and 2 weeks later had a UTI. Then, she had a bad episode of pancreatitis and a few weeks later another UTI.
- Hx of uveitis/hyphema from proin induced hypertension- isolated event- Yang rising? Stasis leading to Heat trapped in upper burner?
o Clinical signs were sudden onset of hyphema in the left eye. A full work up was done and it was determined that the most likely explanation was a hypertensive side effect from proin (started this 6 days prior to onset of proin).
o Her BCS is 4/9, a little on the thin side. Not muscle wasted but I do think she looks a little thinly muscled as well
- Bradyarrhythmia- Yang deficiency
- Hind end weakness/pain- Kidney Qi deficiency, Blood deficiency.
o Owner describes weakness in the hind end. She is not a dog I can put through ortho exams to determine how much pain is related to the weakness.
- Hx of pancreatitis- isolated event- heat from middle burner obstruction?
- Hx of lyme positive (treated and cleared)- pathogen invasion, heat .
o This was back in 2019. No signs of lyme disease itself. She came in for wellness and noted that she has her first seizure shortly before.
- Hx of dermatitis- hasn’t had issue in awhile- Damp and Blood deficiency.
Medications: current
zonisamide 100mg PO BID
phenobarbital 16.2mg PO BID
denamarin advanced PO SID
glycoflex PO EOD
cyclosporine 0.2% eye drops –
gabapentin for vet previsit
levothyroxine
benazepril
incurin
Diet: Purina Pro Plan kibble salmon and rice; smoked duck tricky treats. She is now eating Z/D low fat dry food. This is hydrolyzed diet. It might be possible to change her to fresh food.
Herbs:
Di Tan Tang and Tian Ma Plus II initially for seizures- she did well and the seizures were infrequent for about a year or so before increasing in frequency.
Liver Happy was given around vaccinations and seemed to help as did Pepcid and anti-nausea caused by vaccines.
Rehmannia 8 and Xue Fu Zhu Yu started in Nov 2023. Greatly improved her urge incontinence and improved her PU/PD. She was not having accidents in the house any longer. Continued to have some dribbling of urine though
TCVM:
Tongue: PALE, normal size to full and flaccid, sometimes dry, sometimes moist Liver Blood Deficiency possibly because of the pale Tongue, but Spleen Qi Deficiency more likely?.
- I have repeatedly recorded for years that her tongue is pale. I asked the owner to check at home for me the other day and she said it looked pale to her (I trust her opinion). The sometimes dry, sometimes moist is all in the past few weeks and she has so many things going on that I can’t tie the dry or moist to specific signs.
Pulse: deep, SLOW, sinus arrhythmia, compressible, not super narrow, not really wiry; felt like balloon hitting my finger; possibly slippery?
TCVM diagnosis: best partially educated guesses!
Overall deficient dog (Liver Blood, Spleen Qi, Kidney Yang/Yin) with Excess Heat and Damp
TBO? Heart/Kidney disconnect?
Damp -Spleen Qi deficiency – Why?
Pale, full tongue – Qi, Blood, or Yang deficiency
What is the effect of the seizure medications? I assume they are cold and could be trapping Yang in the lower burner? Or leading to Yang deficiency?
Effect of the Incurin (estrogen) is adding to the Yin.
This dog has such mixed signs, I don’t know how to sort it all out. The persistent pale tongue with low HR leads me to blood and yang deficiency.
- She is still taking Rehmannia 8 and Xue Fu zhu yu. While this did help some with UI…my thinking was there was obstruction of the middle burner and Kidney Qi/yang deficiency…she still required Incurin to resolve the UI. Now her clinical presentation is severe PU/PD and mounting evidence of TBO so I think the herbal prescription should change.
Treatment options:
It seems to me there is significant obstruction here but it is not reflected in the pulse and the tongue seems to show deficiency. I want to make sure I don't do any harm first and foremost.
switch herbs to Xiao Chai Hu Tang? Ge Xia Zhu Yu Tang?
Timeline and description of problems:
12/2019: seizures started. Always preceded by GI signs vomiting, drooling, hyperactivity
- At that time her tongue was pale, wet and white coating but she also had seborrheic dermatitis, pruritus and was lyme positive
- Vaccinated for lyme after course of doxy. Vax make her nauseated and grumpy
2/2020: Started Di Tan Tang and used Liver Happy around vaccinations
- Another seizure in April 2020 and then not again until Nov 30, 2020
12/2020: Started Tian Ma Plus II due to Blood deficiency signs and did not have another seizure for nearly a year
1/2022: UTI
1/2022: Seizure frequency increasing and has 2 seizures end of jan 2022.
- started zonisamide
- also diazepam which made her crazy hyperactive
2/2022: UTI again with GI upset using abx for UTI
2/2022: Corneal ulcer
5/2022: Focal pyoderma on ventral chest
12/2022: severe dental disease and acting painful with hyporexia. Admitted for dental and took chest rads due to crackles and found metallic FB in stomach. Had gastrotomy and removed sharp edged foreign metallic piece. Oral extractions and prophy completed.
1/2023: Seizures, cluster and facial twitching
- increased dose of zonisamide
- She had PU/PD following dose increase (UTI ruled out)
- Phenobarbital added
- Urinary leaking began at this time as well.
1/2023: Pruritus and seborrhea along with hind end weakness (first time noted)
- Responded well to Galliprant for hind end weakness and pain (previously had diarrhea with rimadyl) and topical for skin
- Mild elevations in LE since adding on phenobarbital
6/2023: Treated with proin for UI
- Had hypertensive event and hyphemia in left eye and was very weak in hind end
- Proin was not helpful for UI
- Hyphema was worked up thoroughly with no underlying cause found. Suspected the proin caused hypertension and led to hyphema. Responded well to extended tx with pred acetate and atropine eye drops.
- UI continued.
9/2023: KCS diagnosed
- cyclosporine 2% led to ocular pain and was more comfortable with 0.2% optimmune
11/2023: visit for continued UI
- UI characterized as urge and overflow. Drinks a lot during the day and bladder fills up every 4 hours. Can hold overnight. Leaks if not taken out every 4 hours and occasionally when sleeping/relaxed. Occasionally she has lots of puddles of urine during the day despite having gone out 3 hours earlier. urine is not stinky, and not uncomfortable
Drinks a fair amount of water- hasn't changed in volume since the urine issue started (about 6-8months, started sometime in spring/May)
- Hind end weakness and pain
- No seizures since starting phenobarbital nearly a year ago
- bradyarrhythmia
- Hypothyroid, proteinuric, mild liver enzyme elevations
- No C/S/V/D. Appetite is great. General attitude is good. She is playful at night and generally cranky.
Temperature sensitivities: sensitive to cold, tends to get cold easily; never gets under blankets
Sleeping great at night
- Started on benazepril and levothyroxine
- Started xue fu zhu yu and rehmannia 8
1/2024: follow up
- Marked improvement with UI- no more accidents, slight leaking. Last few days wetting her bed. Thirst the same- drinks a lot during the day
- UA had no evidence of UTI
- A few days later, urinating blood and E.coli UTI identified
- Once that cleared up, still leaking urine and licking vulva
- Elected to start Incurin
3/2024: responded well to incurin with no more UI and no apparent side effects
3/2024: diarrhea after starting a new bag of kibble, developed into severe pancreatitis and was treated with IV fluids and new drug Panoquell.
4/2024: UTI diagnosed again- resistant bacterial infection, moderate inspissated bile with mucus concretions in the gall bladder, coarse mottled hepatomegaly. Chronic hepatitis is given highest consideration, vacuolar hepatopathy is possible. Clinical signs are currently PU/PD, urinary accidents, poor appetite in the morning, some vomiting, weak hind end.