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German Shepherd With Perianal Fistula, Bilat TPLOs, Soft Stool, Anxiety

by lrf9187 - January 30, 2025

Hi Steve,

Hope all is well!

Shiloh is a 9yr FS German Shepherd with bilateral perianal fistula diagnosed in October 2024. She has a history of bilateral anal sacculectomies (trying to find when/why in her history, but no luck so far), bilateral TPLOs for cruciate tears, and anxiety. She's had intermittent skin issues (paws and ears especially), with an MDR Staph skin infection in October after post-op antibiotics for the perianal fistula biopsy. She's also had bouts of soft stool lately, but has had many rounds of antibiotics between surgery, skin things, and diarrhea treated with Flagyl by rdvm. She was on Cytopoint until recently, and still receives Adequan injections every 2 weeks. She's on tacrolimus topically TID and currently on a tapering dose of pred for the second time (1st time we weaned off, she relapsed). Her rdvm is pushing heavily for Atopica but mom would rather avoid it.

Diet is currently raw & freeze-dried raw.
I have her on digestive enzymes, probiotics, CBD+CBG, B12 injection weekly. She's on pred 0.65mg/kg/day right now. RDVM put some kind of ear meds in her ears 2 days ago for ear infection.
Her tongue currently is red/purple.
Her pulse currently is soft, toneless, a bit wide.
A bit cool-seeking.
Not super anxious, but definitely nervous.
Fistula currently look great/totally controlled, and skin and ears look great.

I had her on CHJLGMLT from Nov to Dec. We discontinued steroids during that time and reduced tacrolimus to once daily. Then, she started to have regression of her fistula with the left side progressing slightly and oozing clear liquid.
At that time, pulse was more round/full with a bit more force and tone. Changed to SMS.

Over the next 3 weeks, her fistulae progressed and became significantly painful. RDVM put her back on pred, and a few days later she broke with vomiting and diarrhea. Took quite a few weeks to get her GI back on track, but that's finally controlled, and her fistulae are healed again. She remains on the lower dose of pred (0.65mg/kg/d).
Pulse no is again soft, toneless, wide. Tongue is red/purple.

I'm leaning towards going back to CHJLGMLT when mom gets back from a trip and continue to wean to lowest effective dose or pred/tacrolimus. Any other recommendations?

by naturevet

January 31, 2025

Hi there! It sounds like a challenging case you have there.

The pred is likely 'pruning some branches' to expose the root, which at least in part is likely a Wei Qi deficiency. That produces that flaccid baggy empty pulse you're seeing. The clear discharge is also indicative of Wei Qi deficiency, as well as a need for homeopathic Silicea. I'd try 30C strength once a day.

When the pred is withdrawn, the excess is revealed. Si Miao San was a good guess, but has an internalizing drying and cooling effect, which can make a Wind pathogen due to Wei Qi deficiency worse. So, the failure of it signals a need to disperse, which would steer me away from CHJLGMLT, which internalizes like SMS does.

A persistent localized lesion with a purplish tongue suggests Blood stasis. The response to pred and the red tongue suggests Heat. The response to SMS suggests a need to disperse and maybe expel Wind pathogens. Putting all that together, I would wonder about trying Xian Fang Huo Ming Yin, which addresses all three issues, and pairing it with Bu Zhong Yi Qi Tang. The latter boosts Wei Qi as well as gives Wind expellers a little extra oomph.

If the formula choices aren't quite right, the general thrust should be, so there should finally be some improvements, manifesting as reduced reliance on pred. The BZYQT as well will help address anxiety.

Let us know how it goes. It's the second fistula question today! Must be the season!

Steve

by lrf9187

March 6, 2025

Hi Steve,

She's been on XFHMY (NP 3/4tsp BID) for about 3 weeks (orally & topically) and BZYQT (NP 3/4tsp BID) for a little over 2 weeks. Also did the round of Silicea 30C (no noticeable change). She's 75lbs.
Two weeks ago we also lowered pred to 0.3mg/kg/day (from 0.6mg/kg/d).

There's no change in anxiety.
Still ravenous at night.
R perianal fistula is healed and looks great.
Left one is a little bigger than it was 3wks ago but not terrible.
No new ones.

T: purple, red tip, thick white phlegm
P: weak, thin, deep

Thoughts? Would you increase herb doses or change gears at all?

by naturevet

March 9, 2025

Hi there!

Probably the next thing I would try is a combination of Wu Mei Wan and XFHMY. Wu Mei Wan helps internalize Yang from the upper burner to reduce anxiety and thirst. Once internalized and engaged with Yin, it can mobilize the Blood more readily to heal the fistula. This combination covers the pulse and tongue findings as well, so it should help.

Hopefully that's the case!

Steve

by lrf9187

April 3, 2025

Had improvement but then some regression on XFHMY + BZYQT.
Just swapped BZYQT for WMW and added in ozone therapy and today her fistula that started to recur has healed- yay!
Tongue is a bit more red and a little swollen and pulse was about the same (weak, not much tone).

by lrf9187

April 10, 2025

Hey Steve,

2wks on XFHMY + WMW and the fistula on the left is starting to recur a bit again. It's a tiny purple divot at this point. She's still also on pred 0.25mg/kg/d (no change in dose in the past 3wks), topical tacrolimus with XFHMY added, and gut support. Still has a little soft stool intermittently. She's still very hungry.
Pulse is still soft and weak without much tone. Tongue is red/lavender and dry.

She has a new crusted erythematous inflammation of her lower lip fold. She's also very active from BL-18 to 20. Pulse disappeared when I sedated GB34 and got back to baseline or a little stronger when I tonified it.

I also found out she has a history of papillomas that were recurrent, so clearly wei qi is an issue. Would you add BZYQT back in? Any other recommendations? So frustrating!

by naturevet

April 14, 2025

Hi there,

Definitely BZYQT + XFHMY is one consideration. The tongue doesn't really fit, though. The tongue and the pulse together suggest Stasis Heat Damaging Yin. Si Miao San is one treatment for that. The other is Qing Ying Tang, which has the Blood moving reputation you need for persistent purple lesions.

Given all that, I would substitute Qing Ying Tang for Wu Mei Wan, and see if that gives you the improvements you're looking for. It also fits an aggravation at this time of year, which if not due to Wei Qi deficiency, can be due to Shao Yang disharmony, which QYT actually is a treatment for.

Let us know how things go. I am still optimistic!

Steve

by lrf9187

May 1, 2025

She had diarrhea on QYT once I got her to full dose (I only had the Jing Tang version, so I'm using 2 capsules twice daily). She's been on XFHMY continuously at 3/4 tsp twice daily (she's 70lbs). She didn't have diarrhea on 1 cap BID. But left fistula has persisted, and is maybe slightly larger. It did deepen a bit before I changed to QYT, so it's more open/pink, rather than the thin purple skin over it. She still has a really weak pulse with no tone, but it seems wider. Tongue is red, dry.

I feel like she may have had the best response to Wu Mei Wan + XFHMY may have given us the best results, but perhaps I just need to dose higher? I don't have a materia medica for WMW so I'm a bit lost on what its indications & TCVM principles are.

by naturevet

May 4, 2025

Do you do acupuncture. Testing the response of her pulse to BL 40 would be interesting. If you saw an improvement, then it would imply we need to focus on a Wind invasion strategy (which XFHMY is part of, but maybe she needs more tonification than XFHMY provides). Perhaps adding in Xue Fu Zhu Yu Tang would help. I use it a lot for perineal Blood stasis lesions. It has the same outward push as XFHMY and might help 'fill the pulse' more and give it the circulatory 'oomph' it needs to expel the pathogen.

S

by lrf9187

May 8, 2025

Hi Steve,
Yup! I do. I didn't get a response today to BL-40.
I did restart WMW last week given her regression, and upped the dose (1.25 teaspoons BID from 1tsp BID- she's 70lb). Also did rectal ozone. Whichever did it, the fistula is now responding. Tongue & Pulse are the same as last week, but fistula is much smaller. She's got a little redness between her toes today and increased stiffness (it's been raining for 1wk here), so I'm wondering if there's a Damp component too...

by naturevet

May 11, 2025

That is excellent news! It's great to have feedback from you on this case as they can be so frustrating. My guess is it is a combination of therapies that helps. Maybe improved circulation from the herbs is allowing ozone to penetrate the lesion?

Anyway, hopefully she doesn't acquire new problems, so you won't have to change tacks and can continue the current therapy until the fistula heals!

S

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