Wednesday, March 25, 2009

Haley is Weak and Wobbly

Wednesdays are usually pretty slow around here. We close early and don't usually schedule elective surgeries, sticking to well pet vaccine appointments, or seeing dogs with itchy ears, cats who got in fights-pretty routine stuff. But it never fails that a patient will come along with pretty vague symptoms but is obviously very sick-just like Haley did today. Haley is a 5 year old, very sweet and ordinarily energetic terrier that had been vomiting last week. She seemingly got better, but is now terribly weak in her hind end, can hardly walk, and is trembling all over. She seems cold, dehydrated and her owner may have seen blood in some vomit yesterday. Yuck. Remember our abbreviation lesson? Haley is ADR-ain't doin' right- for sure!

We started with a physical exam and taking her history. Haley wasn't usually the type of dog to eat things she shouldn't-no rocks or parts of toys or sticks and she hadn't gotten into the garbage as far as her owner knew. Besides, her "partner in crime," Henry, wasn't showing any signs of a problem. There were no medications or toxins out for her to get into, and no one had put out rat or slug bait or changed antifreeze lately. There was no diet change and she didn't get any new kind of treat. Her body temperature was indeed a little low, and instead of eliciting pain or just tension as I do on most dogs, her abdomen was completely flaccid. She was indeed limp in the hind end and her eyes seemed to be sunken into her head. She had a big glob of greenish material in her eyes and her gums were cold, dry and tacky. I thought she was dehydrated, but there had to be more to the story. I thought it would be a good idea to get a blood sample and run a profile to see what was going on in her body.

Getting a blood sample was easier said than done. Haley's veins were practically non-existent! At least her peripheral veins, the ones on her legs, were very difficult to find. We settled for drawing a sample from the larger jugular vein in her neck, and even that wasn't easy. Her cold body temperature and whatever was happening to her body seemed to be shunting her blood away from her periphery and likely to the more vital organs-her heart, brain and such. I sure was glad her owner got her in when she did!

We were able to run a panel on Haley's blood in-house in less than an hour while her owner waited. Her electrolytes were totally out of balance, with a dangerously elevated potassium level and very low sodium. Also significant was the very high phosphorus level and elevated creatinine kinase, the muscle enzyme. These blood results were helping me to understand better what was going on in Haley's body-and more importantly, what we needed to address to help her out. When electrolytes become as out of balance as hers were, it can be due to disorders of the endocrine system-and in this case I strongly suspected hypoadrenocorticism or Addison's Disease.

Addison's Disease occurs when the small adrenal gland stops producing enough of the steroid hormones we all need to help combat stress in our lives-gearing up for the fight or flight response when we face something scary or exciting. Corticosteroids come from the cortex or outer layer of the adrenal gland while mineralocorticoids come from the inner medulla area. The glucocorticoids (including cortisol, prednisone, dexamethasone and others) act on the mechanics of sugar, fat, and protein metabolism. They gear the metabolism towards the preparation of burning - rather than storing - fuels so as to be ready for a fight or flight situation.

The mineralocorticoids (such as aldosterone) influence the electrolytes called sodium and potassium. As a general biological rule, where there's sodium or salt, there's water. When the mineralocorticoids circulate as part of the fight or flight preparation, sodium is conserved in anticipation of blood loss so that there will be extra fluid in the vascular compartment (spare blood). When sodium is conserved, potassium is lost as part of the biological balance. This whole picture of fat mobilization, sodium conservation etc. that is part of the fight or flight preparation is far more complex than can be reviewed here but basically:

Corticosteroid hormones are needed to adapt to stressful situations and without these hormones, even small stresses could lead to physiologic disaster, as I fear is happening to Haley.

We often see these Addisonian dogs at fairly young ages, 4 - 5 years old. Females are more likely to have it, and Standard Poodles and Bearded Collies have breed predilections, but of course, any age, breed, sex dog can be affected. Cats can develop Addison's, but it is extremely rare. It is most likely to come to the diagnosis because of a "crisis" situation-a very sick or shocky dog as Haley is presenting. Older treatments for shock, fluids and steroids, just happened to be the remedy for Addisonian crises, too. Since it wasn't likely to hurt and could be very beneficial, we also gave Haley medications to reduce that dangerous level of potassium. We are also giving her medications to protect her stomach as her owner saw blood in her vomit yesterday. This should hold her steady until we get her resting cortisol level and determine if further testing is needed. We can then start her on a definitive treatment for Addisonian dogs-probably DOCP or Percorten, given once every 25 days or so. She will still need some supplemental corticosteroids, prednisone or dexamethasone, when she is undergoing stressful situations, and it will be essential to monitor her electrolytes carefully as fluctuations can cause the weakness and anorexia Haley showed today.

Haley is fortunate because she has an owner who really knew her normal behaviors and what to watch for-when she wasn't herself, she brought her in for an exam. Others have progressed to full blown seizures and worse before getting diagnosed and getting the help they needed. With all these things that can go wrong in our bodies, isn't it amazing how often they all work so well?




Tuesday, March 24, 2009

Run Quik, Run!

Many people who know about dogs, especially the larger breeds, know that they can be prone to joint problems, particularly hip dysplasia. Just what is dysplasia and how does it affect our 4-legged friends? Dysplasia actually refers to the abnormal growth or development of the part of the body affected. My poor dog, Verbal, has both hip and elbow dysplasia. In hips, there would be a bad "fit" of the ball and socket joint-the femoral head and acetabulum. Normal hips have smooth rotation of the femoral head in the acetabulum due to this proper fit along with the cartilage covering and lubricating fluid in the joint.

When an animal (yes, there are some breeds of cats who also get this) has hip dysplasia, the ball and socket do not fit well. The acetabulum is flattened and the femoral head is not held tightly in place, causing slippage and subsequent friction. This makes for an unstable joint and the body’s attempts to stabilize the joint only end up causing changes in the bones of the joint-this is arthritis, and can occur even in very young dogs. Verbal was noticeably "rabbit hopping" in her hind legs due to discomfort when she was only 6 weeks old! That rabbit hopping gait when a dog is running or going up stairs can often lead us to a diagnosis of hip dysplasia, but not always.

We know that some pets may show their discomfort due to hip dysplasia at a very young age as Verbal did, or may not have pain until severe arthritis changes occur in the joint as they age. Radiographs of the joint show us the changes that occur, but the degree of those changes don't necessarily correlate with the severity of lameness. Some very badly lame dogs may only have minor changes on the x-rays and some dogs with terrible x-rays may never show pain. It is true that lighter weight dogs do better than overweight or even normal weight dogs, and some dogs are just more stoic than others.

Genetics are a major cause of hip dysplasia, so ethical breeders always screen their breeding animals BEFORE they use them in their breeding programs. The OFA or Orthopedic Foundation for Animals has a huge data base of many heritable diseases of animals, and hips are a big part of this. Preliminary testing can be done at any age, but "official" OFA radiographs are taken and submitted for evaluation at 2 years of age. These must be done under sedation or anesthesia to ensure accurate positioning (and in affected cases, pain free positioning.) That is why our handsome patient, Quik, came to see us this morning. He is still too young for the official testing, but his owner found out Quik has a half sister affected by hip dysplasia. It is just smart to do all she can find out early if Quik might be affected as well-before too much degenerative joint disease occurs as a result. Some treatments can be done on younger animals that wouldn't be effective on older ones.

Quik is a bit shy but his owner has worked with him a lot. He is a very good boy, and did well for his exam and sedation. We positioned him for his hip radiographs by laying him on the table and extending his hind legs back and flat, parallel to the table-definitely not a position an awake dog would want to make willingly! You'll notice the hips are symmetrical and the patellas are on top of the femurs-good landmarks to tell us we have decent positioning for the radiologist to evaluate the joint conformation. Quik isn't showing any signs of pain or discomfort and when I palpated the joint there was no problem with the motion in either hip. This is truly a screening procedure today. We also took radiographs of his elbows while we were at it and the radiologist should get us his opinion in a day or so.

I mentioned there are "treatments" available for hip dysplasia if we diagnose this condition. So far, Quik's hips look really good. In fact, his owner said he lifted his leg to pee just like the big boy he is for the first time this morning! Oh, the things we celebrate around here :) Young dogs with severe problems of conformation, such as when the ball is luxated or not in the hip socket can be treated surgically with a TPO or FHO-triple pelvic osteotomy and femoral head ostectomy. The TPO is a procedure where the pelvis itself is broken and re-plated in three places to re-position the socket over the femoral head. The FHO is considered a salvage procedure but I really like it and is what we did for Verbal. She actually didn't have a socket but more of a "plate"-that joint was really deformed-so re-positioning it wasn't an option. Instead, we removed the femoral head completely and therefore there was no longer any bone to bone contact-and no more pain. Her gait was fine after that, relying on the strong thigh muscles to support her limb-that is until she blew out her ACL in that same leg some years later! Very young dogs also may benefit from a juvenile pubic symphysiodesis, a procedure where the pubic symphysis (the cartilage seen connecting the right side of the pelvis to the left side) is fused early to allow for more normal alignment in puppies that may be predisposed to hip dysplasia.

Options for older dogs include total hip replacement surgery, where prosthetic joints are implanted, DAR arthroplasty where bone grafts actually build up the rim of the acetabulum to make a deeper socket for the femoral head to sit in. FHO's are still good options for older dog's, too.

Nutrition is a factor in "treating" as well as controlling degradation of the hip joint. Certainly we can't allow an affected dog to become too fat. Those large breed puppies who grow too fast or who have their bones and tendons grow at different rates put unnatural stresses on the bones, often causing dysplasia or other developmental problems to occur. One study showed that when puppies of hip dysplasia prone breeds were allowed to free feed, two thirds went on to develop hip dysplasia while only one third developed hip dysplasia when the same diet was fed in meals. Another study showed German Shepherds were nearly twice as likely to develop hip dysplasia if their adult weights were above average. Studies such as these have led to the development of puppy foods designed for large breed puppies, where the optimal nutritional plane is lower than for small breed puppies. It is just common sense that feeding a Great Dane is different than feeding a Chihuahua! There are nutritional supplements to help repair cartilage, pain medications, and anti-inflammatory medications. Physical therapy and massage are also important and helpful in non-surgical joint therapy. Many people have utilized acupuncture and other alternative therapies for their pets.

While I tease Verbal about being my "genetic disaster," it is actually true, and a heartbreaking thing to have happened to her. We can only hope that all people who breed dogs will be as responsible as Quik's owner is, screening for this devastating, painful disease and weeding out the affected ones from the gene pool. That way our dogs can run and play through out their lives, happy and pain-free-run Quik, run!


Thursday, March 19, 2009

Happy Birthday to Me-Almost!

I walked into the hospital this morning to be greeted by streamers and lime green (my favorite color) balloons, banners, even a pinata. My Birthday is in a few days, and my wonderful staff is spoiling me rotten today-aren't I lucky? They out do themselves every year-all the lions and giraffes and zebras are terrific-very festive and just right for the veterinary hospital. I love that they are all working together for me, as they always do.

Winston came in this morning and sure didn't seem too worried about all the decorations. He was wiggling and bouncing, much happier than his owner saw him acting yesterday when she was so concerned for him. He had been lethargic, not eating, feverish, vomiting-a pretty sick Rat Terrier. Those little guys are always busy, happy things-so this was very worrisome. We asked some questions of his owner and found out that right before he got sick, she fed him some raw chicken-very likely the culprit.

Even though Winston has been getting raw meat about once a week throughout his life, it only takes one time like this for an owner to really understand the potential dangers of feeding raw diets. Many breeders will hail the benefits, always coming back to "wild" animals and their raw diets being so beneficial to them-better hair coats, maintaining weight, better immunity-the list goes on and on. If there is an ailment, raw diets have been reported to be the cure-all. But we know that like any food, balance is the key. Raw diets may have their place, but often are fed by people who don't understand the concept or don't take the proper precautions-and the pets pay the price.

The fact is, dogs aren't closely related to wild animals at all. They have been domesticated for some 50,000 years! Their digestive systems have evolved beyond that of a coyote or wolf, so comparing them really isn't accurate. While it is possible to feed raw diets in a healthy manner, it is expensive and very time consuming to do so. Consulting with a veterinary nutritionist is essential to determine your individual pet's requirements-it isn't enough to throw some meat and veggies and rice in a blender and call it good.

There are some very real risks to feeding raw diets-and I have seen and treated all of these, including Winston's likely case of gastritis/enteritis. Perforation of any part of the GI system from the bones fed in raw diets is immediately dangerous. I have also seen impactions of bone material when it has been properly chewed up but accumulates in a tubular organ. Broken teeth from the very hard bones is also a risk, no matter how beneficial they may be at cleaning the teeth. These problems may be minimized if the bone is ground up in a blender before feeding.

Nutritional inadequacy is very common, as I mentioned. Osteodystrophy and rickets can occur when diets aren't balanced. There is at least one raw diet that has undergone AAFCO feeding trials, Nature's Variety Instinct, so this can just be purchased and fed as a complete raw diet. If people are set on preparing their own food, consulting with nutritionists at veterinary teaching hospitals or through websites like: and who offer information about raw and home made diets.

The other main concern about raw diets is the contamination with pathogens. This shouldn't be a huge problem in otherwise healthy dogs or cats, but can be an issue in very young, very old or immunosuppressed animals-and people. Don't forget the risk to the humans preparing the food. A relatively unscientific survey by Consumer Reports of grocery chicken showed 80% contamination with Campylobacter, and about 15% with Salmonella - organic and free range were worse in this survey. E. coli is ever-present as well. We have many researched journal articles that support this concern too. So, just the public health issue is enough to make this way of feeding undesirable-simply cooking the ingredients eliminates the pathogens.

You would think that the treatment for exposure to bacteria would be antibiotics, but not in Winston's case. He was actually suffering from a condition caused from the death of those bacteria and the subsequent release of the toxins they produce upon dying. This is called endotoxemia or endotoxic shock in severe cases. Killing off more bacteria could result in worsening of the condition. We instead treat with lots of fluids and some medicine that is anti-endotoxin if needed. Since he really was improving over just last night, we decided to treat him as an out patient and have his owner monitor him at home. We loaded him up with some subcutaneous fluids (SQ fluids)-allowing them to absorb through the small blood vessels called capillaries in the fatty tissues under the skin. His owner will likely forgo the raw meats in the future and instead will likely cook any extra meats she offers him-just to be safe.

It is true that many toxicities have occured from traditional commercial diets due to contamination and dangerous additives-so they aren't guaranteed for safety. Still, they are less risky over all and generally the better choice for busy people who just want the best for their pets.

More surprises awaited me at lunch time-my crazy, wonderful staff decorated the treatment area with more jungle attire and laid out a huge meal for all to share. They gave me a sweet jungle animal card with some VERY generous gift certificates-I have told them over and over to not spend their hard earned money on me, but they have huge hearts-as you would know if you have ever had them care for you or your pet. One of the certificates was perfect for the day's theme-admission to the zoo! We even had jungle themed games-pin the tail on the lion, limbo and others-all with great prizes, too. Verbal, my goofy yellow dog, was right in the middle of all the food and fun-we had to stop her quickly when the pinata was broken-all that candy all over the floor was very tempting. I bet Twitchi and Noodles, our hospital cats, will be finding wrapped candies for quite awhile!

So, I get to celebrate my birthday for several days in a row instead of just a single one like "normal" people do. I guess I wouldn't like that if I was really bothered about my age, but what's a few more gray hairs compared to all this fun and support from good friends and co-workers? Happy Birthday to me-almost!


Tuesday, March 17, 2009

Yes, Roscoe, Miracles Do Happen

An appointment about a month ago looked simple enough on the calendar-check cough. I was presented with Roscoe, a bouncy, happy 2 1/2 year old Boxer, full of life and very much loved by his human family. And yes, he was coughing-a harsh, dry cough, almost a honking sound that came from deep within his chest. He looked exhausted-as did his humans. No one could sleep with all that coughing going on. Now, "kennel cough" certainly can present this way, as can a myriad of other conditions and diseases. Simple rest and cough suppressants usually do the trick. But Roscoe was a sick dog-he was losing weight and this cough had been going on for some time and it was only worsening. I thought it would be best to take some radiographs of his chest to be sure we weren't dealing with one of the more serious conditions right off-and his owners agreed.

No one expected what we found. He was only 2 1/2 years old after all! Roscoe had masses throughout his lung fields-and one giant one on the right side of his chest. Because of his breed (Boxers, unfortunately, have a very high incidence) and the sudden onset-and now this terrible finding in his lungs, lung cancer had to be high on our list of differentials, or rule-outs, as the cause of Roscoe's cough. Understandably, his owners were just devastated when they saw the films and the news sunk in. Remember how I wrote about "It Is A Whole Family's Diagnosis?" This was certainly the case for Roscoe. He had some young children in the family, too, who just wouldn't understand this horrible news. We set about making a plan for confirming what we suspected and getting him any help we could.

First, we decided to do some blood work-it looked really good. That could mean there was a lower chance that this aggressive looking disease had metastasized or spread to other organs of his body-although blood work is not definitive in this regard. Next, we attempted to take a fine needle aspirate or sample of the cells of that large mass in the right lung field. We took several samples-and got several different cell types back! It was frustrating. The pathologist couldn't commit to a single disease, saying that the different cells were indicative of several conditions. Finally, we decided to send Roscoe to the veterinary oncology specialists and have them evaluate him.

The oncologists were quite pessimistic as well. They took some follow up chest x-rays and the mass in his chest had actually doubled from the time when I had seen him-in just a week! They suspected primary lung cancer and as ill as he was during his visit to them, didn't expect him to live longer than 1 to 2 weeks. Roscoe's owners were distraught. They asked if there was any chance this could be something else-he was such a young dog! The oncologists explained that Boxers were a "special" breed when it came to cancer, and we can actually see it in any breed, but in a 2 1/2 year old Boxer it wasn't as surprising. Tragic, yes. But they did say that there was another disease that, although very rare, could manifest in a similar way as Roscoe's disease had. This condition is called pulmonary infiltrates with eosinophilia-or PIE for short.

I had never heard of this kind of PIE, so did what research I could. There wasn't much out there, but we did find that if Roscoe had this condition, he would respond very quickly and very dramatically to a simple drug called prednisone. No need for the more advanced (and costly) chemotherapeutic medications, just this antiinflammatory drug. We had absolutely nothing to lose, so Roscoe was started on the pred. Well, you guessed it-he got better! His owners were hesitant to get their hopes up after such a dismal prognosis from both me, their primary care giver, and from the specialists. We called them a few times over the week and each time they reported decreased coughing, better energy, more sleeping through the night-everything he needed to be doing.

Just to be sure, we had Roscoe in this week for some follow up radiographs of his chest. We figured they couldn't "lie" to us. We could see if those masses were decreasing in size or if it was just false hope as his owners feared. Look at that picture! The big mass is almost gone! I couldn't find all those little ones at all. It really was a miracle! I rushed to show the films to Roscoe's owner in the exam room-she was so excited she had tears of joy and gave me a big hug. Oh, it felt so good, especially after the terrible time that family went through.

Roscoe was one of the fortunate ones, for sure. He'll have to be on the medication for quite a while, but that's OK. He seems to be handling it fine-the alternative is unthinkable. We can't expect things like this to happen all the time-that's what makes miracles, well, miraculous! I am very thankful for this one case turning out as it has, and will do my best to pursue all options for my patients, even when the eveidence seems seems overwhelmingly bad. Miracles do happen.


Friday, March 13, 2009

It's A Whole Family's Diagnosis

I was talking (or rather e-mailing) to a friend the other day about the stresses each of us face day to day in our respective jobs. We are fortunate, of course, because we actually do have jobs, and actually like what we do. Not everyone can say that, for sure.

We were having this "discussion" on the day after Tasha, a beautiful, sweet Golden Retriever had been in to see me. She had some ominous swellings under her throat, in front of her shoulders, in her axilla (arm pits) and inguinal region (groin.) These are all areas you will find a dog's lymph nodes, and even though enlargement can occur because of infections, I felt this wasn't the case for Tasha. We took aspirates of those swellings, put the material on slides and submitted them to the lab for a diagnosis. Sometimes needle aspirates are non-diagnostic or only suggestive of certain conditions or diseases. This wasn't the case for Tasha-the diagnosis was definitive-she had lymphoma.

Lymphoma is a cancer of the lymphatic system, the nodes and vessels in our bodies through which foreign material or organisms get "filtered" or dealt with by the cells of the immune system. There are actually a number of different ways this can occur. Some cells produce antibodies, others phagocytose or literally "eat" the foreign material or organisms. Some "turn on" other cells, regulating their activity to help destroy those invaders.

Lymphocytes are the main cells of the lymphatic system and they act in all of those ways mentioned. The lymph vessels serve as a circulatory path for lymphocytes as well as being a collection system directing foreign substances toward the lymph nodes where the processes occur. Lymph vessels connect with the blood stream at several points allowing lymphocytes access to virtually the entire body.

Many people who "always wanted to be a veterinarian" mention their love of animals, their goodness, how wonderful it must be to work with them, etc. But most forget the very real "human factor" of veterinary medicine. Who is actually bringing that pet in to the veterinarian to begin with? Who is responsible for describing the illness or symptoms-certainly a good physical exam reveals a lot, but really knowing a pet's personality and how his or her behavior is changed is essential to coming to a complete diagnosis. And of course, who will be administering any needed medications? Loving animals isn't enough to work in the veterinary field, really in any capacity. Humans are a pretty important component.

The human-animal bond is a wonderful thing-we see examples of it every day. An older man with his cat-talking with him I found out she was actually his recently deceased wife's cat, and this kitty is his link to her. A bouncy, happy Cocker Spaniel puppy-in a household full of kids because of a daycare situation. A Border Collie who's job it is to alert her owners to oncoming seizures so she can get herself into a safe place/position. You remember Mikey and his owner-she is working very hard to afford his treatment for cancer. The list goes on and on...and on! It is awesome to see the varied ways the bond is manifested-we love humans who love animals!

So it goes that when I make a terrible diagnosis like lymphoma, it really isn't just Tasha that gets that diagnosis. It is the entire family's diagnosis. Of course they all were devestated. I found a couple of booklets that I hope will help Tasha's children in the family hear the news of her cancer and how to cope with her impending death. The books might allow them to put together mementos, photos, poems or other writings about her. I gave her adult humans information on lymphoma itself, how it could be treated, referral options to veterinary oncologists, chemotherapy, the works. The whole family will have to be involved in the decisions that will have to be made, what kind of treatments to select, how much money can they afford to spend, when is it time to say "enough" and just how will we go about saying that final goodbye? Will each person want to be with her at the end or prefer to say goodbye and remember her that way? Should we arrange a home visit for the euthanasia when the time comes, or will that leave unpleasant memories associated with the home? Everyone is different in how they feel about those things. We gave Tasha's family a brochure about "how to know when it is time"-a question everyone struggles with. This is so very hard!

I am lucky to have this blog to write about the emotions that sure do seem to be overwhelming at times. And friends and family as I mentioned who "get it." They know I'm not the kind of person who can work 9 - 5 and turn off my emotions when I step out of the hospital. I'll be thinking about, researching for, worrying about and praying for those pets and families who love them long after the designated appointment time. But I try not to dwell on my cases-I have a lot of "extra-curricular" activities, and my own critters certainly help! My entire family comes together for me-just like Tasha's will for her.



Thursday, March 12, 2009

Take A Deep Breath

Well, the radiologist's consultation of Stella's chest x-ray's came back yesterday-diffuse bronchial thickening consistent with feline asthma. Other less likely rule-outs are bacterial bronchitis and aelurostrongylosis (lung worms.) Whew. No mention of cancer. Since her blood work didn't really show evidence of infection, and because she is an indoor cat with very little risk of exposure for lung worms, I am going to start treating her for asthma first and see how she does. It only figures that this cat, who disappears under the bed, far, far from reach the second you just think about medicating her, will be the one who needs life long maintenance medications. Oh joy. I certainly feel the pain of all my clients who swear up and down they just can't medicate their pets-Stella does not make it easy. I can only imagine the U-Tube video of me crawling under the bed, (always when I'm late for work!) grabbing her tail and dragging her out hissing and spitting at me. Thank goodness the actual pilling act isn't hard-I've had plenty of practice medicating cats!

Thank you, everyone, who expressed your concern for Stella and for me. I appreciated the kind comments, Nicki, and the moral support-you do understand what it is like to be "mom" and doctor at the same time.

So, just what does this diagnosis of feline asthma mean for Stella...and for me? The problems start because of changes in her lungs. The airways actually constrict because of the formation of mucus, the inflammation of the airway and subsequent ulceration, and finally actual spasms of the airway muscles. When the airways are constricted, the cat can not take a deep breath, won't be able to exercise or play for long periods, will have coughing episodes, (as Stella does)and they may wheeze when they breathe. So far we have been lucky in that Stella has just had the low-grade, chronic cough as her only symptom, but an acute or sudden asthmatic crisis can occur at any time and could actually be life threatening as I have seen in other patients. There may be no obvious reason for the crisis, or it may be triggered by allergies or stressful events.

It is likely that the airways of affected cats are diseased all the time and actually flare up and worsen during the crisis episodes. This is very similar to what occurs with human asthmatics. That is why treatment is likely needed all the time, not just during those respiratory emergencies. Our goal, of course, is to try and prevent those emergencies. So, darn it, Stella will need long term medication. Looks like I'll be crawling under the bed with her quite frequently.

Since the primary cause of the airway constriction in asthmatic cats is inflammation, it makes sense that treatment revolves around anti-inflammatory medications. Corticosteroids are the gold standard for reducing inflammation and can be administered orally, by injection and even by inhaler. Don't laugh! Cats can and do receive inhalant medications for asthma just like humans do, although specially fitted masks need to be used. Other medications that can be helpful are airway dilators such as terbutaline. Because allergies often trigger severe asthma symptoms, antihistamines can be helpful for many asthmatic cats. Cyclosporine is an immunomodulator that is relatively new in its use for asthma cats. It is particularly useful for those cats who can not tolerate corticosteroids because of their side effects, concurrent diabetic cats, cats with calcium oxalate bladder stone histories, etc. It can be expensive, but cats are small so dosing shouldn't be prohibitive.

Environmental control is imprtant in these asthmatic cats. Remember we talked about second hand smoke causing respiratory problems in pets? Never smoke around an asthmatic cat. Try to use dust-free cat litter, and regularly replace air filters in your home. I have seen some cats who develop sensitivities to laundry detergents or fabric softeners, perfumes, even carpet cleaners, so evaluate your home for sources of possible irritants to your cats respiratory tract. Remember, they are much closer to the ground and very, very sensitive to environmental changes.

If Stella becomes too wiley or difficult to medicate every day, I may have to resort to an injection of a long-lasting corticosteroid to control the inflammation in her airways. It isn't without its risks, however, but could be a good alternative to fighting with her every darned time she needs a pill. Stress can trigger those crisis episodes-definitely something we want to avoid!

So, feline asthma is a crummy diagnosis because it is a disease that is rarely "cured." We can only hope to manage it and avoid the terrible respiratory emergencies, gasping for breath, tongue turning blue episodes that can be life threatening. Leave it to a vet's cat to come down with it-thanks a lot, Stella. Actually, I am quite relieved her cough wasn't anything more serious, and am hoping her new medication will help her take that deep breath and stop her coughing real soon. She has to be fit to be able to run away from Spartacus when he attacks her, after all.


Tuesday, March 10, 2009


The title of my blog seemed relevant again today. No, Spartacus hasn't relapsed or anything. Today it is his sister, Stella, that reluctantly came to work with me today. Very reluctantly, actually. I had to crawl under the bed and grab hold of her tail (dang, don't tell her vet!) so she wouldn't run away again, finally stuffed her into the carrier and got her into the hospital. Maybe she associates the carrier and the car with going to cat shows when she was younger. Stella was, and still is, a gorgeous Maine Coon cat, and it was with extreme pride that I took her to several cat shows to show her off. She HATED it. I had only shown two other cats before her, and for only a very short time, so I saw the huge difference between cats who genuinely loved the attention, all the primping, combing, fluffing up (I doubt any cat really likes the bath part..) and Stella. They would come to the front of their cages, reaching out to passers by, meowing and purring, arching their back for the petting by the judge, playing with offered toys, really strutting their stuff. Stella hunched in the back of the display cage, crouched into a ball when the judge picked her up, and trembled with fear when it was all over. Needless to say, her show career didn't last long.

Stella has been coughing for a while now, but recently she has been doing it every day. It is one of those harsh, hacking coughs, non-productive, where she extends her whole neck out and down as if she is going to pass a hairball-but she only rarely does that. I have been combing her a lot to try and decrease the amount of hair she might ingest, but that didn't reduce the coughing episodes. I have found that I don't tend to do a very thorough job when I "examine" my pets at home, so off to the hospital she went today.

Her nurses weighed her and took her temperature-all was fine there. She isn't fat like her brother, Spartacus. I listened to her heart and lungs-other than having an elevated heart rate, likely due to fear, her chest sounded fine. Her oral exam was great-Stella has been a fortunate pedigreed cat in that her teeth and gums have always been healthy with minimal care on my part. Many of my other "pure-bred" cats haven't been as lucky, often having severe orodontal disease. I could elicit or cause a mild cough when I palpated Stella's neck, but it wasn't anything like the harsh, extended neck episodes she does at home. I wasn't convinced the issue was with her neck or throat. Her abdomen palpated fine, and the rest of her exam was normal as well.

Since Stella wasn't readily letting on the cause of her cough, I decided to pursue some further diagnostic tests while I had her here. Her nurses drew some blood for a general panel and CBC (complete blood count.) They also took chest radiographs, but since she is small, most of her body fit on the x-ray plates. We got good views of her abdomen, too. Her blood work showed one value a bit elevated-the CK or creatine kinase, a muscle enzyme. It can be elevated for many reasons, often from trauma to muscles as happens after being hit by a car or after a grand mal seizure, or the CK can be high when there is heart disease. The heart is muscle, after all. I've also seen it elevate after soft tissue trauma, such as after surgery. The value can change rapidly, so a single elevated value should be taken with a grain of salt. I will likely repeat it periodically to see if it is a trend (for it to be rising) or if it is actually on the way back down. But I did have two relatives of Stella (half brothers) die from heart failure at very young ages, so you can bet I will be watching this value. Coughing can certainly be a symptom of heart disease.

Her chest radiographs were more concerning. It looked like there were some fuzzy patches or splotches in her lung fields-possible masses? These could be anything from bacterial or fungal infection, (pretty rare in this area) parasites, (lung worms?) changes from asthma, or (gulp!) even cancer. Stella would be awfully young for this, (she is 5 1/2 years old) but we have seen that cancer can do any darned thing it wants to, so we have to put it on the list of rule-outs. I decided not to panic (yet!) and sent the films to the radiologist for interpretation. It will only be another day or two to find out what he thinks and then I can make a plan to treat her. I sure don't want to jump to any conclusions, but you can imagine my mind is going in a hundred different directions thinking of worst case scenarios.

Stella will be more than happy to hop into that carrier now. She certainly knows it means she is getting the heck out of here, back to her buddy, Spartacus, waiting at home for her. I feel bad I waited so long to bring her in and deal with this cough, but just like any other pet owner, I knew how much she hated "going to the vet," what a pain she was going to be to medicate if that's what we decide to do for her, and I was honestly hoping it would just get better on its own. Where have I heard that before? I'll be sure to keep you posted on what the final diagnosis is, if we do indeed come up with one, and how she does with everything. Sometimes it really sucks being a vet's cat!


Monday, March 9, 2009

How Do You Know It Is Time?

It was a snowy day here (Come on! It is March. We should be done with that nonsense already!) so there are quite a few empty spots in the appointment book. I'm certain that is why the appointment for a euthanasia of an old dog made such an impact. They generally do, actually, and that is as it should be. The day that my staff and I can put an animal to "sleep" with no emotion is the day we should consider leaving the profession. Each and every euthanasia appointment represents the end of a relationship between that human or family and their special friend. Perhaps that pet is the last link to a deceased spouse or parent. Maybe they are the only source of friendship or comfort and support to a lonely, single person or one who has a serious illness. Bonds between children and pets are so wonderful-and don't last long enough. Service dogs, of course, have very important rolls in the lives of disabled people. The types of relationships are as varied as are the reasons for making that final appointment.

It may be simply "old age." Old bones and joints lose their bounce and freedom of movement so even the most simple actions are painful. Organs like the liver and kidney and heart can fail, and even though we have come a long way in the treatment of many of these diseases, there does eventually come a time when treatments are no longer helping the patient and may even be a source of stress. Medicating an old cat who fights violently every time just may not be the "right" thing to do to the cat, much less the relationship between that cat and his human. I had a wonderful old tabby cat named Tony who had a form of glaucoma when he got older. He was prescribed some eye drops by our ophthalmologist. Tony HATED them! He acted like I was putting acid in his eyes every darned time I did them. I just couldn't see putting him through that even if it could have helped his eyes. That darned cat!

Sometimes emergencies come up, pets can be hit by cars, mauled by other animals, endure broken bones eat things they shouldn't-the list goes on and on. Some of these situations may not be fixable; others may treatable be given extreme amounts of money that an owner just may not have. We talked before about euthanasia for aggressive animals-ones who can't safely be adopted out. Regardless of the situation, your decision to have your pet euthanized is very serious, and never easy to make.

You aren't alone, though. Although ultimately you alone are responsible for your pet's care and welfare, your friends and family may have valuable input into your situation with your pet. But you should never make the decision simply because a friend or family member tells you to. You should also consult with your veterinarian before the time comes. They can help you decide not only what is right for the pet, but can ask some questions to help you decide what is right for you, too. Be sure to ask questions about your pet's medical problems that might be a factor-don't be embarrassed to have them repeat the information or ask them to write things down. I have often had clients who will be facing the decision soon come in ahead of time to sign all the paperwork and even pay for it if they wish. That way you don't have to deal with all that stuff when those inevitable strong emotions are at hand. Some people wish to arrange for home euthanasias if their veterinarians offer this service. I also have some little booklets and handouts that can help children (and you) prepare to say goodbye-it is really best to be straight forward and honest with them.

You will very likely know when it is time. Really. You spend so much time with your special friend. You know what they like doing, eating, who they love to be around, get up to greet-everything that makes their life worth living. If a pet is no longer enjoying say 3 out of the 4 most important activities in his or her life, the time is likely near. Are there more bad days than good? Does he or she have a terminal illness and the emotional and financial strain is just too much to handle any longer? Would you, in all honesty, be willing to trade bodies with your pet and live their lives?

Once you've come to this difficult decision, you have still another decision to make-aftercare of your pet's body. Some people are fortunate to have property where it would be appropriate to bury a beloved dog under his favorite shade tree in the back yard. Cremation is a popular choice, with your pet's ashes either being returned or distributed in a group and used as fertilizer-life goes on. All my deceased pets were cremated (except my horse Ladyhawke) and their little urns are on my fireplace. I envision them all going in with me when my time comes!

The actual euthanasia is usually very quick and quite painless. We often shave over a vein on the leg of a pet so we will have better access to a vein, but sometimes they are difficult to find in older, debilitated pets. Some veterinarians give sedatives prior to the injection of a massive overdose of anesthetic agents. These are often brightly colored fluids so they can't be mistaken for anything else in a hospital setting. Following the injection, the animal will likely stop breathing and their heart will stop. The veterinarian or assistant will listen to the heart to be sure this has occurred and let you know your friend has passed. There can be sporadic twitches or contractions, even actions that sound like gasping for breath, but these are unconscious -the pet is not trying to come back. Many pets will void their bowels or bladder. Their eyes usually remain open, the natural position.

Not all people feel they should or could be present at this point. It is a very personal decision and we respect each owner for making the choice that is right for them. Some may want to be present until the pet is sedated only and then leave. Regardless, the procedure will still be carried out in as compassionate and as dignified manner as possible.

I wrote about grieving and bereavement in a previous blog. Grief over the loss of your friend is very real, one you should not feel embarrassed to share with your veterinarian-he or she will understand, even when other friends or family members might not "get" what you are going through. It will be very hard, and you will no doubt be very lonely after such a loss-I am always so sorry for that. But I can rest easy knowing I provided the best I could for the pet-you should, too. It is the ultimate gift of love.


Thursday, March 5, 2009

Kill Those Cancer Cells!

Do you remember a special dog I wrote about named Mikey? He had a big spleen we had to remove because it was big and bleeding. Unfortunately, it was found to be enlarged due to hemangiosarcoma, a type of cancer of vascular organs. It had spread to at least one lobe of the liver, too, so just removing the spleen wasn't going to help him for long. Mikey is fortunate to be owned by a very loving human who wants to do the very best for him. After consulting with veterinary oncologists, we decided to start Mikey on a course of chemotherapy after he healed from surgery.

Now the principle behind chemotherapy is simple: kill those wandering cancer cells that were left behind after surgery. But the drugs used to do this can be very toxic to the organs of the body and their otherwise healthy cells. So there can be a fine line between effective doses (killing the cancer cells) and toxic ones (those that could make the patient ill.) We certainly don't want the treatment to be worse than the original disease.

We probably all know humans who have undergone chemotherapy themselves. It can be very nauseating, patients often lose a lot of weight, can have their hair fall out, or experience other side effects from the drugs. It can be difficult to know if these are really side effects from the drug or a progression of the cancer disease itself. Dogs are usually pretty tolerant of most chemo drugs. Even still, we take precautions like administering anti-nausea medications prior to giving the chemo agents. Mikey is a pretty sensitive dog-he goes through episodes of being picky about his food, anyway, and this second dose of chemo is really making him nauseous. Despite the anti-nausea medication, he has vomited and he just isn't eating yet, and it is going on day 4. I am going to check him over this afternoon and see if there is anything else going on.

Dogs rarely lose their hair due to chemotherapy. I used to say"never" but many years ago I had a very sweet, beautiful Standard Poodle patient with a soft tissue sarcoma that actually did lose all her hair after the very first dose of her chemo drug! It was quite a shock. I called the veterinary oncologist and they assured me that poodles were the exception and yes, it would grow back in just like human chemo patients. There weren't any wig makers for poodles that I knew of, though.

Nutrition can be an important part of fighting cancer. Mikey is on a prescription diet called N/D for "neoplasia diet." It is formulated to keep his cancer-stressed body healthy while starving those constantly dividing cancer cells. Some people choose to formulate their own homemade diets for this purpose, but we are so lucky that we have the prescription diet folks do it for us now!

Most chemotherapy is administered in rounds or specific protocols depending on a few things. Staging a cancer can really help decide which protocol will give the optimum results, and even this means different things to different people. For some owners, it is the longer survival time. For others, it is the best quality of life-good palliative care, pain control. Aspirating or taking samples from regional lymph nodes can help determine if the cancer has spread in the body. Radiographs or ultrasound can search for evidence of this metastatic disease. We only had to look around when we had Mikey's abdomen opened up to visually identify the affected liver. We did take chest radiographs, though and at the time, they appeared free from tumors. We chose a chemotherapy protocol where his drug is administered intravenously during a day in the hospital once every 21 days for 5 times. He wouldn't have to stay over in the hospital unless there were any complications from the drug or from the cancer itself, and so far, other than his nausea, he is doing remarkably well.

Prior to most chemotherapy regimens, we draw blood to test the complete blood count of the patient. We want to be sure the medications and/or the cancer isn't suppressing the immune system or affecting the patient's ability to handle the next round of therapy. Because of this testing, the hospital stay, the cost of the drugs themselves, the pre-medications, the special diet and supplements, treating cancer can be extremely expensive for a pet owner. Of course, there are no guarantees of success when we are dealing with such a serious condition as cancer. Mikey's owner knows all this. She is far from wealthy, but her love knows no bounds. She is hard at work, raising money to help continue his care. We have searched to find the least expensive source of his medications, and treatments every 21 days rather than weekly sure does help. He is one lucky dog! We all should be loved that much.


Wednesday, March 4, 2009

If you smoke, quit for your pet!

By now everyone knows how dangerous smoking is for you. Even the dangers of second hand smoke to family members, especially children, co-workers, fellow diners, etc., are well known and have resulted in so many laws on the books as to have made smoking in public places virtually impossible. Thank God for that. But there are still far too many people who do not realize the dangers of second hand smoke to their furry and feathered family members-it can and does hurt these animals, often more so than their larger human counterparts.

It isn't just the awful smell in the fur that I notice when a smoker's pet comes in for an exam. They will often have red, irritated eyes, a dingy, dull hair coat, and very often have a cough or other respiratory problems, many times the very reason for the visit in the first place. Dogs who live with smokers are more likely to get nasal and lung cancers than those who live with nonsmokers. Brachycephalic (the flat-faced ones) dogs are at higher risks for breathing issues and lung cancer while longer nosed dogs like greyhounds are predisposed to nasal cancers. Smoker's dogs also scratch and chew at their skin just like allergy dogs do. Indoor cats living with smokers have twice the risk of lymphoma, a deadly cancer, and a higher risk of oral neoplasms. This is probably because the carcinogens settle in their fur and these fastidious groomers lick them off constantly, getting these cancer-causing chemicals in their mouths. We see a much higher incidence of asthmatic and lung inflammation problems in smoker's cats. Birds and small mammals like hamsters and rats are even more vulnerable due to their smaller sizes and higher metabolic rates. They are often sneezing, coughing, have eye problems and feather plucking when sharing the home of smoking humans.

When a critter comes in for a health exam and I notice the tell-tale smell on their fur, I try not to be accusatory or judgemental. I have had my own share of issues and know the smoker likely wants to quit themselves. But I do gently warn them about these dangers of second hand smoke to their pets, and some people are genuinely surprised about it. I do remember one older lady who had smoked for years. When she learned her habit was likely the reason for her little Yorkie's terrible cough, she first strted smoking only outdoors. She was finally able to stop altogether. I was so proud of her! She hadn't been able to do it for herself, but did make the huge change because of her beloved friend.

If you do smoke, be sure to do so away from the area where your animals live. It isn't enough to simply open a window. Smoke outside only, and be sure to tell visitors not to smoke in your home. Never smoke in your car with your dog, even with the windows rolled down. After smoking, be sure to wash your hands before petting or holding your pet. Nicotine can get on your hands and be transferred to your pet's fur. And definitely be sure to keep packs of cigarettes or butts, ashtrays, cigars, nicotine gum or patches or even smokeless tobacco products well away from your dog or puppy. Nicotine in these products is very toxic and could even kill a pet if enough is ingested. Call your veterinarian or poison control if you suspect this has happened.

Smokers know they need to quit, but it sure can be hard. Here is a website for more info about second hand smoke and how to quit:
Do it not only for yourself but for the health of your beloved pet. They will breathe easier and thank you for it. And you will certainly live longer-the more time to spend with your pets!


Tuesday, March 3, 2009

Advocacy for CJ

Being a veterinarian has it's challenges in regards to asking a patient "where does it hurt?" Our critters usually can't speak up when they are injured, ate something bad, or just plain don't feel well. Now, my dog's name is "Verbal"-she certainly does her fair share of talking to anyone who will listen, but when it comes to making a diagnosis of an illness or injury, I as her owner, have to speak up for her.

Being an advocate for your pet's health is so important, an essential condition of ownership in my book. A recent case really illustrates just how it can make a difference; sitting back passively waiting for doctors to help just didn't cut it for CJ.

CJ is a personable, 7 1/2 year old Border Collie who moved to Washington state from Arizona (an important part of his history we will come back to) a couple of years ago with his humans. They noticed him having some hind limb lameness, occasional stiffness attributed to hip dysplasia or arthritis pain. But last summer he had a very arched back and we found he was knuckling his hind feet. He had decreased proprioceptive and righting reflexes-he didn't "know" where his hind legs were in space. That is usually automatic for us, something we do without thinking about it. When CJ's hind feet were turned over, he took some time to right them again. This is usually due to a lesion in the spinal column slowing down or interfering with the transmission of information from the leg to the brain and back again. We decided to take some radiographs of CJ's spine, but also hoped to include some of his abdomen in the pictures as he had some symptoms of abdominal discomfort, too. He was not only painful but also nauseated, not eating as well, which can certainly happen because of pain. CJ's x-rays really didn't help much. They did not show any bony problems with the spinal column or abdominal organ abnormalities. It did tell us that neither his hips or other sources of arthritis were a cause of his discomfort-there was no evidence of these problems anywhere on the radiographs. A bland diet and pain medications along with gastric protectants only helped him sporadically.

CJ was back in to see me when his symptoms seemed to worsen. His back became more arched, he was very cautious about lowering himself to the ground before eating (he wouldn't just lower his head to eat from a standing position) and he seemed to have trouble negotiating himself out of the corner he got himself into. We ran some blood work to see if he could have picked up an infection as a cause for the signs. The blood work didn't help in that regard-it was perfectly normal. We began to discuss the possibility of referring CJ to a specialist, likely a neurologist, for a spinal tap and perhaps advanced imaging such as an MRI for further diagnostics. Another option was to try CJ on a course of antiinflammatory medications-and this is the direction we decided to go.

The response was pretty immediate. CJ felt better, was back to playing with his buddy, Storm, and if we kept him on the gastric protectant, he even ate better. In the meantime, CJ's owner arranged for a consultation with the local veterinary neurologist. We sent copies of our lab work and x-rays with CJ, and after examining him, this doctor confirmed our suspicions of a spinal lesion in CJ. He recommended the spinal tap and MRI, both expensive tests that require general anesthesia, and likely leading into surgery if indicated by their findings. Not long after this, CJ developed severe, bloody diarrhea, likely a side effect of his medication. We tapered him off his medications and added others to combat the side effects. His diarrhea symptoms resolved eventually, but then his back problems came back in full force. His owners saved up the money and got him in for the recommended MRI and surgery.

CJ had a spinal mass in his lumbar region-the prognosis wasn't good. The neurologist was quite worried this was a tumor, but hadn't seen one that involved 2 disc spaces as this one did. They were not able to de-bulk it well as it infiltrated the delicate tissues. They submitted samples to the lab for identification, but decided to start him on chemotherapy right away.

Well, this was another loop in the roller coaster ride. The pathology report came back a few days later-no cancer! The mass was really an abscess, a bundle of walled off infection. So, this is good news, right? The neurologist put CJ on a long course of antibiotics and we all breathed a sigh of relief.

During the 9 weeks (!) of antibiotic therapy, CJ had good days and bad days. He still knuckled over quite a lot, and he lost more weight, really in the form of muscle atrophy from not using those hind legs much. His once glorious hair coat became thin and patches form surgery never grew back. He was extremely picky about eating-he just wasn't thriving. I attributed a lot to the stress of such a major surgery and having this big infection in his body, and his anorexia was likely due to the nausea from his antibiotics. He did start to eat much better when he finally reached the end of that long course of medication. We put him on some essential amino acids and increased his exercise/physical therapy to increase his muscle mass.

This is where patient advocacy really came into play. CJ's owners just never were happy with his progress, and didn't sit still when repeated queries to the neurologist weren't answered. They contacted the doctors at the state veterinary teaching hospital and got some interesting suggestions. Remember I told you that CJ had come from Arizona? Well, this neurologist had recently seen a patient that came from this area and had similar clinical signs as CJ. That dog had tested positive for a systemic fungal infection, rare in our part of the country but much more common in the south west. Yes, the tests were expensive-there were numerous fungi to test for. But we drew the blood and sent off the panels. Wouldn't you know it? CJ tested positive for the fungal organism that causes Valley Fever. It could very easily cause the granuloma-like lesion he had on his spinal column, and no antibiotic would resolve a fungal infection. We have asked the pathologist if it would be possible to go back and restain the tissue sample to try and identify the coccidiodes organism and in the meantime, have started CJ on a systemic antifungal medication. I chose one that is good for diseases of the central nervous system and has a lower incidence of toxicity-a problem with many anti-fungal drugs.

The diagnosis is a blessing and a curse. If it turns out to be the cause of CJ's symptoms-great! Hopefully the medication will get to the source of the infection, not easy to do in an encapsulated tissue walled off from the body like this was. It may take months or even years of therapy; systemic fungal infections are known for their tenacity. CJ could become toxic from the medication, developing liver issues if the medication can't be eliminated from the body. We will do periodic liver function tests and Valley Fever titers to monitor his response to treatment.

CJ's owners are so very frustrated about the perceived lack of help they got from their first referral doctor who seemed to dismiss their suggestions of this exact disease as a possible cause of CJ's problems way back in the beginning of all this. I am so impressed with their stick-to-it-ness and their sincere desire to do whatever it takes to help their boy. I feel fortunate to be working on their team, and really hope CJ is finally on the road to health.