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.

Peace,
DrReneigh