CURRENT PROBLEM: Sera has been lip-smacking, yawning and swallowing more frequently than usual, as well as having some episodes of whining behavior, especially in the evening. She doesn't seem quite herself, sometimes laying sphinx-like, staring off into space and whining. She is just a shade over 8.5 years now.

RELEVANT HEALTH HISTORY/CHRONIC ISSUES: Her chronic eye disease, pannus and KCS, is rather poorly controlled and currently treated with frequent cleaning and Optivet eye irrigating solution with Sodium Hyalauronate. Cyclosporine drops were discontinued when an irritation to the carrier oil (first corn, subsequently coconut), developed. A short trial using fish oil as an anti-inflammatory drop was unsuccessful. We try to keep her eyes clean and instill tears frequently, with the goal of keeping her comfortable.

She does have hip and elbow degenerative disease with moderate and increasing difficulty in getting around. She takes Nutramax Double Strength Cosequin DS, 3/day; and also takes Springtime Inc. Joint Health Chewables, 2/day. We did a short course of attempted pain relief with buffered aspirin, but discontinued it to rule it out as a cause of (or to avoid further), possible GI irritation. She currently takes no other pain relief meds.

Her appetite is good, she eats Pinnacle Trout and Sweet Potato (2.5 cups/day, split between two meals), and takes Solid Gold Seameal (1 T/day), Springtime, Inc. Longevity (1 T/day), NuVet Plus Daily Wafer Supplement, and Dermapet Eicosaderm (omega oil supplement, four pumps/day). She gets 1/4C kefir with her evening meal.

Her stools are always firm and the volume is small.

CURRRENT RELEVANT CLINIC VISIT HISTORY: In July 2010 when Sera went in to her regular vet clinic for her annual exam, we had a senior blood panel including urinalysis done. There were some abnormal values in her bloodwork and urinalysis.

Urinalysis: H bilirubin = 1+
Bloodwork: H ALT(SGPT) = 121
H HGB: = 19.1
L AUTO PLATELET = 132
Platelet comment: scanning of the blood b smear revealed adequate platelet numbers.
Due to clumping and/or large platelets the
automated platelet number cannot be accurately
determined.

At that time no treatment was recommended. We seconded that opinion with Sera’s mobile vet, who said with so few values elevated, and the level of elevation being low, a wait and see attitude was reasonable. Sera continued with all lip smacking symptoms listed above, and continued to seem a bit “off” to me.

Then at the end of November we took a fecal and urine sample in during Sera’s routine nail trim. The fecal sample was positive for three types of parasites: giardia, tapeworm, physaloptera. I was shocked and have no idea where she could have gotten these parasites. All four dogs were treated with three days of Panacur granules. Sera’s urine also revealed a UTI, which was treated with Cephalexin (4/day for 10 days, 500mg). At this point she was referred to Michigan Veterinary Specialists, Dr. Elin, for further evaluation of her lip smacking and whining behaviors. A dental exam was also recommended and has been scheduled.

At MVS on 12/9, Sera had an abdominal ultrasound and thoracic radiography to evaluate her GI tract and oropharynx and esophagus.

An abdominal ultrasound “revealed subtle changes in the spleen that are most consistent with splenic inflammation/splennic remodeling”.

Radiographs revealed “a small volume of air in the extra-thoracic esophagus, just caudal to the upper esophageal sphincter”, with “a very mild diffuse bronchial and interstitial pattern present. Normal cardiovascular structures, minimal air present in the intra-thoracic esophagus”.

Folate and Cobalamin assay values (from blood sample), were reported as
normal.

At this appointment as well, Sera’s stool and urine were re-checked (urine obtained both directly from bladder and free catch, urine was cultured), both subsequently reported as negative.

Also at this appointment, Sera was prescribed Metronidazole 500 mg/twice a day, “as an effective antibiotic for patients with GI upsets regardless of the cause. Moreover its’ employment is a sort of diagnostic test. If Sera’s clinical signs abate while on it, that would argue for GI disease more strongly”. We did complete this course of meds, symptoms continued as before.

Sera has also recently completed a course of Prednisone prescribed by her regular vet clinic to rule out an allergy based cause for her lip-smacking, swallowing, etc., behavior. No change in the behaviors were noted, but her chronic eye inflammation and some inflammatory bumps on her feet did improve dramatically while on this drug therapy, only to revert back to their original severity once drug therapy ended.

The specialty veterinary clinic has recommended that we pursue upper endoscopy, requiring general anesthesia and considerable cost. Sera has her canine dentistry specialist appointment tomorrow to definitively rule out a dental contribution to the cause of her behavior.

As I write this out I realize the clinical picture is probably much too complicated to even ask for an opinion on an internet message board, but I am just at my wits end in trying to figure out how I can help my girl, and I'm just wondering if this constellation of symptoms, imaging results, and bloodwork abnormalities ring a bell with anyone, or if anyone has an opinion about what might be going on...or any suggestions on how I can best support her systems while we investigate further, any input would be greatly appreciated. The veterinary dentist we are going to see tomorrow is considered tops in his field, and we should be able to rule out (or in) the contribution of dental disease to the picture.

Thanks for reading...I think denial (that my girl is aging, that i'm going to loose her), may be contributing to my difficulty in processing and understanding all this, because it usually doesn't seem to be so hard.

It is scary, when you know something is wrong, and you can find, and you can't stop it

Do you have a copy of the blood and urinalysis results? If so, I would like to take a look at them.

I had never heard of the stomach worm: http://www.peteducation.com/article.cfm?c=2+2090&aid=759 I would recommend re-treatment of the panacur in so many days, can't remember if it's 10, 14, or 21 days. Does anyone know? I had this problem when Indy had raccoon roundworms, we forgot to retreat and she got sick again, and all these are nasty buggers.

The low platelets are probably related to the spleen issue. The large platelets are an indication that the immune system is busy creating new ones since they are being destroyed.

And when I hear those two things, the first thing I am going to think of is tick disease, but that's only because I've seen so much of it. If she was given pred without antibiotics (like doxycycline), that would make me nervous. I sometimes wonder if a severe and deep giardia infection can cause some of these abnormalities.

If the pred made things better then there is significant inflammation. The inflammation is either immune-mediated and this is an immune system disease that needs only suppression, OR, this is inflammation caused by infection and suppression only will make the underlying infection worse.

The bilirubin in the urine I think goes along with the elevated liver enzymes, both signs of liver problems. I would strongly recommend some liver support. There are several good products out there, this is the one that has a lot of successes on the tick list: http://www.iherb.com/country-life-biochem-liver-support-factors-100-tablets/1670?at=0

I wonder if any of these parasites can affect the esophagus. I have no idea about the air and esophagus thing - did they say anything about that in particular? Is it air for sure, or enlarged at all? When Indy had those raccoon roundworms, when initially treated, she had a lot of gagging and reverse sneezing issues initially.

For Max's pannus, I am using pred drops once a week, and artifical tears several times a day. The oral doxy is helping a lot too. I would consider some artificial tears over the wash perhaps? I am experimenting with pred drops that have antibiotics in them, but he seems sensitive to the antibiotic.

Just a few thoughts.

i do have copies of the blood and urine work, but am having a brain freeze, how do i transmit them to you?

pred drops = cyclosporine drops?

i asked the specialist doc about tick disease, i can't believe it, but i think he said not in eastern michigan. could that be?

i will immediately start the liver support.

and thank you for the moral support and auxillary brain, this has been a really challenging and difficult past year, and i've been just stretched way too thin.

oh, and no enlargement of the esophagus, only air.

Can you scan the results? If so, you can email them to me? worse comes to worse, snail mail?

There are three types of drops used for pannus: cyclosporin, tacrolimus (stronger than cyclosporine), and steroids (pred or dexamethasone (sp?), either with or without antibiotics). The least irritating for Max are the pred drops.

I just found a research paper that found 3 cats in East Lansing positive for Anaplasmosa (either anaplasmosa, ehrlichia or babesia are most likely culprits in sera's case)
https://www.vetmed.auburn.edu/uploads/a6...47_194_2007.pdf
I don't think that's Eastern MI, but I know that we have had tick disease all over the surrounding states too. Maybe a conversation with the Michigan Lyme Disease foundation can help? http://www.hvcn.org/info/mlda/ Personally, tick diseases are so elusive and under-reported, I am skeptical of most all these statements.

This may not be a tick disease, but it's a definite rule-out, based on the platelet, spleen, and liver issue. It might be some organism that responds to the same treatment. Many of us on the tick list have to purchase our own antibiotics to treat. Sometimes the cheapest diagnostic is a trial run of doxycycline.

I know how hard it is when they are so sick, I'm so sorry, I remember that you knew she wasn't feeling right.

do you have access to a fax?

No, I'm not at work until next week, and then only about half the print shows up on the machine there

I wish I had the knowledge to help but all I can do is offer lots of

I am keeping your Sera girl in my thoughts and prayers and hope that the dental shows something.

Me too, lots of support! I hope she is okay. I guess if push comet to shove you can re-type all the test values for Lisa, but that would be time consuming.

Take a digital picture of them? I now remember someone doing that with their cellphone camera!

You could take them to Staples and have them scanned into a pdf. I do this a lot.

I do the picture thing with receipts and things since my scanner doesn't always work. Then it's in a nice jpeg and can be made into whatever needed in Photoshop.

The only weird thing I can think of is http://www.marvistavet.com/html/body_myasthenia_gravis.html but not really so again, no idea.

Mila has the regular old prednisone eye drops and then tacrolimus for her pannus and plasmoma.

I wonder if "making" her drink more throughout the day would help.
http://pets.webmd.com/dogs/my-dog-smacking-lips

*Complex partial seizures???
http://www.k9web.com/dog-faqs/medical/epilepsy.html

Have you tried any Pepcid or more natural tummy stuff? Could it be an indigestion type thing?

*That interests me most almost?

Katherine,
I have a fax here at work. If you want you could fax to me and I can scan and email to Lisa. Just let me know!

jean, yes, we've done the pepcid ac trial to see if that helped (and it didn't).

kris, i am going to fax these to you before i head off to the dental vet.

lisa, included is a lab result sheet that i just got this morning that i had forgotten about, which shows her ALT as increased from the 120's to the 170's. and i also forgot to mention that the local vet and tech who cuts her nails both report enlarged cervical lymph nodes, but that was not a finding of the specialty vet.

thank you for the good thoughts and support. off to fax...

Kris, thank you so much!!

katieliz, wondering, was there a CBC with the November bloodwork, a page that included platelet and neutrophil type counts? The chemistry page said 1 of 1, so I'm thinking it wasn't run, but I just wanted to make sure.....if not, I'm pretty surprised that there hasn't been follow-up blood counts since July.

I will be back a little bit later....I don't see a slam dunk here, but I have a couple of thoughts. Without a follow-up to the CBC, it's harder too.

When the swollen lymph nodes were found, were you still using the cyclosporine drops for the eyes?

Some DGL licorice can really help sooth the stomach. It won't cure anything, but it helps the lining of the stomach. Have you ever tried probiotics or l-glutamine? These are just band-aids for right now though. I'm thinking of how to help the stomach recover from the parasites, certainly doesn't get at the bigger picture.

In Brief: lip smacking, whining, discomfort, trance

July: platelet and liver irregularities in bloodwork

11/29: fecal and urinalysis (uti, giardia, tapeworm, physaloptera), 3 days of panacur, 10 days of Ceph

12/9: abdominal ultrasounds (splenic inflammation) and chest xray (a very mild diffuse bronchial and interstitial pattern), SIBO test (negative), feces redone (submitted to lab, negative) and urine redone (directly from bladder, negative), metro prescribed.

misc:
symptoms did not respond to pred.
upper endoscopy recommended
enlarged cervical lymph nodes
stomach worm link: http://www.scribd.com/doc/23745438/C-F-Physaloptera-Infection-in-Dogs-and-Cats



Any news today? I haven't seen you online, hope everything is okay.

I've been looking up all sorts of stuff - symptoms can be from tick infection (ehrlichia, anaplasmosa, babesia), lepto, fungal, and probably other stuff, but.....let's look for horses rather than zebras first. (Did you know that pneumonitis, one of your rule outs, is most commonly found in people with pet birds? But so can things like ehrlichia, fungal infections, etc.)

One of my concerns is that the previous infections (giardia, etc.) were severe (severe enough to affect organs) and were not treated thoroughly. These things can be difficult to find in fecals (giardia for sure, and I have found papers that describe the best way to diagnose Physaloptera is via endoscopy and not fecal).

Was there any improvement at all on the panacur? Slight or otherwise? With those parasites, I would have expected at least some symptoms, and at least some improvement. If you didn't see improvement at all, I would question whether the treatment was effective.

Also curious if you have tried any dietary changes, like a week of homecooked bland diet to note response?

Having done the abdominal ultrasound, this sounds like infection to me. But of what?

Any news????

well. here's what happened at our visit with dr. ben colmery the doggie dentist.

i'd seen dr. ben a long time ago with another dog, but had forgotten how down to earth and forthright he is. we went into the exam room, i'd also forgotten that he doesn't shake hands, he hugs. well, he says, so this is the mystery dog. sera gets up in the people chair in the exam room. he says, well, that's quite an eye problem you've got there girl, and proceeds to open her mouth and starts doing something to her gums that i can't quite see. after about half a minute he stands back, shakes his head and says, does sera ever have episodes of long, ropey, stringy saliva? wow, i say, yes, she does...when she's outside with her ball in her mouth the saliva just strings out of her mouth on both sides and the ball is just covered...how did you know that. he shakes his head again and says, sjogren's syndrome. the doggy equivalent of sjogren's syndrome. dry eye, dry mouth, (which is what's causing the lip smacking), immune mediated disease. lots of other possible systems involvement come with this...urinary, respiratory, others. he believes sera has global immune related disease. he also thinks she should be on tramadol for the discomfort she has from her degenerative joint disease, because he thinks that is likely what's causing the whining and staring off into space behavior. he does not think she needs to be anesthetized and scoped. he says, "not to disagree with my esteemed collegue mark (dr. elin from the specialty clinic, who did the ultrasound), but when you (meaning me), said she sometimes has stringy, ropey, saliva...well, that was the icing on the cake...this dog has sjogren's syndrome. i look in the mouths of dogs all day long, every day. i know what i'm talking about. this dog has the doggy equivalent of sjogren's syndrome."

he tells me there is no quantitative test and no magic bullet treatment. i am sitting there just incredibly relieved to have someone tell me something that makes sense and feels right. i tell him that my goal for her is to keep her comfortable, and i understand she's going on nine years old, and i've never had one go double digits, so i understand what's coming. he read her lab reports and said the numbers are not high enough to be anything we should currently worry about. her stool was again clear of parasites, second test i've had done. she did not have any swollen lymph nodes. he recommends i look into a spray that is zinc and vitamin c and something else, has max in it's name, i have to google that. he says her teeth are fine and at her age he would not anesthetize her and clean them. he hugs me good-bye (and not in a weird way or anything, just a real sincere, hey, i'm glad i could help you way), and says call me if you have any questions.

okay, i'm a believer. now i'm not saying there couldn't be somethig else going on concurrently, but all of this makes pretty good sense to me, knowing how all those immune system diseases can take an incredible toll. and dr. ben has a pretty credentialed and positive reputation.

so my plan would be to begin researching how i can best support her immune system, and i'm open to any and all suggestions. also appreciate any and all other thoughts and opinions about all of this.

i told someone yesterday that it's now for sure, the winter of 2010-2011 is when i officially became old. all this just wore me out yesterday and i went to bed at an unheard of (for me) early hour of about 11pm. and now i'm a day behind in everything.

thanks all for everything...input, support, ideas.

here is sera, waiting for dad to come home...yes, sera could use to loose a few pounds, 94 yesterday, too, too heavy.

I agree that she doesn't need the endoscopy.

I also agree she has system-wide immune system dysfunction and most of what your dental guy said.

However, I think that jumping to immune-mediated disease as the sole cause may be a fatal decision. I hope I am wrong. I would run that CBC again at some point soon and see what is going on.

I would strongly suggest looking into the doxycycline and niacinamide protocol for immune suppression. That will cover your bases for the immune system AND amny underlying infections. The risk-benefit ratio here would be in your favor.

If you do this, run a CBC before you start.

how/where do i find out more about the doxycycline and niacinamide protocol? i will have blood drawn for another CBC tomorrow.