Pinuki is now eight years old. She did spend her birthday with her friends at Veterinary Holistic Care. It has been over five months since she has been bleeding. Kalu is demanding attention in the naughtiest of ways. I am exhausted; too exhausted to write anything "original" right now. So to catch you up, please read the excerpt from an e-mail I just sent to Drs. Maniet and Saylor. Much of the "research" information I got from Mary Straus through her website
Dogaware http://dogaware.com/index.html. I have removed the names of the veterinarians whose information I forwarded because I have not asked their permission to disclose their identities.
Piniki had a full day of the new treatment plan. The only significant difference so far is increased thirst. She had nosebleeds yesterday morning and this morning – not as bad as Tuesday morning. Throughout the day she had bloody nasal discharge off and on. She continues to have signs of allergy – nasal congestion, discharge from the eyes, watery discharge from both nostrils.
I am not sure I remember this correctly, but did you say if there is no change in symptoms after 3 days, we would stop the natural hydrocortisone? What do you think about adding an anti-anxiety medication? I have some NutriCalm and can finish it. However, at this point the cost is prohibitive. Perhaps I could give the NutriCalm until it runs out (about 10 days) while something like Buspirone has a chance to take effect?
As a lay person, I am trying to help figure out the best way to treat what I see as Pinuki’s symptoms:
- Persistent, chronic epistaxis (left-sided until ligation of carotid artery, bilateral after ligation, left-sided since starting doxy);
- Generalized anxiety, specific noise phobia (which cannot be avoided)
- Seasonal allergies
- Left-sided intermittent, stifle pain (because of the bleeding she is not getting arthritis supplements)
As mentioned, the ideal goal of treatment would be cure. If that is not possible, stabilizing the symptoms and preventing the negative effects of chronic bleeding (i.e. anemia) – optimal health under the circumstances – would be good. How will we monitor the effects of chronic bleeding (i.e. bloodwork at predetermined intervals?) I will also follow up with Dr. Saylor regarding treatment options if we cannot stop or control the bleeding.
The information below is for your consideration and a follow-up to our appointment. I am inclined to start anti-anxiety medications sooner than later.
Things to Consider:
Anxiety Medication – I would like to try treating the anxiety. There is a lot we do not know about what is going on with Pinuki. One thing I know for sure - she is anxious. She also has a specific noise phobia that cannot be avoided (noise generated by upstairs neighbors). And, managing the bleeds cause her considerable anxiety. Buspirone is Dr. Dodman's http://www.thepetdocs.com/cadog.html first choice for treating anxiety and noise phobias, but he says it's important to give a high enough dosage. It must be given continuously for at least four to six weeks in order to determine whether or not it will help. He recommends starting with 1 mg/kg twice a day, increasing to twice as much (1 mg per pound of body weight twice a day) if needed. Dr. Dodman says that when buspirone doesn't work for anxiety issues, it is usually due to the dosage being too low. He recommends starting with a dosage of 1 mg/kg of body weight twice daily. This dosage can be doubled if needed. Blood Pressure Medication - One other thing worth trying would be blood pressure medication -- I know her BP has been tested and is normal, but medication might still possibly be helpful. Amlodipine is strictly for BP; Enalapril is given to dogs with heart disease as it has other effects as well. Clonidine, which is used to treat anxiety and is short acting, is a human BP medication that could also be tried. It is short-acting, so not the type of thing that would work long term, but might be good to try for a few days to see if it helps. It is given to dogs with normal BP and so should be safe. Here's dosage information: Recommended dosage for anxiety is 0.1 mg for dogs <20 lb, 0.2 mg for dogs 20-50 lb, 0.3 mg for dogs >50 lb. It is given once a day with food. Effect lasts about 6 hours; may take one to two weeks to reach maximum effect. Should be weaned off to avoid a sudden spike in blood pressure. Dr. Dodman recommends dosages up to 0.05 mg/kg (1.36 mg for a 60-pound dog) twice a day or as needed. The drug takes effect in about half an hour and lasts three to four hours.
Thoughts from Veterinarians:
Vivastem (stem cell fluid) :
…if inflammatory it might [work], I did stem cell therapy on my guy. There is a new stem cell option that your vet can even do in his office and does not require surgery to obtain the stem cell. The company is vivastem. It is 2 injections done 1 week apart and has been phenomenal in treating so many things. I think it might help your dog… here is the link for the Vivastem I think you will find it exciting. It gives hope when we cannot find it sometimes. http://www.vivastem.com/index.html I don't mark it up a lot but in the big dogs it is around $300 per injection (this one anyway). I know it does not talk about use for such things but it certainly wouldn't hurt. If it does it could open up a whole new use for it. I would use an injectin SubQ Under the skin.
Interesting “lipoma theory” (at least to me):
I am concerned about the lipoma left of the cervical spine. I have seen other masses under lipomas but I would think that would be visible on an MRI. Also, maybe the mass is pressing on other structures causing increased pressure to the head and neck. That could explain why the bleeding is now on the other side too. I dont know if there is a way to check blood pressure in the head alone. Systemic blood pressure at the back end of the body may not be reflective of what is going on in the head. I would try to get a bunch of different pressure readings at various times too. Worst case, if all else fails, you may have to get the mass surgically removed or at least explored to make sure it is not the problem.
I’d run an extended diagnostic PCR panel for a more complete infectious disease screen (chronic in nasal turbinates) than the Idexx panel, plus a fungal screen and also Neospora, bartonella , and toxoplasmosis (raw meat ? ). The alternative is to treat her empirically for such disorders with doxycycline, clindamycin, and itraconazole or fluconazole (rather than ketaconazole, which has more side effects). [not all at once ! ]. PART II I agree, after reading everything, that the lipoma is large enough to have pressed on her nerve supply and caused the pain. I still think that there could be a fungal infection of the nasal turbinates, now that the epistaxis has shifted to the right nostril. As she eats a raw diet, I’d either test her for toxoplasmosis (and Neospora, other fungi like aspergillus etc) or try a course of Clindamycin for 21 days. A course of itraconazole or fluconazole should be considered as well, if the tests for other fungal diseases aren’t run. IF all else fails, I’d remove the lipoma.
Again, all the vets say the lipoma could not be causing the bleeds. Agreed, but it could be sending “molecular messages” to her vasculature in head and neck region.
Repeat BMBT. Scinitgraphy with radiolabelled RBS's or selective angiography during a bleed to localize lesion (may be difficult due to left carotid artery ligation); may be able to perform chemical embolization for treatment during selective angiography. Nutritional evaluation for deficiences or excesses that may result in coagulation issues.
As an anesthesiologist, I guess I find it hard to relate the mri to the bleeding, although it is intriguing that it started after she had the scan. Usually blood pressure under anesthesia is low, not high, and that protocol is about the most benign one that one can devise. Has she had an abdominal ultrasound? I didn’t see that listed on the list. Sometimes abnormalities in the spleen can cause weird changes in platelet function too.. my bias is platelets, as we really don’t see other diseases that are not associated with masses in the nose that cause bleeding in normal animals…but it’s also my area of research. How much does she bleed; is it always a small trickle, or is it a daily but intermittent large amount? bone marrow aspirate; sometimes disease in the bone marrow can cause alterations of the platelets and can also cause pain as well. PART II The only thing I know with regards to propofol involves lysis of red blood cells, and any dyscrasia should show up on the CBC, which is normal. These also don’t show up after a single exposure, usually in cats, and usually after about a month of repeated propofol anesthesias.. She is one of the most bizarre cases that I’ve heard of…
Other Tidbits:
Sangre de Drago, from Wendy Groomes:
it stops internal and external bleeding, they use it for machete wounds in the Amazon.
Bryonia (anecdotal) I went through the same thing with my 6.5 year old boy for 6 weeks before I put him down. I did not go through the group and tried the same things you mentioned you had used plus more including K9 Immunity. Bryonia did help a bit but there are still no answers after an autopsy as to what caused this. I could not take it any longer as he was severely anemic and the blood loss was getting greater each time.
